Short-term effect on pain and function of neurophysiological education and sensorimotor retraining compared to usual physiotherapy in patients with chronic or recurrent non-specific low back pain, a pilot randomized controlled trial

Background: Non-specific chronic low back pain (NSCLBP) is a major health problem. Identification of subgroups and appropriate treatment regimen was proposed as a key priority by the Cochrane Back Review Group. We developed a multimodal treatment (MMT) for patients with moderate to severe disability and medium risk of poor outcome. MMT includes a) neurophysiological education on the perception of pain to decrease self-limitation due to catastrophizing believes about the nature of NSCLBP, b) sensory training of the lower trunk because these patients predominantly show poor sensory acuity of the trunk, and c) motor training to regain definite movement control of the trunk. A pilot study was conducted to investigate the feasibility of MMT, prior to a larger RCT, with focus on patients’ adherence and the evaluation of short-term effects on pain and disability of MMT when compared to usual physiotherapy. Method: We conducted a randomised controlled trial (RCT) in a primary care physiotherapy centre in Switzerland. Outcome assessment was 12 weeks after baseline. Patients with NSCLBP, considerable disability (five or more points on the Roland and Morris Disability Questionnaire (RMDQ) and medium or high risk of poor outcome on the Keele Start Back Tool (KSBT) were randomly allocated to either MMT or usual physiotherapy treatment (UPT) by an independent research assistant. Treatment included up to 16 sessions over 8 to 12 weeks. Both groups were given additional home training of 10 to 30 minutes to be performed five times per week. Adherence to treatment was evaluated in order to assess the feasibility of the treatment. Assessments were conducted by an independent blinded person. The primary outcome was pain (NRS 0-10) and the secondary outcome was disability (RMDQ). Between-group effects with Student’s t-test or the Mann-Whitney U test and the standardized mean difference of the primary outcome were calculated. Results: Twenty-eight patients (46% male, mean age 41.5 years (SD 10.6)) were randomized to MMT (n = 14) or UPT (n = 14). Patients’ adherence to treatment was >80% in both groups. Pain reduction (NRS; [95% CI]) was 2.14 [1.0 to 3.5] in the MMT and 0.69 [-2.0 to 2.5.] in the UPT. The between-group difference was 1.45 [0.0 to 4.0] (p = 0.03), representing a moderate effect size of 0.66 [-0.1 to 1.5]. Reduction in disability on the RMDQ was 6.71 [4.2 to 9.3] in MMT and 4.69 [1.9 to 7.4] in UPT, with a non-significant between-group difference of 2.02 [-1.5 to 5.6] (p = 0.25). The required sample size for a RCT with six months follow-up was estimated at 170 patients. Conclusions: MMT was found to be feasible and to significantly reduce pain in the short term when compared with UPT. A future RCT with a six-month follow-up would require approximately 170 patients

Short-term effect on pain and function of neurophysiological education and sensorimotor retraining compared to usual physiotherapy in patients with chronic or recurrent non-specific low back pain : a pilot randomized controlled trial

Background: Non-specific chronic low back pain (NSCLBP) is a major health problem. Identification of subgroups and appropriate treatment regimen was proposed as a key priority by the Cochrane Back Review Group. We developed a multimodal treatment (MMT) for patients with moderate to severe disability and medium risk of poor outcome. MMT includes a) neurophysiological education on the perception of pain to decrease self-limitation due to catastrophizing believes about the nature of NSCLBP, b) sensory training of the lower trunk because these patients predominantly show poor sensory acuity of the trunk, and c) motor training to regain definite movement control of the trunk. A pilot study was conducted to investigate the feasibility of MMT, prior to a larger RCT, with focus on patients’ adherence and the evaluation of short-term effects on pain and disability of MMT when compared to usual physiotherapy. Method: We conducted a randomised controlled trial (RCT) in a primary care physiotherapy centre in Switzerland. Outcome assessment was 12 weeks after baseline. Patients with NSCLBP, considerable disability (five or more points on the Roland and Morris Disability Questionnaire (RMDQ) and medium or high risk of poor outcome on the Keele Start Back Tool (KSBT) were randomly allocated to either MMT or usual physiotherapy treatment (UPT) by an independent research assistant. Treatment included up to 16 sessions over 8 to 12 weeks. Both groups were given additional home training of 10 to 30 minutes to be performed five times per week. Adherence to treatment was evaluated in order to assess the feasibility of the treatment. Assessments were conducted by an independent blinded person. The primary outcome was pain (NRS 0-10) and the secondary outcome was disability (RMDQ). Between-group effects with Student’s t-test or the Mann-Whitney U test and the standardized mean difference of the primary outcome were calculated. Results: Twenty-eight patients (46% male, mean age 41.5 years (SD 10.6)) were randomized to MMT (n = 14) or UPT (n = 14). Patients’ adherence to treatment was >80% in both groups. Pain reduction (NRS; [95% CI]) was 2.14 [1.0 to 3.5] in the MMT and 0.69 [-2.0 to 2.5.] in the UPT. The between-group difference was 1.45 [0.0 to 4.0] (p = 0.03), representing a moderate effect size of 0.66 [-0.1 to 1.5]. Reduction in disability on the RMDQ was 6.71 [4.2 to 9.3] in MMT and 4.69 [1.9 to 7.4] in UPT, with a non-significant between-group difference of 2.02 [-1.5 to 5.6] (p = 0.25). The required sample size for a RCT with six months follow-up was estimated at 170 patients. Conclusions: MMT was found to be feasible and to significantly reduce pain in the short term when compared with UPT. A future RCT with a six-month follow-up would require approximately 170 patients

Standardized, comprehensive, hospital-based circuit training in people with multiple sclerosis (MS-FIT): Results on feasibility, adherence and satisfaction of the training intervention.

Background: We developed a standardized, comprehensive, ambulatory, hospital-based neurorehabilitation program ("MS-Fit") to improve disability, activities of daily living and quality of life in people with multiple sclerosis (PwMS). Aim: To assess feasibility, adherence and satisfaction of the training intervention. Design: Prospective multi-center cohort study analysis. Population: PwMS, aged 18 to 75 years, complaining about multiple sclerosis-related disability affecting activities of daily living and/or quality of life. Methods: A standardized, ambulatory, hospital-based circuit training consisting of six workstations (aerobic exercise training, strength upper limbs, balance, manual dexterity, reactivity, strength and flexibility lower limbs) was performed two hours, twice weekly, for two months in groups of two to six participants supervised by experienced physiotherapists. Physiotherapists adapted the type and intensity of training according to the participants' individual performance using a training booklet. Program satisfaction and adherence were evaluated using a questionnaire and the attendance rate (clinicaltrials.gov Identifier: NCT02440516). Results: 55 participants started (mean age 52.82 years +/- 10.68 standard deviation, range 29-74; 69% female; median Expanded Disability Status Scale 3.5, range 1.0-7.0) and 49 (89%) finished the training program. Main reasons to drop out during the training were lack of time, travel problems, social issues or uthoff's phenomenon during the summer. All participants finalizing the training achieved >80% (mean 92.26%, ±7.59) attendance rate and sent back the questionnaire. Overall participant's satisfaction was high with a median of 9 points (range 4-10) on a Likert scale from 0-10. Program quality was rated "good" with an overall median score of 39/50 points (range 26-50) and 95% of the participants would recommend the program to others. Conclusions: MS-Fit is a feasible training program with high patient satisfaction and adherence. It enables high intensity ambulatory training and can be easily reproduced due to its standardized nature. Clinical rehabilitation impact: MS-FIT enables a standardized ambulatory high intensity training that is easily reproducible. Participants benefit from group training and from individual adaption of the training through professional supervision

Ein Hungerstreik ist eine Protesthandlung: Zwangsernährung widerspricht dem ärztlichen Berufsethos – welche Aufgabe haben Ärzte und Pflegefachkräfte?

Im August dieses Jahres entschied das Bundesgericht, dass «die Strafvollzugsbehörde eine Zwangsernährung anordnen muss, wenn dies der einzige weg ist, irreversible Schäden oder den Tod des Gefangenen zu vermeiden». Damit rücken die Gesundheitsdienste der Gefängnisse in den Blickpunkt der Öffentlichkeit, die eine solche Anordnung gegebenenfalls auszuführen hätten. Diese Konstellation steht im Widerspruch zu den Grundwerten der medizinischen Ethik. Der Respekt der Autonomie eines urteilsfähigen Patienten, der mit einem Hungerstreik gegen seine Lage protestiert, muss ein zentrales Anliegen der Ärzte und pflegenden bleiben. Die Unabhängigkeit der Ärzte und pflegenden, die Respektierung der Standesregeln, die Garantie der Vertraulichkeit und das Recht auf Verweigerung medizinischer Handlungen aus Gewissensgründen gewährleisten den Schutz dieser ethischen Grundwerte; und diese Grundwerte sind für die Ausübung der medizinischen Tätigkeit im Gefängnis – wie auch in allen anderen Einrichtungen, in denen Menschen medizinisch betreut werden – unabdingbar

Floral isolation, specialized pollination, and pollinator behavior in orchids

Floral isolation is a form of prepollination reproductive isolation mediated by floral morphology (morphological isolation) and pollinator behavior (ethological isolation). Here we review mechanisms and evolutionary consequences of floral isolation in various pollination systems. Furthermore, we compare key features of floral isolation, i.e., pollinator sharing and specialization in pollination, in different orchid pollination systems. In orchid pollination, pollinator sharing is generally low, indicating strong floral isolation. The pollinators' motivation to visit flowers (specifically) can be due to both foraging or reproductive behavior. In both types of behavior, innate preferences for floral signals can be quickly overruled by learning. In pollination systems in which reproductive behavior of pollinators triggers flower visits, lower pollinator sharing was evident compared with systems with foraging behavior, probably because pollinators displaying reproductive behavior show higher fidelity in their visitation patterns. Orchids pollinated through reproductive behavior also use fewer pollinators than orchids pollinated through foraging behavior. No association between specialization and pollinator sharing was found. Thus, generalized pollination does not impede floral isolation, as orchids with many pollinators may nonetheless have low pollinator sharing. Specialization in pollination was, however, linked to orchid species richness in our analysis. Flower size, spur, and column morphology are most important for morphological isolation, and floral scent is most important for ethological isolation. These traits may be based on few genes, implying that floral isolation can be brought about by few genes of large effect