Neurorehabilitation

UvodnikEditoria

Low back pain - from definition to diagnosis

Križobolja predstavlja bol ili nelagodnost koju bolesnik osjeća u području leđa, između rebranih lukova i donje glutealne brazde. Jedan je od najčešćih uzroka traženja liječničke pomoći, drugi je po redu uzrok izostajanja s posla, te je zbog velikih direktnih i indirektnih troškova vrlo važan socijalno-medicinski i ekonomski teret za pojedinca, obitelj i društvo. Klasificira se kao nespecifična, bez poznatog uzroka i kao specifična križobolja, za koju je poznat patomorfološki uzročni čimbenik. U postavljanju dijagnoze važna je iscrpna anamneza i klinički pregled. Proširena dijagnostička obrada potrebna je u slučajevima evidentiranja radikulopatije ili specifične ozbiljne patologije, odnosno nakon evidentiranja rizičnih faktora i simptomatologije crvenih zastava. Također, posebnu pozornost treba obratiti na psihosocijalne čimbenike ili tzv žute zastave, kao na najznačajnije prediktore kroniciteta križobolje te prediktore dugotrajne bolesnikove onesposobljenosti.Low back pain is defined as pain and discomfort, localised below the costal margin and above the inferior gluteal folds, with or without leg pain. It is one of the most commonest cause of seeking physician office visits, secound cause of sick leave, and because of high direct and indirect costs it has great medical, social and economic impact for individual, family and society. Non-specific low back pain is defined as low back pain not attributed to recognisable, known specific pathology and specific low back pain which has known pathomorfological cause. For most patients with low back pain a thorough history taking and clinical examination are suffitient. Extended diagnostic analysis are needed in the case of nerve root pain/radicular pain and serious spinal pathology, respectively after identification of red flags. Moreover, great attention has to be achieved at psychosocial factors or so called yellow flags which increase the risk of developing chronic low back pain and long term disability (including work loss associated with low back pain)

OSTHEOARTHRITIS – EXERCISE AS A DISEASE-MODIFYING DRUG (DMARD)?

Cilj ovog preglednog rada jest predstaviti vježbu kao nefarmakološku metodu liječenja osteoartritisa (OA) kroz preporuke i smjernice dobre kliničke prakse o djelovanju vježbe na bol i funkciju zgloba te odgovoriti na pitanje može li se vježba koristiti u modifikaciji procesa OA. Kroz pregled literature najveći broj smjernica dobre kliničke prakse objavljen je za liječenje OA koljena, kuka i šaka, s obzirom na to da su ove tri zglobne razine s najvećom prevalencijom OA u osoba starije dobi. Opće preporuke za izbor vježbi kod starijih osoba i osoba s kroničnim bolestima s OA su aerobni trening srednjeg intenziteta i progresivni trening snaženja glavnih mišićnih grupa, s visokom učinkovitosti u smanjenju bolnog podražaja i poboljšanja funkcije. Kombinacija dijete i vježbe daje bolje rezultate u učinkovitosti na smanjenje boli i poboljšanje funkcije, nego samo vježba. S obzirom na to da su brojne studije potvrdile postojanje proupalnih citokina u serumu kod bolesnika s OA, dokazano je da vježba pokazuje antiupalni učinak upravo djelujući na medijatore upale. Nadalje, kako je debljina rizični čimbenik za razvoj OA, i dio metaboličkog sindroma, također je dokazano da je vježba najučinkovitija nefarmakološka metoda u liječenju metaboličkog sindroma i debljine, a dijetalnim programom i vježbom zajedno postižemo bolje protuupalne, analgetske i funkcijske učinke, nego dijetom i vježbom pojedinačno. Zaključak. Vježba je ključna metoda nefarmakoloških mjera liječenja OA. I aerobne vježbe i vježbe snaženja su učinkovite u smanjenju bola i poboljšanju funkcije. S obzirom da je OA kronična bolest niskog intenziteta upale, jedan od efekata vježbe koji se u posljednje vrijeme istražuje jest smanjenje razine serumskih proupalnih citokina i povećanje serumskih protuupalnih citokina. No, nažalost, ne postoji velik broj studija koje evaluiraju protuupalne učinke vježbe u OA, a iako su rezultati obećavajući, još uvijek su nedosljedni zbog raznih ograničavajućih faktora u metodologiji studija.The objective of this review is to present evidence-based recommendations and guidelines for exercise as a non-pharmacological management of osteoarthritis (OA), as well as regarding the effects of exercise on pain and function. The review also aims at providing the answer to the question whether exercise might be useful as a disease-modifying anti-rheumatic drug. A literature survey shows that the majority of recommendations were published for knee, hip, and hand OA, because the estimated prevalence of OA in elderly people is the highest in these three joint levels. The general recommendations for the selection of exercises in older people and chronically ill persons with knee OA are aerobic moderate-intensity training and progressive strength training involving the major muscle groups, with high-quality research evidence corroborating pain reduction and improved physical function. A combination of diet and exercise results in less knee pain and better function than each of the methods implemented separately. In view of the fact of multiple studies demonstrating that serum cytokine levels, which are markers of chronic lowgrade inflammation, are elevated in OA, it has been proven that regular exercise has an anti-inflammatory effect on mediators of inflammation. Furthermore, since obesity is known to be a part of metabolic syndrome and a risk factor in the development of OA, it has been established recently that exercise may be considered as the most effective non-pharmacological tool for the treatment of metabolic syndrome and obesity. By introducing a program combining diet and exercise, better anti-inflammatory, analgesic, and functional effects have been achieved than by diet or exercise individually. Conclusion. Exercise is the cornerstone non-pharmacological method in the management of OA. Both aerobic and strengthening exercises have been found to be effective in terms of decreasing pain and improving function. Considering the fact that OA is a chronic low-grade inflammatory disease, one of the recently investigated exercise effects is a decrease of serum pro-inflammatory cytokine levels and an increase of anti-inflammatory cytokines. Unfortunately, due to the absence of a larger number of studies on the anti-inflammatory effects of exercise, the existing results, although promising, may still be inconsistent because of the various limitations in the research methodologies

EVALUATION OF PAIN AND LOCAL PHARMACOLOGICAL PAIN TREATMENT IN RHEUMATOLOGY

U ovome preglednom radu prikazana je metodološka problematika u vezi s velikim brojem raznih alata i upitnika koji se rabe u obradi kronične mišićno-koštane boli kod reumatološkog bolesnika, uz osvrt na lokalno farmakološko liječenje boli. Pouzdana i valjana evaluacija boli baza je ne samo za vođenje kliničkih istraživanja nego i za učinkovito liječenje boli u kliničkoj praksi. Složena priroda boli čini njezino objektivno mjerenje gotovo nemogućim. Evaluacija kronične mišićno- -koštane boli i njezin učinak na fi zičku, emocionalnu i socijalnu funkciju te kvalitetu života iziskuje kvalita tivne multidimenzionalne upitnike i alate. Glavna preporuka, dakle, jest da bi upitnik trebao pokrivati više dimenzija, od evaluacije boli, preko evaluacije umora, poremećaja spavanja, fi zičke funkcije, emocionalne funkcije, bolesnikove procjene općeg zadovoljstva te kvalitete života. Iako je svakodnevno sve veći broj upitnika i publikacija koji se odnose na mjerenje raznih aspekata kronične boli, razina je suglasja istraživača i kliničara niska i još nema unifi ciranog pri stupa navedenom problemu te i nadalje postoji potreba za razvojem novoga, boljeg upitnika i alata za mjerenje boli i praćenje liječenja kronične boli. S obzirom na to da su boli u zglobovima i u mekim tkivima mišićno-koštanog sustava najčešći simptomi u bolesnika s reumatskim bolestima, lokalno farmakološko liječenje boli ima važno mjesto u algoritmima liječenja tih bolesti. Lijek se aplicira topički preko kože ili injicira u bolno mjesto, s kontrolom mišićno-koštanog ultrazvuka ili bez nje. Lijekovi koji se najčešće rabe i pokazuju učinkovitost potvrđenu dokazima dobre kliničke prakse jesu NSAR i korti kosteroidi.Th e objective of this review is to present outcome measurement tools for chronic musculoskeletal pain in rheumatology patients and to provide an overview of local pharmacological pain treatment. Reliable and valid assessment of pain is fundamental for both clinical trials and eff ective pain management. Th e complex nature of pain makes objective measurement impossible. Evaluation of chronic musculoskeletal pain and its impact on physical, emotional, and social functions requires multidimensional qualitative tools and health-related quality of life instruments. Th e main recommendation concerning outcome measurements of pain is that they should include an evaluation of pain, fatigue, disturbed sleep, physical functioning, emotional functioning, and patient global ratings of satisfaction and quality of life. Despite the growing fi eld of new instruments and publications related to measuring the various aspects of chronic pain, there is still little agreement on the topic among researchers and clinical experts and no unifi ed approach has been adopted. Th ere is still considerable need for the development of a core set of measurement tools and response criteria regarding chronic pain management. It is well known that pain in articular joints and soft tissues of the musculoskeletal system represents the most common symptom presenting to rheumatologists. Th erefore, local pharmacological pain tretment has an important role in rheumatology treatment algorithms. Topical administration, as well as injection administration in joints and soft tissue trigger points, can be done under the control of musculoskeletal ultrasound. Th e most frequently prescribed drugs include NSARs and corticosteroids, with their eff ectiveness being well-proven in evidence-based practice

Neurorehabilitation

UvodnikEditoria

Neurorehabilitation robotics: past, present, future

Robotika u neurorehabilitaciji osoba nakon moždanog udara ima svoje mjesto u rehabilitacijskom protokolu. Iako postoje različiti dizajni i vrste robota, dvije su osnovne grupe: egzoskeletni roboti, te roboti koji aktiviraju distalni, krajnji dio uda (od engl. end-effector robot). Obje vrste robota koriste se za rehabilitaciju hemiparetične ruke, te za rehabilitaciju hoda kod hemiparetične noge i oštećenja ravnoteže. Glavni cilj je robotom usmjerena vježba dostizanja zadataka sa stalnim povećanjem intenziteta i broja ponavljanja. Bolesnici koji provode terapiju robotom u kombinaciji s fizioterapijom imaju bolji motorički i funkcijski ishod nego bolesnici koji provode samo fizioterapiju. Nadalje, bolesnici u subakutnoj fazi imaju veću korist od bolesnika u kroničnoj fazi neurološkog oštećenja, kao što i bolesnici koji imaju težu hemiparezu imaju bolje krajnje rezultate terapije robotom nego bolesnici koji imaju blažu hemiparezu. Usporedbom egzoskeletnog i end-efektornog robota nisu se pronašle razlike u krajnjoj učinkovitosti.Robotics in brain stroke neurorehabilitation is used as a constituent part of rehabilitation protocols. The diverse robotic devices can be parsed into two broad categories: the „exoskeletal“ and „end-effector“ robotic design. Both robotic devices can be used in hemiparetic hand rehabilitation, as well as in hemiparetic gait rehabilitation and balance impairment. The main rehabilitation goal is task-oriented accompanied by the intensify-matched exercise. Patients who conduct robotics therapy, in combination with physiotherapy, have a significant increase in motoric and functional outcome as compared to the patients who undergo conventional physiotherapy alone. Furthermore, the patients in subacute phase have greater benefit from robotics than chronic brain stroke patients. In addition, patients who are non-ambulatory at intervention onset may benefit more, but ambulatory patients may not benefit from this type of training. The role of the type of device (exoskeletal vs. end-effector) is still not clear