Chronic venous insufficiency--from pathophysiology to therapy. 3: Physical therapy of venous diseases

In patients with chronic venous insufficiency (CVI), stage-oriented physiotherapy can be employed in addition to surgery, drug treatment and sclerotherapy, with both prophylactic and curative intent. Apart from improving the hemodynamic situation, physiotherapy aims in particular to preserve or reactivate the active and passive pump mechanisms of the lower limbs, for example, the calf muscle pump and the ankle pump. Consequently the wide spectrum of physiotherapeutic measures includes such measures as compression therapy, anticongestion positioning, massage and exercise, all of which can be supplemented or replaced, as didacted by the condition prevailing, by hydrotherapy, electrotherapy, balneotherapy or climatic therapy.     

Efficiency and costs of medical exercise therapy, conventional physiotherapy, and self-exercise in patients with chronic low back pain. A pragmatic, randomized, single-blinded, controlled trial with 1-year follow-up

STUDY DESIGN: A multicenter, randomized, single-blinded controlled trial with 1-year follow-up. OBJECTIVES: To evaluate the efficiency of progressively graded medical exercise therapy, conventional physiotherapy, and self-exercise by walking in patients with chronic low back pain. SUMMARY AND BACKGROUND DATA: Varieties of medical exercise therapy and conventional physiotherapy are considered to reduce symptoms, improve function, and decrease sickness absence, but this opinion is controversial. METHODS: Patients with chronic low back pain or radicular pain sick-listed for more than 8 weeks and less than 52 weeks (Sickness Certificate II) were included. The treatment lasted 3 months (36 treatments). Pain intensity, functional ability, patient satisfaction, return to work, number of days on sick leave, and costs were recorded. RESULTS: Of the 208 patients included in this study, 71 were randomly assigned to medical exercise therapy, 67 to conventional physiotherapy, and 70 to self-exercise. Thirty-three (15.8%) patients dropped out during the treatment period. No difference was observed between the medical exercise therapy and conventional physiotherapy groups, but both were significantly better than self-exercise group. Patient satisfaction was highest for medical exercise therapy. Return to work rates were equal for all 3 intervention groups at assessment 15 months after therapy was started, with 123 patients were back to work. In terms of costs for days on sick leave, the medical exercise therapy group saved 906,732 Norwegian Kroner (NOK) ($122,531.00), and the conventional physiotherapy group saved NOK 1,882,560 ($254,200.00), compared with the self-exercise group. CONCLUSIONS: The efficiency of medical exercise therapy and conventional physiotherapy is shown. Leaving patients with chronic low back pain untampered poses a risk of worsening the disability, resulting in longer periods of sick leave.     

Combination of physiotherapeutic exercise therapy with bencyclane in intermittent claudication (author's transl)

Earlier investigations had shown that an intensive physiotherapy program with 30 treatments in 6 weeks was the most rational therapy for intermittent claudication, but the question whether the therapeutic success could be improved by the addition of "vasoactive" substances remained open. For this reason, bencyclane was added to the basic physiotherapy in a double blind trial involving 109 ambulant patients. 91 or these were evaluated. The treatment group (n = 45) showed a greater increase in walking distance of 21.7% compared with the placebo group (n = 46). Also in the evaluation of the therapeutic success rate, the treatment group showed better results (84.4%) than the placebo group (71.7%). From this it can be concluded that the basic physiotherapy can be effectively supported with bencyclane.     

Scabies: case presentation

Long-term outcome after surgical treatment of temporomandibular joint ankylosis is not always satisfactory in children. Interposition of a temporalis muscle flap is insufficient to ensure good functional results if the surgical procedure is not followed by careful active and passive physiotherapy. The results can be evaluated only after the child has grown.     

The diagnosis and medical management of pulmonary parenchymal mycobacterial diseases

Pulmonary mycobacterial infections are an increasing clinical problem. The complex task of isolation and identification of the specific mycobacteria requires special stains, cultures, biochemical testing, and nucleic acid probes. Once the organism has been identified, the therapy with multiple drugs will be dictated by the type of organism and its drug susceptibility. An increasing number of patients presenting with drug-resistant tuberculosis or nontuberculous pulmonary mycobacterial infections require individualized, prolonged multi-drug regimens. The thoracic surgeon must be aware of the subtleties of mycobacterial pulmonary infections because diagnosis and failed medical treatment may require surgical intervention.     

Prevention of respiratory complications after abdominal surgery

Abdominal surgery, especially upper abdominal surgical procedures are known to adversely affect pulmonary function. Pulmonary complications are the most frequent cause of postoperative morbidity and mortality. This review article aimed to analyse the incidence and risk factors for postoperative pulmonary morbidity and their prevention. The most important means for preoperative assessment is the clinical examination; pulmonary function tests (spirometry) are not reliably predictive for postoperative pulmonary complications. Age, type of surgical procedure, smoking and nutritional state have all been identified as potential predictors for postoperative complications. However, usually there is not enough preoperative time available to obtain beneficial effects of stopping smoking and improvement of nutritional state. In patients with COPD, a preoperative multidisciplinary evaluation including the primary care physician, pulmonologist/intensivist, anesthesiologist and surgeon is required. Consensus as to preoperative physiologic state, therapeutic preparation, and postoperative management is essential. Simple spirometry and arterial blood gas analysis are indicated in patients exhibiting symptoms of obstructive airway disease. There are no values that contra-indicate an essential surgical procedure. Smoking should stop at least 8 weeks preoperatively. Preoperative therapy for elective surgery with antibiotics, beta2-agonist, or anticholinergic bronchodilator aerosols, as well as training in cough and lung expansion techniques should begin at least 24 to 48 hours preoperatively. Postoperative therapy should be continued for 3 to 5 days. Usually, anaesthesia is responsible for early complications, whereas surgical procedures are often associated with delayed morbidity. Laparoscopic procedures are recommended, as postoperative morbidity and hospital stay seem reduced in patients without COPD. Regional anaesthesia is given as having less adverse effects on pulmonary function than general anaesthesia. However, for unknown reasons these benefits are not associated with a decrease in postoperative respiratory complications. Moreover, the quality or the type of postoperative analgesia does not influence postoperative respiratory morbidity. Postoperatively, oxygen administration increases SaO2, but cannot abolish desaturation due to obstructive apnea. The various techniques of physiotherapy (chest physiotherapy, incentive spirometry, continuous positive airway pressure breathing) seem to be equivalent in efficacy; but intermittent positive pressure breathing has no advantages, compared with the other treatments and could even be deleterious. Chest physiotherapy and incentive spirometry are the most practical methods available for decreasing secretion contents of airways, whereas continuous positive airway pressure breathing is efficient on atelectasis. In stage II or III COPD patients, admission in a intensive therapy unit and prolonged mechanical ventilation may be required.     

The chronocorrection of disorders in the blood coagulation rhythm with kurantil in patients with decompensated rheumatic heart defects

The circadian pattern of hemocoagulation was studied in patients with decompensated rheumatic heart disease (DRHD) concurrent with stages I-II circulatory failure (CF) during complex treatment or medical treatment with disaggregants. Biorhythmological studies demonstrated that in patients with DRHD and CF chronotherapy with curantyl had some advantages over the traditional therapy during complex drug therapy. In these patients, the chronopatterns of circadian rhythms of hemocoagulative parameters tended to normalize under the influence of curantyl chronotherapy, by diminishing the signs of external desynchronization. Advantages of chronotherapy over the traditional treatment found in patients with DRHD and stages I-II CF, as manifested by its clinical effect in shorter periods (on days 4-5) when small daily and course doses of the drug were used. Based on the biorhythmological studies of hemostatic parameters, a method of curantyl chronotherapy was developed for patients with DRHD and stages I-II CF, which may optimize the therapeutical process in patients with this abnormality.     

Physiotherapy for prevention and treatment of chronic hemophilic synovitis

Hemophilia is a hereditary lifelong bleeding disorder affecting males. The nature of the condition predisposes the person to bleed intraarticularly and intermuscularly. Without intervention with replacement factor therapy and physiotherapy, the consequences can lead to chronic synovitis and severe joint hemarthropathy. Physiotherapeutic interventions are available that may help to prevent and treat the sequelae of recurrent hemarthrosis. No particular method of treatment has been shown to eradicate hemorrhages; however, there are protocols that can help. The use of physiotherapy techniques including electrotherapy, joint care, and exercise are extremely important, especially in developing countries where blood products are scarce.     

Treatment of idiopathic scoliosis in children

This is an update on the surgical and orthopedic management of scoliosis in children. After a review of the biomechanical factors underlying the scoliotic deformity in the three dimensions, methods and indications of conservative treatment combining physiotherapy and full-time or part-time bracing are discussed. Development of new segmental spinal instrumentation devices has modified the surgical treatment of scoliosis by allowing three-dimensional correction of deformities and obviating the need for postoperative immobilization in a cast or corset. Results of conservative treatment are analyzed in an original series of 56 children with progressive scoliosis treated when the angulation was still under 30 degrees. Mean follow-up since the end of treatment is 14 years. Results show that proper conservative treatment arrests progression and modifies the natural history of scoliosis. Outcome after surgical treatment is analyzed in an original and recent series composed of the 50 first children who had posterior surgery with the new Cotrel-Dubousset instrumentation. Results of anterior surgery (V.D.S. instrumentation), which is still indicated in some cases, are analyzed in an older series of 18 cases. When the deformities are too severe to allow conservative treatment, short segment fusion effectively corrects the scoliosis and reliably provides good cosmetic and functional results.     

The "Qualified Detoxification Treatment of Drug Dependent Patients" Federal Model Project in a general hospital: concept, investments and clinical results

For 150,000 drug addicts 5,200 therapy slots are available in Germany. Until the late 80's detoxification treatment was only given a subordinate role in treating drug addicts. Due to the threat of the infectious disease AIDS and the increasing number of drug deaths new concepts were explored: In 1991 the first qualified detoxification ward for drug addicts was opened in a general hospital under the auspices of the Federal German model project "compact therapy for comprehensive drug treatment". Subsequently more than ten detoxification wards specifically for drug addicts were established in Bavaria alone, primarily in psychiatric county hospitals. Drug addicts are accepted into these qualified detoxification wards without preparation and precondition. Data of 1656 drug addicts were analysed who were treated between 1991 and 1996 at the ward described below: More than 70% come directly from the scene and 33% were accepted for the first time to inpatient detoxification treatment. Most of them are diagnosed with addictions to at least two substances (three substances 44%, two substances 24%). Many suffer from additional diseases: In 1079 out of 1656 a positive hepatitis-C serology was found, 22% had previously tried to commit suicide, 37% had to be treated in intensive-care because of life-threatening intoxication. Nevertheless, 58% of the drug addicts are transferred into continuing therapy after detoxification treatment or they continue to work in permanent employment. During detoxification treatment no patient died. Acceptance, additional diseases which can be diagnosed and treated best in a general hospital, and the high prevalence of addicted persons (at least 17-24%) in internal medical or surgical wards suggest that establishing qualified wards with special settings for addicts in general hospital is useful.     

Surgical treatment of endocarditis

Since early investigators first suggested that the treatment of endocarditis should include valve replacement for infections not readily controlled with medical therapy alone, the role of surgery has become expanded, yet refined, to improve the outcome of patients with this potentially fatal disease. Innovative surgical techniques have also been developed in an effort to improve the results of surgical treatment for complex sequelae of invasive infections. This article examines the current indications for surgical intervention, compares the various surgical options, and assesses the expected short-and long-term outcome after valve replacement for patients with native valve or prosthetic valve endocarditis.     

The feasibility of smoking bans on psychiatric units

Cryptococcal meningitis has a high mortality rate of central nervous infection. The patients usually die of the disease itself, or complications from increased intracranial pressure. Early diagnosis and treatment, including surgical drainage, will improve the results. In this series, twenty-one patients with high intracranial pressure (ICP > 300 mmH2 O) are presented. Fourteen received implantation of Ommaya reservoir to aspirate cerebrospinal fluid (CSF) for relief of symptoms of ICP. Meanwhile 4 of these 14 patients also received intraventricular injection of amphotericin B because of poor response to systemic drugs. Another seven patient received systemic drug therapy only. Survival during therapy occurred in 11 of 14 patients in the surgical group, compared with only 1 of 7 patients treated by drug therapy alone (P = 0.019). In the 14 patients who received implantation of an Ommaya reservoir, there was one complication of CSF leakage when the reservoir ruptured because of repeated aspiration. For patients with cryptococcal meningitis with high ICP, early implantation of an Ommaya reservoir will improve the survival rate.     

Outcome of trigger finger treatment in diabetes

Trigger finger is an underdiagnosed hand disorder causing disability in longstanding diabetic patients. Sixty diabetic patients [39 insulin-dependent diabetes mellitus (IDDM) and 21 non-insulin-dependent diabetes mellitus (NIDDM)] and 60 nondiabetic patients were examined. All were initially treated by steroid injections: failure to alleviate symptoms was the indication for surgery. The incidence of multiple digit involvement was higher in IDDM patients as compared with the control group (p < 0.001). The diffuse type was 1.45 times more frequent in IDDM and NIDDM than in nondiabetic patients (p < 0.008). The diabetic patients had a relatively longer duration of symptoms (p < 0.003). Significantly, a higher recovery rate upon steroid injection was achieved in control patients as compared with the diabetic ones (p < 0.001). IDDM patients required more surgery compared with NIDDMs and, in 13.3% of diabetic patients, the surgical outcome was not successful. Diabetic patients should be diagnosed early for multiple and diffuse types of trigger digits. Steroid injection as the first mode of therapy is highly recommended although not always successful. Surgery is the definitive treatment but requires a long course of physiotherapy and may be associated with some complications.     

Alfentanil attenuates the cardiopulmonary response of critically ill patients to an acute increase in oxygen demand induced by chest physiotherapy

Critically ill patients often are subjected to interventions that acutely increase oxygen demand and require increased output of the cardiac and respiratory systems. This study explored whether alfentanil could attenuate the response to chest physical therapy, a procedure that increases oxygen consumption by 40%-50%. Patients were examined during two consecutive therapy sessions. In random order, they received either a placebo or alfentanil (30 or 60 micrograms/kg) 2 min before treatment. In Group 1 (n = 11, 30 micrograms/kg alfentanil) only the arterial blood pressure increases induced by chest physical therapy were attenuated. In Group 2 (n = 12, 60 micrograms/kg) alfentanil attenuated the increases in heart rate, central venous pressure, and pulmonary artery systolic pressures as well as systemic blood pressure. Neither dose of alfentanil altered the increases in oxygen consumption, carbon dioxide elimination, oxygen delivery, or extraction ratio. Thus alfentanil attenuated the hemodynamic responses to chest physiotherapy in a dose-dependent fashion. This was likely due to its vagotonic actions. In contrast, alfentanil had no effect on the balance between oxygen demand and delivery during chest physiotherapy. There was thus a dissociation between the hemodynamic and metabolic responses.     

Liposomes containing boronophenylalanine for boron neutron capture therapy

In the present work, liposomes loaded with Boronophenylalanine (BPA), with or without stabilization, were formulated for the application in boron neutron capture therapy. BPA was encapsulated into liposomes as a complex with fructose, but also as a free drug in two different pH buffers. The influence of critical variables (cholesterol content, drug:lipid molar ratio, osmotic stress of liposomes containing hyperosmotic drug solution) on liposome morphology and drug content was evaluated. The drug content and dissolution profile of different BPA loaded liposomes were also studied. The physical stability of liposomes in terms of changes in the size distribution in different osmotic pressure buffers and the chemical oxidation of phospholipids during storing conditions were investigated. The encapsulation efficiencies of all formulations were always satisfactory, being between 20-48%; even when the liposomes were exposed to high osmotic stress, the particle size was below 200 nm. The BPA-fructose complex loaded liposomes showed a slower drug release profile.     

Uncommon multisystemic involvement in a case of Henoch-Sch?nlein purpura

Patients with critical chronic limb ischaemia may be addressed by different approaches: conservatively with control of risk factors and in some cases also medical treatment, or by amputation, primarily or secondarily, following attempt to revascularise, or treatment may be surgical, either with endovascular or open vascular surgery. The different options are shortly described, with indications and likely results which may be obtained in each case. The paper concludes that no matter what treatment is considered, control of risk factors is of benefit. Patients who, judged by the vascular surgeon, are operable, and who are physically active and without serious medical risk factors, are best treated with open surgical revascularisation. In high risk cases or when inoperable, medical therapy may be an option. Endovascular treatment may be considered in patients with high surgical risk. Primary amputation should be considered in cases where outcome of surgical treatment may be seriously affected by medical risk factors, in cases with progressive ischaemia, in cases where the chances of successful surgery are small or when the patient is in a situation where the benefit of surgery is negligible.     

Bladder dysfunctions in encephalomyelitis disseminata--drug and interventional therapeutic options

Patients with disseminated encephalomyelitis have various urological presentations, ranging from pollakisuria to urge incontinence. After detailed evaluation (neuro-urological examination, urodynamic investigation) drug therapy and various interventional methods must be adapted to the individual manifestations. Patients with detrusor hyperreflexia are treated with oral anticholinergic agents (oxybutynin, trospium chloride, propiverine). Patients with urinary retention are recommended to be managed with clean intermittent (self)-catheterisation. The various interventional therapeutic options (bladder denervation, electrostimulation, local treatment with botulinum toxin) and the surgical therapy (sacral deafferentation and anterior root stimulation, bladder neck closure and cystostomy, sphincterotomy or augmentation cystoplasty) must be reserved for special cases.     

Buerger's disease

Diagnostic criteria and therapeutic strategies for Buerger's disease have been established recently. However, there are many unknown factors concerning its etiology and exacerbation. Further studies are necessary for the better understanding of these factors and it is important to establish therapeutic modalities matching the pathology. Although drug therapy is the basic approach to treatment of the disease, aggressive surgical treatment also can prove to be effective in many cases.     

Current issues in the management of chronic obstructive pulmonary diseases

Chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity and mortality, especially among smokers. Many guidelines that have recently been issued emphasize that COPD is not inaccessible to therapeutic measures: although few interventions are capable of affecting its natural history (i.e. smoking cessation and, in patients with severe resting hypoxaemia, oxygen therapy), several others have a demonstrated effect on symptoms and, thereby, quality of life. The effects of inhaled corticosteroids, and alpha 1-antitrypsin replacement therapy in emphysema due to alpha 1-antitrypsin deficiency are currently being studied. When there is a marked increase in mucus production, chest physiotherapy using controlled expiration and directed cough may be useful. Inhaled bronchodilators are frequently effective on dyspnoea, anticholinergic agents being more suitable for continuous symptoms. Rehabilitation, which includes education and psychosocial care, chest physiotherapy, nutritional care and exercise training, also improves quality of life. When there is persistent severe alveolar hypoventilation despite oxygen therapy, long-term mechanical ventilation may be considered. Surgical options in the treatment of emphysema include resection of giant bullae and lung volume reduction surgery. Lung transplantation should be proposed only in patients with end-stage disease, the difficulty here being to define what 'end-stage' means. Finally, all preventive and some therapeutic interventions are likely to be more effective early in the course of the disease. Thus, efforts should be made to detect airways obstruction early in subjects at risk, such as smokers.     

The management of young adults with cystic fibrosis: 'genes, jeans and genies'

Cystic fibrosis is now an adult disease. The understanding of the basic pathophysiology of this disease has increased considerably over the past decade. This has resulted in effective management protocols and the development of innovative approaches to therapy. Management of young adults is complex and requires expert medical care delivered in a sensitive and appropriate way. The daily treatment schedule for many adults involves physiotherapy; nebulized, oral and i.v. drugs; exercise and nutritional supplements. Adherence to such treatment while living a busy school, work and social life is extremely difficult for patients. The psychological implications of having a disease with very significant morbidity and mortality also has an enormous impact on individuals with CF. Many of these issues have evolved as survival has increased and the next few decades may produce more unexpected 'genies'. These may be from the disease itself or from some of the exciting new treatments currently being developed. It is important that individuals with CF are fully involved in decisions relating to their treatment and that CF teams provide optimal and appropriate care to enable these young adults to enjoy their lives to the fullest extent.