Zusammenfassung Dieses gemeinsame Positionspapier der 3 Fachgesellschaften Bundesarbeitsgemeinschaft der Akutkrankenh?user mit Abteilungen f?r fach?bergreifende Fr?hrehabilitation (BAG Fr?hrehabilitation), Berufsverband der Rehabilitations?rzte Deutschlands (BVPRM) und Deutsche Gesellschaft f?r Physikalische Medizin und Rehabilitation (DGPMR) stellt den aktuellen Stand, die Perspektiven und notwendige Ma?nahmen zur Weiterentwicklung der fach?bergreifenden Fr?hrehabilitation dar. Fr?hrehabilitation ist die fr?hestm?glich einsetzende Therapie in Kombination aus akutmedizinischer und rehabilitationsmedizinischer Behandlung. Fr?hrehabilitation ist dabei als erstes Glied einer nahtlosen Rehabilitationskette zu verstehen, gleichzeitig integraler und gesetzlich geforderter Bestandteil der Krankenhausbehandlung. Die Notwendigkeit und die Bedeutung der Fr?hrehabilitation steigen durch die demografische und die medizinisch-technische Entwicklung. Internationale Richtlinien (WHO, EU) und die nationale Gesetzgebung begr?nden ein Recht auf Fr?hrehabilitation. Das Positionspapier grenzt die fach?bergreifende Fr?hrehabilitation von der Fr?hmobilisation und der postakuten Rehabilitation ab. Ferner erfolgt die Einordnung in den Kontext weiterer Formen der Fr?hrehabilitation. Die verschiedenen Arten der Leistungserbringung, im Besonderen die bettenf?hrenden Fr?hrehabilitationsstationen (Acute Rehabilitation Units) und die Behandlung durch ein dezentrales Fr?hrehabilitationsteam (Acute Rehabilitation Team), werden dargestellt. Ziele und Aufgaben sowie strukturelle und prozessuale Voraussetzungen werden definiert. Typische Indikationen werden synoptisch dargestellt und sowohl Indikationskriterien als auch Ausschlusskriterien f?r die Indikationsstellung zur Fr?hrehabilitation daraus abgeleitet. Die Versorgungsstruktur in Deutschland und regionale Unterschiede werden analysiert und Bedarfssch?tzungen gegen?bergestellt. Aus ?konomischer Sicht wird das Finanzierungssystem der Fr?hrehabilitation im DRG-System diskutiert, das den Ressourcenaufwand derzeit nur inad?quat abbildet. Auf der Grundlage dieser Analysen werden grunds?tzliche Forderungen abgeleitet und ein Katalog konkreter Ma?nahmen zur Weiterentwicklung der Fr?hrehabilitation vorgelegt. Bereits vorhandene Ans?tze der Fr?hrehabilitation im Akutkrankenhaus sollen gest?rkt werden. Gesetzliche Vorgaben sollen umgesetzt und eine fach?bergreifende, bedarfsgerechte Versorgung mit Leistungen der Fr?hrehabilitation sichergestellt werden.
Background: Reduced exercise capacity in patients with heart failure (HF) could be partially explained by skeletal muscle dysfunction. We compared skeletal muscle function, structure, and metabolism among clinically stable outpatients with HF with preserved ejection fraction, HF with reduced ejection fraction, and healthy controls (HC). Furthermore, the molecular, metabolic, and clinical profile of patients with reduced muscle endurance was described. Methods: Fifty-five participants were recruited prospectively at the University Hospital Jena (17 HF with preserved ejection fraction, 18 HF with reduced ejection fraction, and 20 HC). All participants underwent echocardiography, cardiopulmonary exercise testing, 6-minute walking test, isokinetic muscle function, and skeletal muscle biopsies. Expression levels of fatty acid oxidation, glucose metabolism, atrophy genes, and proteins as well as inflammatory biomarkers were assessed. Mitochondria were evaluated using electron microscopy. Results: Patients with HF with preserved ejection fraction showed compared with HF with reduced ejection fraction and HC reduced muscle strength (eccentric extension: 13.3±5.0 versus 18.0±5.9 versus 17.9±5.1 Nm/kg, P =0.04), elevated levels of MSTN-2 (myostatin-2), FBXO-32 (F-box only protein 32 [Atrogin1]) gene and protein, and smaller mitochondrial size ( P <0.05). Mitochondrial function and fatty acid and glucose metabolism were impaired in HF-patients compared with HC ( P <0.05). In a multiple regression analysis, GDF-15 (growth and differentiation factor 15), CPT1B (carnitine palmitoyltransferase IB)-protein and oral anticoagulation were independent factors for predicting reduced muscle endurance after adjusting for age (log10 GDF-15 [pg/mL] [B, −54.3 (95% CI, −106 to −2.00), P =0.043], log10 CPT1B per fold increase [B, 49.3 (95% CI, 1.90–96.77), P =0.042]; oral anticoagulation present [B, 44.8 (95% CI, 27.90–61.78), P <0.001]). Conclusions: Patients with HF with preserved ejection fraction have worse muscle function and predominant muscle atrophy compared with those with HF with reduced ejection fraction and HC. Inflammatory biomarkers, fatty acid oxidation, and oral anticoagulation were independent factors for predicting reduced muscle endurance.
BackgroundWalking disabilities negatively affect inclusion in society and quality of life and increase the risk for secondary complications. It has been shown that external feedback applied by therapists and/or robotic training devices enables individuals with gait abnormalities to consciously normalize their gait pattern. However, little is known about the effects of a technically-assisted over ground feedback therapy. The aim of this study was to assess whether automatic real-time feedback provided by a shoe-mounted inertial-sensor-based gait therapy system is feasible in individuals with gait impairments after incomplete spinal cord injury (iSCI), stroke and in the elderly.MethodsIn a non-controlled proof-of-concept study, feedback by tablet computer-generated verbalized instructions was given to individuals with iSCI, stroke and old age for normalization of an individually selected gait parameter (stride length, stance or swing duration, or foot-to-ground angle). The training phase consisted of 3 consecutive visits. Four weeks post training a follow-up visit was performed. Visits started with an initial gait analysis (iGA) without feedback, followed by 5 feedback training sessions of 2–3 min and a gait analysis at the end. A universal evaluation and FB scheme based on equidistant levels of deviations from the mean normal value (1 level = 1 standard deviation (SD) of the physiological reference for the feedback parameter) was used for assessment of gait quality as well as for automated adaptation of training difficulty. Overall changes in level over iGAs were detected using a Friedman’s Test. Post-hoc testing was achieved with paired Wilcoxon Tests. The users’ satisfaction was assessed by a customized questionnaire.ResultsFifteen individuals with iSCI, 11 after stroke and 15 elderly completed the training. The average level at iGA significantly decreased over the visits in all groups (Friedman’s test, p < 0.0001), with the biggest decrease between the first and second training visit (4.78 ± 2.84 to 3.02 ± 2.43, p < 0.0001, paired Wilcoxon test). Overall, users rated the system’s usability and its therapeutic effect as positive.ConclusionsMobile, real-time, verbalized feedback is feasible and results in a normalization of the feedback gait parameter. The results form a first basis for using real-time feedback in task-specific motor rehabilitation programs.Trial registrationDRKS00011853, retrospectively registered on 2017/03/23.Electronic supplementary materialThe online version of this article (10.1186/s12984-018-0389-4) contains supplementary material, which is available to authorized users.
Background: The antisense oligonucleotide Nusinersen recently became the first approved drug against spinal muscular atrophy (SMA). It was approved for all ages, albeit the clinical trials were conducted exclusively on children. Hence, clinical data on adults being treated with Nusinersen is scarce. In this case series, we report on drug application, organizational demands, and preliminary effects during the first 10 months of treatment with Nusinersen in seven adult patients. Methods: All patients received intrathecal injections with Nusinersen. In cases with severe spinal deformities, we performed computed tomography (CT)-guided applications. We conducted a total of 40 administrations of Nusinersen. We evaluated the patients with motor, pulmonary, and laboratory assessments, and tracked patient-reported outcome. Results: Intrathecal administration of Nusinersen was successful in most patients, even though access to the lumbar intrathecal space in adults with SMA is often challenging. No severe adverse events occurred. Six of the seven patients reported stabilization of motor function or reduction in symptom severity. The changes in the assessed scores did not reach a significant level within this short time period. Conclusions: Treating adult SMA patients with Nusinersen is feasible and most patients consider it beneficial. It demands a complex organizational and interdisciplinary effort. Due to the slowly decreasing motor functions in adult SMA patients, long observation phases for this recently approved treatment are needed to allow conclusions about effectiveness of Nusinersen in adults.
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