Pain in patients attending outpatient rehabilitation: results of a pilot study

The aim of the study was to investigate pain occurrence, characteristics and correlations in an outpatient rehabilitation setting. This was an observational pilot study. The setting was an outpatient rehabilitation facility. The subjects included all patients attending physiotherapy in the week 25th to 29th September 2010 and the interventions were made using self-administered questionnaire. Ongoing pain was assessed by a yes-no question, pain intensity by a numeric rating scale (NRS) ranging 0-10. Pain-related medication was investigated, along with pain characteristics, patient treatment expectations, life satisfaction, and catastrophism. Of the 201 patients, 12 were excluded and 189 enrolled (age 63.6 ± 15.6; 70.4% women). Pain (mean NRS = 5.6 ± 2.4) was reported by 60.9% patients (66% orthopedic and 40% neurological). In 87.8% cases, pain was chronic (>6 months). According to patients reporting pain, the main objectives of treatment were both pain relief and functional recovery for 51%; pain relief for 24.9%; functional recovery for 22.8%. Low treatment expectations were reported by 15.3% patients; catastrophism by 40.7%; 28.6% patients were on pain medication: use of drugs was related to age (p = 0.005), pain intensity (p = 0.009) and catastrophism (p = 0.0003). In a multivariate analysis, pain was independently correlated with an orthopedic versus neurological diagnosis (p = 0.000), and with reduced treatment expectations (p = 0.020), while independent of age (p = 0.74) gender (p = 0.22), and catastrophism (0.17). A high prevalence of pain was observed in outpatients undergoing rehabilitation. Pain was chronic in most cases. Pain relief was the most desired treatment outcome by patients reporting pain. Pain complaint was independently correlated to orthopedic vs neurological diagnosis and to reduced treatment expectations.

CO2 laser vaporization for the treatment of vaginal intraepithelial neoplasia: effectiveness and predictive factors for recurrence

OBJECTIVE

To evaluate the outcome of vaginal intraepithelial neoplasia (VaIN) treatment with CO2 laser vaporization in terms of local recurrence and progression to vaginal carcinoma. Additionally, the authors investigated the predictive factors for first recurrence.

MATERIALS AND METHODS

The medical records of all patients treated for VaIN with CO2 laser vaporization at Sant'Anna Hospital in Turin (1995-2012), were retrospectively reviewed. A univariate logistic model was applied to evaluate selected clinical features as predictive factors for recurrence. A multivariate logistic regression analysis was then carried out including significant risk factors after univariate analysis (p < 0.05).

RESULTS

The analysis included 285 out of 302 patients. Seventy-one (25%) women relapsed; of these 24 VaIN 1 (22%), 37 VaIN 2 (27%), and ten VaIN 3 (26%). The median time to the first recurrence was 5.2 months (1.4-127.8) for VaIN 1, 6.6 months (1-85.2) for VaIN 2, and 3.6 months (1.2-62) for VaIN 3. Sixty-one out of 71 patients were retreated with CO2 laser vaporization. At the last follow-up visit, 273 (96%) women were free from VaIN. No patients progressed to vaginal carcinoma. The multivariate model showed a higher risk of VaIN recurrence in the case of previous hysterectomy (HR 3.3, 95% CI 1.7-6.3, p < 0.001) and concomitant H-SIL on the Pap smear (HR 1.9, 95% CI 1.2-3.1, p = 0.008).

CONCLUSION

CO2 laser vaporization is an effective low impact treatment for VaIN. Despite this, VaIN recur, in particular in cases of previous hysterectomy and concomitant H-SIL on the Pap smear. An intensive follow-up is proposed for women with a high risk of VaIN relapse.

Mediterranean diet and health status: an updated meta-analysis and a proposal for a literature-based adherence score

OBJECTIVE

To update previous meta-analyses of cohort studies that investigated the association between the Mediterranean diet and health status and to utilize data coming from all of the cohort studies for proposing a literature-based adherence score to the Mediterranean diet.

DESIGN

We conducted a comprehensive literature search through all electronic databases up to June 2013.

SETTING

Cohort prospective studies investigating adherence to the Mediterranean diet and health outcomes. Cut-off values of food groups used to compute the adherence score were obtained.

SUBJECTS

The updated search was performed in an overall population of 4 172 412 subjects, with eighteen recent studies that were not present in the previous meta-analyses.

RESULTS

A 2-point increase in adherence score to the Mediterranean diet was reported to determine an 8 % reduction of overall mortality (relative risk = 0·92; 95 % CI 0·91, 0·93), a 10 % reduced risk of CVD (relative risk = 0·90; 95 % CI 0·87, 0·92) and a 4 % reduction of neoplastic disease (relative risk = 0·96; 95 % CI 0·95, 0·97). We utilized data coming from all cohort studies available in the literature for proposing a literature-based adherence score. Such a score ranges from 0 (minimal adherence) to 18 (maximal adherence) points and includes three different categories of consumption for each food group composing the Mediterranean diet.

CONCLUSIONS

The Mediterranean diet was found to be a healthy dietary pattern in terms of morbidity and mortality. By using data from the cohort studies we proposed a literature-based adherence score that can represent an easy tool for the estimation of adherence to the Mediterranean diet also at the individual level.

Alterations of haemorheological parameters in patients with peripheral arterial disease

Peripheral arterial disease (PAD), is a common manifestation of systemic atherosclerosis. Advances on the development of such vascular disease have described with a number of novel risk factors. Hyperviscosity, due to alterations of blood cells and plasma components, may play a role on the pathogenesis of the disease. Aim of this study was to evaluate the possible association between hemorheological variables and PAD. The hemorheological variables [whole blood viscosity (WBV), erythrocyte deformability index (DI), plasma viscosity (PLV)] were analyzed in 90 patients and in 180 healthy subjects. WBV and PLV were measured by a Rotational Viscosimeter and DI by a filtrometer. DI and PLV were significantly different in patients as compared to controls. To investigate the possible association between these parameters and the disease we divided the study population into tertiles. At the univariate analysis, we found a significant association between the highest tertiles of PLV, of DI and the disease. A model adjusted for traditional risk factors showed an association between highest tertiles of PLV and PAD. After adjustment for confounding parameters highest tertiles of PLV remained to be significantly associated with the disease. Our data indicate that an alteration of plasma viscosity may modulate the predisposition to PAD.

Predictors of response to exercise therapy for chronic low back pain: result of a prospective study with one year follow-up

BACKGROUND

Low back pain (LBP) management is a critical public health issue in all developed countries. Most approaches show evidence of effects only in the short term.

AIM

To identify predictors of functional outcome on discharge and at 1 year.

DESIGN

Prospective cohort study.

SETTING

Outpatient rehabilitation department.

POPULATION

Patients aged >18 addressed to exercise therapy for persisting LBP.

METHODS

The individually designed physiotherapy program provided 7 sessions (45'); patients were given advice to stay active and continue exercise program on discharge. Baseline (T0) assessment included: age, sex, time since onset, pain-related drug use, previous treatments, job, physical activity, pain (NRS) and Mental Health (SF36 sub-score); at follow-up (T2), we also enquired to on adherence to exercise prescription, physical activity, drugs. The primary outcome measure was the Roland and Morris Disability Questionnaire (RMDQ) patients scoring improvement >30% (minimal clinical important difference) were classified as respondent.

RESULTS

211 completed follow-up (70% women; age 70.4±11.9). Average RMDQ score was reduced by 35% at T1 and by 31% at T2; NRS by 28% (T1) and 24% (T2); 125 patients (59%) were responders on discharge; 106 (50%) at follow-up. Only higher baseline NRS predicted poor response to treatment at T1 (OR=0.83, 95% CI: 0.71-0.95, P=0.012)). At T2, older age (OR=0.94, 95% CI: 0.91-0.98, P=0.003), drug use (OR=0.18, 95% CI: 0.08-4,69, P<0.001) and previous treatments (OR 0.33, 95% CI: 0.15 to 0.71, P=0.004) were significantly associated with poor response, while, baseline mental health (OR=1.1, 95% CI: 1.01-1.24, P=0.02) and adherence to exercises for LBP (OR=2.10, 95% CI: 1.03-4.42, P=0.04) predicted improved outcome.

CONCLUSIONS

The individually designed exercise therapy program for chronic LBP was associated to clinically significant functional improvement both on discharge and at 1 year. Only severe pain intensity predicted poor treatment response on discharge. At one year, younger age and better mental health predicted improved outcome, while use of drugs and previous LBP treatments were associated with worse response. Adherence to the exercise program almost doubled the probability of a favorable outcome.

CLINICAL REHABILITATION IMPACT

Adherence to an extensive individually designed exercise therapy program improves long term functional outcome of chronic low back pain.

Higher uric acid levels are associated with better functional recovery in elderly patients receiving cardiac rehabilitation

BACKGROUND AND AIMS

Whether uric acid (UA) serves as risk factor for cardiovascular diseases or as antioxidant defense has not yet been completely clarified. In this study we investigated the effects of UA on functional recovery in patients receiving cardiac rehabilitation.

METHODS AND RESULTS

306 patients, 209 men and 97 women, age range 25-87 years (mean 68 ± 11), performed the 6-min walk test (6mWT) before and after the rehabilitation, and the increase in walking distance was considered as the outcome measure of the study. Baseline UA serum levels ranged from 1.0 to 10.9 mg/dL (mean 5.2 ± 1.7). As there was a significant (p = 0.005) age*UA levels interaction, patients were divided into two subgroups, less then 65 years (n. 103, 68 men and 35 women, mean age 56 ± 9) and 65 years or more (n. 203, 141 men and 62 women, mean age 74 ± 5). After adjusting for relevant confounders, higher UA levels remained independent positive predictors of the increase in walking distance in older (p < 0.001) but not in younger patients (p = 0.807).

CONCLUSIONS

Our findings show an independent association of higher UA levels with better functional recovery after cardiac rehabilitation selectively in elderly patients, suggesting that higher UA levels might reflect the decline in antioxidant defenses that occurs with advancing age. Future studies aimed at understanding the several contradictions concerning UA should, probably, address the issue within this perspective.

The Mugello study, a survey of nonagenarians living in Tuscany: design, methods and participants' general characteristics

BACKGROUND

Previous studies on nonagenarians have widely investigated functional and cognitive decline, falls, predictors of mortality, inflammation and aging genetics. However, some intriguing domains, such as body composition, daily energy expenditure, sleep quality and physical activity, as well as endothelial progenitor cells and "omics" fields, such as proteomics or metabolomics, have been poorly explored. In this preliminary paper we report design, methods and characteristics of participants in the Mugello Study, a survey of nonagenarians aimed at filling these gaps.

METHODS

475 non selected nonagenarians, 130 men and 345 women, mean age 92.6 years ± SD 2.6, received a visit by a trained physician at their residence. Along with the assessment of social, functional and cognitive status, reported in this paper, participants also underwent instrumental examinations, including body impedance assessment and continuous direct calorimetry, and were administered a series of validated questionnaires. Further, 385 participants accepted to undergo blood withdrawal.

RESULTS

In 52 cases the visit was conducted in nursing homes. Among the 423 home-living participants, 91 lived alone and 77 were not looked after by any caregiver. Altogether, 154 participants over 475 were free from disabilities and 266 showed Mini Mental State Examination raw scores ≥ 21. Men showed less disability and cognitive impairment (p<0.001, for both).

CONCLUSIONS

As a whole, our findings are comparable to those reported in other surveys. Future studies, by using the Mugello Study database and biologic bank, that will be available to all researchers, will shed some more light on the aging process in nonagenarians.

Effects of a structured physical activity intervention on measures of physical performance in frail elderly patients after cardiac rehabilitation: a pilot study with 1-year follow-up

The objective of this prospective randomized controlled study was to compare the long-term effects of a structured physical activity intervention with those of aerobic exercises alone, in a cohort of elderly patients who had undergone elective cardiac surgery, and who were classified as frail at the end of rehabilitation based on their Short Physical Performance Battery (SPPB) score. At the end of rehabilitation, 140 frail elderly patients were randomly allocated either to the intervention group (IG) or to the control group (CG). CG participants received the usual aerobic exercise prescription, while IG participants were also taught additional exercises for strength, flexibility, balance and coordination. The improvement in SPPB score after 1 year was the outcome of the study. IG showed a significant improvement in SPPB score (9.0 ± 1.1 vs. 7.7 ± 1.4, p < 0.001), while no significant change was found in CG (7.7 ± 1.6 vs. 7.6 ± 1.5, p = 0.252). IG also showed a significantly higher proportion of participants who improved their SPPB score of at least 1 point (70 vs. 37%, p < 0.001). In conclusions, our structured physical activity intervention significantly improves the SPPB score in frail elderly patients who have undergone elective cardiac surgery. An intervention that improves the SPPB score might delay the occurrence of mobility disability.

Mediterranean diet and health

Over the last decades, a considerable body of evidence supported the hypothesis that diet and dietary factors play a relevant role in the occurrence of diseases. To date, all the major scientific associations as well as the World Health Organization and the nonscientific organizations place an ever-increasing emphasis on the role of diet in preventing noncommunicable diseases. Many studies have evaluated the associations between food groups, foods, or nutrients and chronic diseases, and a consensus about the role of nutritional factors in the etiology of common diseases, such as cardiovascular and neoplastic diseases, has gradually emerged. Indeed, data from analytical and experimental studies indicated a relation between increased consumption of some food categories such as fruits and vegetables, fiber and whole grains, fish, and moderate consumption of alcohol and reduced risk of major chronic degenerative diseases, whereas increased total caloric intake, body weight, meat, and fats are associated with greater risk. However, the appropriate dietary strategy to prevent chronic degenerative diseases remains a challenging and a highly relevant issue. Recently, Mediterranean diet has been extensively reported to be associated with a favorable health outcome and a better quality of life. In the present review, we encompass the updated evidence of the beneficial effects of Mediterranean diet in the occurrence of major chronic degenerative diseases.

[Clinical profiling of a complex, asyntomatic patient beyond the standard assessment of cardiovascular risk]

The multi-dimensional evaluation of an elderly hypertensive subject, asyntomatic yet complex, evidences the need for a clinical assessment going beyond the limits of the traditional analysis of cardiovascular risk. The case here described provides a reasoned guide for the integration of all risk elements and factors in the global definition of the risk profile of an individual in primary prevention, and only apparently at moderate cardiovascular risk.

Predictors of functional outcome in patients with chronic low back pain undergoing back school, individual physiotherapy or spinal manipulation

BACKGROUND

Recent studies on chronic low back pain (cLBP) rehabilitation suggest that predictors of treatment outcome may be differ according to the considered conservative treatment.

AIM

To identify predictors of response to back school (BS), individual physiotherapy (IP) or spinal manipulation (SM) for cLBP.

POPULATION

outpatients with cLBP.

SETTING

Outpatient rehabilitation department.

DESIGN

Retrospective analysis from a randomized trial.

METHODS

Two hundred and ten patients with cLBP were randomly assigned to either BS, IP or SM; the Roland Morris Disability Questionnaire (RM) was assessed before and after treatment: those who decreased their RM score <2.5 were considered non-responders. Baseline potential predictors of outcome included demographics, general and cLBP history, life satisfaction.

RESULTS

Of the 205 patients who completed treatment (140/205 women, age 58+14 years), non-responders were 72 (34.2%). SM showed the highest functional improvement and the lowest non-response rate. In a multivariable logistic regression, lower baseline RM score (OR 0.82, 95% CI 0.76-0.89, P<0.001) and received treatment (OR 0.32, 95% CI 0.21-0.50, P<0.001) were independent predictors of non-response. Being in the lowest tertile of baseline RM score (<6) predicted non response to treatment for BS and IP, but not for SM (same risk for all tertiles).

CONCLUSIONS

In our patients with cLBP lower baseline pain-related disability predicted non-response to physiotherapy, but not to spinal manipulation.

CLINICAL REHABILITATION IMPACT

Our results suggest that, independent form other characteristics, patients with cLBP and low pain-related disability should first consider spinal manipulation as a conservative treatment.

Insomnia and risk of cardiovascular disease: a meta-analysis

OBJECTIVE

Increasing evidence suggests an association between insomnia and cardiovascular disease. We performed a systematic review with meta-analysis of all the available prospective studies that investigated the association between insomnia and risk of developing and/or dying from cardiovascular disease.

DESIGN

Systematic review and meta-analysis of prospective cohort studies.

METHODS

We conducted an electronic literature search through MedLine, Embase, Google Scholar, Web of Science, The Cochrane Library and bibliographies of retrieved articles up to December 2011. Studies were included if they were prospective, had assessment of insomnia or sleep complaints at baseline, evaluated subjects free of cardiovascular disease at baseline and measured the association between insomnia and risk of developing and/or dying from cardiovascular disease.

RESULTS

After the review process 13 prospective studies were included in the final analysis. These studies included 122,501 subjects followed for a time ranging from three to 20 years. A total of 6332 cardiovascular events occurred during the follow-up. Insomnia was assessed through questionnaire and defined as either difficulty of initiating or maintaining sleep or presence of restless, disturbed nights. The cumulative analysis for all the studies under a random-effects model showed that insomnia determined an increased risk (+45%) of developing or dying from cardiovascular disease during the follow-up (relative risk 1.45, 95% confidence interval 1.29-1.62; p < 0.00001), with no evidence of heterogeneity across the studies (I 2: 19%; p = 0.14).

CONCLUSION

Insomnia is associated with an increased risk of developing and/or dying from cardiovascular disease.

The improvement of walking speed after cardiac rehabilitation is associated with the reduction in the metabolic cost of walking in older persons

BACKGROUND

To walk a given distance older persons consume more metabolic energy than younger adults across all speeds. As physical activity interventions improve a variety of physical performance measures in older persons, including walking speed, in this study we hypothesized that the improvement of walking speed might be associated with the reduction of the metabolic cost of walking and we tested our hypothesis in a selected sample of older patients receiving cardiac rehabilitation.

METHODS

In 120 patients (88 men and 32 women, mean age 74.1 years±SD 5.0) we assessed energy expenditure during the 6-min Walk Test (6mWT) before and after the rehabilitation using a portable system for direct calorimetry.

RESULTS

On the 6mWT performed after the rehabilitation patients significantly increased total energy expenditure (28.0 kcal±SD 8.3 vs. 25.7 kcal±SD 7.6, p<0.001), the distance walked (398 m±SD 93 vs. 343 m±SD 95, p<0.001) and, consequently, walking speed (1.11 m/s±SD 0.26 vs. 0.95m/s±SD 0.26, p<0.001) while the metabolic cost of walking, i.e. the amount of energy used to move a body mass of 1 kg for a distance of 1m, was significantly reduced (1.00 cal/kg/m±SD 0.19 vs. 1.11 cal/kg/m±SD 0.32, p<0.001).

CONCLUSIONS

In older patients receiving cardiac rehabilitation the improvement of walking speed is associated with the improvement of walking economy. This might be a contributory factor to the favourable effects of physical activity interventions on physical performance measures.

Adaptive physical activity and back pain: a non-randomised community-based intervention trial

BACKGROUND

Back pain is a significant problem due to the high healthcare utilization, rising costs of care and low effectiveness of many current treatments.

AIM

Aim of this study was to determine the effects of a community-based Adapted Physical Activity (APA) program focused on chronic, non-specific back pain.

DESIGN

Open-label intervention study.

SETTING

Community.

POPULATION

All patients admitted to Empoli Rehabilitation Department for non-specific back pain for at least three months, were considered for APA. Exclusion criteria were: "red flags", difficulty/disability in basic daily living activities, severe/acute medical conditions, acute pain, psychiatric disease or cognitive impairment, severe visuoauditory deficit. Overall, 650 persons were enrolled.

METHODS

The APA program, including strength and flexibility training and exercises for improving posture was delivered for 12 months, with 1-hour group classes three times per week.

RESULTS

Overall 261 (40.2%) subjects completed the 12-month APA program and were compared to the 310 (47.7%) who were screened but failed to initiate or complete the study. There were no significant differences in baseline demographic and clinical characteristics between groups. Patients who followed the APA program reported significantly improved health status and significant back pain improvement, compared with those who did not adhere to the program. In the logistic regression analysis adjusted for age and gender, a distance from home to gymnasium greater than the median for the study population (2.6 km) was the only baseline characteristic significantly associated with an increased risk of non-adherence (OR 1.44, 95%CI 1.01-2.13; P=0.04).

CONCLUSION

This study suggests that a community-based APA program can improve back pain and health status in persons with chronic, non-specific low back pain. CLINICA REHABILITATION IMPACT: These findings highlight the potential for new approaches to manage chronic disease and disability by facilitating a healthy lifestyle and promoting physical activity through implementation of community-based exercise programs.

High sensitivity C-reactive protein predicts the development of new carotid artery plaques in older persons

BACKGROUND AND AIM

Previous studies have shown that increased levels of C-reactive protein (CRP) predict cardiovascular events, including stroke, myocardial infarction and death from cardiovascular causes. Previous studies have also shown that increased levels of CRP are strong predictors of the progression of pre-existing carotid artery plaques. However, whether CRP is involved in the development of new plaques, that may or may not be associated with clinical events, in subjects with clean carotid arteries has been scarcely investigated.

METHODS AND RESULTS

486 "InCHIANTI" Study participants (200 men and 286 women, 72% aged 65 years and over) free from carotid artery plaques at baseline, also underwent carotid artery scan three years later. We tested the association of baseline characteristics, cardiovascular risk factors and inflammatory markers with the development of new carotid artery plaques. Older participants were significantly more likely to develop new plaques. Independent of age, the relative risks of developing new plaques associated with heavy smoking and family history of atherosclerosis were 1.7 (95%CI 1.5-1.9) and 1.9 (95%CI 1.2-3.1), respectively. Participants with high (>3 μg/mL) and moderate (≥1 and ≤3 μg/mL) CRP levels had a relative risk of 2.2 (95%CI 1.9-2.6) and 1.9 (95%CI 1.6-2.3) respectively, when compared with subjects with low (<1 μg/mL) CRP levels. Surprisingly, risk factors such as hypertension, diabetes, dyslipidemia and overweight/obesity were not significant predictors of the development of new carotid artery plaques.

CONCLUSIONS

High CRP levels independently predict the development of new plaques in older persons with carotid arteries free from atherosclerotic lesions.

Predictors of short- and long-term outcome in patients with chronic non-specific neck pain undergoing an exercise-based rehabilitation program: a prospective cohort study with 1-year follow-up

The aim of this study was to describe the clinical course of patients with chronic, non-specific neck pain undergoing a public health covered, exercise-based rehabilitation program and to identify predictors of poor outcome. A prospective cohort study was carried out on patients with non-specific neck pain (6 months or longer), referred by their general practitioner to a 6-session program, including education and individually tailored exercise. The primary outcome measure for the course of neck pain was the Northwick neck pain questionnaire (NPQ) administered on baseline, discharge, and 1 year from discharge. Poor outcome was defined as NPQ score improving <30% (minimal clinically important difference-MCID-NPQ). The potential predictors included demographics, general health and psychological factors, neck pain history, and the clinical features described by NPQ. From January 2008 to June 2009, 212 patients were consecutively assessed for eligibility: 178 were enrolled and 162 completed follow-up (mean age = 65.3; 75% women). Baseline NPQ average score (40.7 + 17.1) improved by MCID on discharge (26.1 + 16.3) and at 1 year (28.5 + 17.3%). The poor outcome was reported by 45% patients on discharge and by 56% at follow-up. Pain-related medication intake independently predicted poor short- (OR 4.24; 95% CI 1.83-9.84; p = 0.001) and long-term (OR 2.69; 95% CI 1.19-6.06; p = 0.017) outcome, and catastrophizing (OR 2.91; 95% CI 1.31-6.48; p = 0.009) predicted poor outcome at 1 year. Our cohort of patients with chronic neck pain undergoing an exercise-based rehabilitation program reported improvement by or beyond MICD-NPQ in 55% cases on discharge and in 44% cases at 1 year. Poor outcome was predicted by pain-related medication intake in the short and long term, and by catastrophizing in the long term.

Physical activity and risk of cognitive decline: a meta-analysis of prospective studies

OBJECTIVE

The relationship between physical activity and cognitive function is intriguing but controversial. We performed a systematic meta-analysis of all the available prospective studies that investigated the association between physical activity and risk of cognitive decline in nondemented subjects.

METHODS

We conducted an electronic literature search through MedLine, Embase, Google Scholar, Web of Science, The Cochrane Library and bibliographies of retrieved articles up to January 2010. Studies were included if they analysed prospectively the association between physical activity and cognitive decline in nondemented subjects.

RESULTS

After the review process, 15 prospective studies (12 cohorts) were included in the final analysis. These studies included 33,816 nondemented subjects followed for 1-12 years. A total of 3210 patients showed cognitive decline during the follow-up. The cumulative analysis for all the studies under a random-effects model showed that subjects who performed a high level of physical activity were significantly protected (-38%) against cognitive decline during the follow-up (hazard ratio (HR) 0.62, 95% confidence interval (CI) 0.54-0.70; P < 0.00001). Furthermore, even analysis of low-to-moderate level exercise also showed a significant protection (-35%) against cognitive impairment (HR 0.65, 95% CI 0.57-0.75; P < 0.00001).

CONCLUSION

This is the first meta-analysis to evaluate the role of physical activity on cognitive decline amongst nondemented subjects. The present results suggest a significant and consistent protection for all levels of physical activity against the occurrence of cognitive decline.

Spinal manipulation compared with back school and with individually delivered physiotherapy for the treatment of chronic low back pain: a randomized trial with one-year follow-up

OBJECTIVE

To compare spinal manipulation, back school and individual physiotherapy in the treatment of chronic low back pain.

DESIGN

Randomized trial, 12-month follow-up.

SETTING

Outpatient rehabilitation department.

PARTICIPANTS

210 patients with chronic, non-specific low back pain, 140/210 women, age 59 +/- 14 years.

INTERVENTIONS

Back school and individual physiotherapy scheduled 15 1-hour-sessions for 3 weeks. Back school included: group exercise, education/ ergonomics; individual physiotherapy: exercise, passive mobilization and soft-tissue treatment. Spinal manipulation, given according to Manual Medicine, scheduled 4 to 6 20'-sessions once-a-week.

OUTCOME

Roland Morris Disability Questionnaire (scoring 0-24) and Pain Rating Scale (scoring 0-6) were assessed at baseline, discharge 3, 6, and 12 months.

RESULTS

205 patients completed the study. At discharge, disability score decreased by 3.7 +/- 4.1 for back school, 4.4 +/- 3.7 for individual physiotherapy, 6.7 +/- 3.9 for manipulation; pain score reduction was 0.9 +/- 1.1, 1.1 +/- 1.0, 1.0 +/- 1.1, respectively. At 12 months, disability score reduction was 4.2 +/- 4.8 for back school, 4.0 +/- 5.1 for individual physiotherapy, 5.9 +/- 4.6 for manipulation; pain score reduction was 0.7 +/- 1.2, 0.4 +/- 1.3, and 1.5 +/- 1.1, respectively. Spinal manipulation was associated with higher functional improvement and long-term pain relief than back school or individual physiotherapy, but received more further treatment at follow-ups (P < 0.001); pain recurrences and drug intake were also reduced compared to back school (P < 0.05) or individual physiotherapy (P < 0.001).

CONCLUSIONS

Spinal manipulation provided better short and long-term functional improvement, and more pain relief in the follow-up than either back school or individual physiotherapy.

Internal jugular vein valves: an assessment of prevalence, morphology and competence by color Doppler echography in 240 healthy subjects

The presence of valves in the head and neck veins is known since classical anatomical dissections. Previous studies have investigated whether jugular veins show constant valves at their ostium and whether these valves are physiologically competent, but, unluckily, these studies have reported conflicting results. Further, recent observations have raised the question whether the incompetence of jugular vein valves might play a pivotal role in neurological disorders related to venous engorgement of the brain. In this study we examined 462 internal jugular veins by using an echocolorodoppler apparatus. In particular, we assessed the presence, morphology and competence of valves at their ostium. Unilateral jugular vein valves were present in 406 cases (88%), mainly on the right side. The most frequently observed morphology (75%, 305 cases) was the two-leaflet valve, and jugular vein valves were incompetent in the huge majority of cases (365 cases, 90%). Our findings confirm the anatomical variability predicted from classical anatomical studies but, unluckily, do not provide additional evidence on the possible role of jugular vein valves in physiology and pathology. Further studies are strongly needed to determine whether these valves actually play an important role in counteracting chest venous pressure and in preventing reflux towards the brain.

Assessment of internal diameters of abdominal and femoral blood vessels in 250 living subjects using color Doppler ultrasonography

Acquiring data about venous or arterial vessel size is important for several reasons, given the increasing incidence of thomboembolic phenomena and arterial aneurysms and the emerging new vascular techniques. We studied 250 healthy subjects (125 men and 125 women; age range: 50 to 91 years) with no known vascular pathology, nor hypertension, nor diabetes. We assessed the caliber of abdominal aorta, inferior vena cava, iliac and femoral arteries and viens by color doppler ultrasonography, and analyzed the results with regard to sex, height, weight and body surface of each subject. The mean caliber measure of the large abdominal vessels appeared lower than the value obtained from cadavers. There was a direct proportion between the left and right vessels of the same subject. The difference in vessel caliber between male and female subjects was statistically significant. There was no correlation between vessel caliber and age, height or body surface area.

Measures of physical performance capture the excess disability associated with hip pain or knee pain in older persons

BACKGROUND

Hip pain (HP) and knee pain (KP) may specifically affect function and performance; few studies investigate the functional impact of HP or KP in the same population.

METHODS

Population-based sample of older individuals living in the Chianti area (Tuscany, Italy) (1998-2000); 1006 persons (564 women and 442 men) were included in this analysis; 11.9% reported HP and 22.4% reported KP in the past 4 weeks. Self-reported disability and lower extremity performance, measured by 400-m walk test and by the short physical performance battery (SPPB, including standing balance, chair raising, and 4-m walk test), were compared in participants reporting HP or KP versus those free of these conditions; the relationship of HP or KP with performance and self-reported disability was studied, adjusting for age, sex, hip or knee flexibility, muscle strength, multiple joint pain, major medical conditions, and depression.

RESULTS

Participants reporting HP were more likely to report disability in shopping, cutting toenails, carrying a shopping bag, and using public transportation; those with KP reported more disability in cutting toenails and carrying a shopping bag. Participants reporting HP or KP had significantly lower SPPB scores. Adjusting by SPPB, pain no longer predicted self-reported disability, except for "HP-carrying a shopping bag."

CONCLUSIONS

In our cohort of older persons, those with HP reported disability in a wider range of activities than those with KP. Physical performance measured by SPPB was impaired in both conditions. Reduced lower extremity performance captures the excess disability associated with either HP or KP.