Efficacy of Mulligan joint mobilizations and trunk stabilization exercises versus isometric knee strengthening in the management of knee osteoarthritis: a randomized controlled trial

BACKGROUND

Knee osteoarthritis (KOA) progression is often influenced by biomechanical factors. Biomechanical interventions, such as Trunk stabilization exercise (TSE) and Mulligan joint mobilization (MWM), may offer relief from KOA symptoms and potentially slow disease progression. However, the comparative efficacy of these therapies remains uncertain. This study aimed to compare the efficacy of TSE, Mulligan joint mobilization, and isometric knee strengthening (KSE) on disability, pain severity, and aerobic exercise capacity in patients with KOA.

METHODOLOGY

A randomized controlled trial (RCT) with three intervention groups was conducted between September 2020 to February 2021. The study enrolled adults aged between 40 and 60 years with a confirmed KOA diagnosis recruited from the physical therapy clinic of the Sindh Institute of Physical Medicine and Rehabilitation, Pakistan. Participants were randomly assigned to receive 24 sessions of either TSE, MWM, or KSE. The knee's functionality was assessed using the Knee Injury and Osteoarthritis Outcome Score (KOOS), pain on a visual analogue scale (VAS), and two objective functional tests-the 6-minute walk test (6MWT) and the 11-stair climb test (SCT). These assessments were conducted at baseline, the third week, and the sixth week. Changes in outcome measures were analyzed using a mixed-design ANOVA with Bonferroni post-hoc analysis, with statistical significance set at a p-value < 0.05.

RESULT

Of the 60 participants, 22 (36.7%) were females, and 38 (63.3%) were males. Within-group analysis revealed a significant improvement in all outcome measures at the third week (p < 0.05) and sixth week (p < 0.05). Notably, the TSE group exhibited a greater reduction in mean difference (M.D) in VAS scores than the MWM and KSE groups across various measures in the third week. At rest, during stair ascent, and descent, the TSE group showed significant improvements in VAS scores: MWM (-2.05; -1.94; -1.94), TSE (-2.38; -2.5; -2.5), KSE (-1.05; -0.63; -0.63). Additionally, during sub-maximal exercise capacity assessment, the TSE group showed greater improvement (MWM 12.89; TSE 22.68; KSE 7.89), as well as in Knee Injury and Osteoarthritis Outcome Score for activities of daily living (KOOS-ADL) (MWM 20.84; TSE 28.84; KSE 12.68), and KOOS-pain (MWM 24.84; TSE 27.77; KSE 5.77) at the third-week assessment (p < 0.05). The TSE group demonstrated significant improvements (p < 0.05) across various measures in the sixth week. Specifically, improvements were observed in VAS scores at rest (MWM - 4.15; TSE - 4.42; KSE - 3.78), during stair ascent (MWM - 3.89; TSE - 4.88; KSE - 3.56) and descent (MWM - 3.78; TSE - 4.05; KSE - 2.94). Furthermore, significant improvements were noted in the stair climb test (MWM - 7.05; TSE - 7.16; KSE - 4.21), 6-minute walk test (6MWT) (MWM 22.42; TSE 37.6; KSE 13.84), KOOS-pain (MWM 41.47; TSE 49.11; KSE 28.73), and KOOS-ADL (MWM 40.31; TSE 50.57; KSE 26.05).

CONCLUSION

In this study in patients with KOA, TSE had greater efficacy compared to MWM and KSE in enhancing functional levels, reducing pain, improving sub-maximal exercise capacity, and performance on the stair climb test. Importantly, mean scores between the groups, particularly in the TSE group, reached the minimally important level, particularly in key areas such as pain, functional levels, sub-maximal exercise capacity, and stair climb performance. Clinicians should consider the significant pain reduction, improved functionality, and enhanced exercise capacity demonstrated by TSE, indicating its potential as a valuable therapeutic choice for individuals with KOA.

TRIAL NO

ClinicalTrials.gov = NCT04099017 23/9/2019.

Mobile health: Is your next rehabilitation's specialist in your pocket?

The past few decades have witnessed an unprecedented surge in health-related mobile applications. However, most of these applications primarily focus on lifestyle domains such as sleep, fitness, and nutrition. A notable stride in this landscape involves the emergence of applications catering specifically to rehabilitation needs. This expert review aims to provide an encompassing overview of the wide spectrum of apps available for both assessment and rehabilitation. It delves into the existing constraints associated with these tools and deliberates on the potential avenues for future advancements and integration for future advancements and integration. The transformative potential of this mobile, affordable, and user-friendly technology in reshaping the field of rehabilitation sciences will be highlighted. This article underscores how harnessing these innovations can elevate accessibility and effectiveness in the rehabilitation processes, leading to improved overall outcomes and wellbeing.

Multidisciplinary Team Working in Rehabilitation Medicine: Advantages and challenges

Healthcare is delivered in a very complicated environment where numerous variables affect the patient related outcomes. A multidisciplinary team that places a high priority on patient satisfaction and healthcare quality can help to simplify and manage the environment of complex healthcare delivery. The foundation of rehabilitation treatments is a multidisciplinary team approach to provide interventions and care for the patients. Regardless of the population studied, multidisciplinary rehabilitation has been shown to be more effective than therapy delivered by individual therapists in a number of different populations. Due to the patient's complex impairments, a team-based approach is necessary for assessments and facilitates coordinated care planning in the rehabilitation settings. The aim of this paper is to offer a narrative review of the advantages and challenges of multidisciplinary team working. The key components of teamwork in rehabilitation are the individualization of patient care and effective team communication.

Fat but Fit: How physical fitness can mitigate the cardiovascular risks of obesity?

Obesity has long been recognized as a major independent risk factor for cardiovascular diseases (CVD). However, intriguing paradoxes such as the "obesity paradox" and the "fat but fit" phenomenon have been associated with it. The "fat but fit" paradigm suggests that overweight or obese individuals might face a lower risk of developing cardiovascular disease if they possess high levels of physical fitness. In other words, higher fitness levels may mitigate the negative impact of obesity on cardiovascular risk, leading to a reduction in overall mortality due to CVD. The evidence surrounding this paradox is conflicting, highlighting the necessity for further research. The complex relationship between physical fitness, obesity, and cardiometabolic health is influenced by individual and environmental factors. Consequently, it becomes imperative to conduct more studies to comprehend this intricate interplay fully. To address this issue, it is important to focus on formulating strategies that promote the maintenance and enhancement of cardiorespiratory fitness in overweight and obese individuals. Moreover, including fitness evaluations in comprehensive risk stratification can significantly improve clinical decision-making.

A Brief Review of Inpatient Palliative Rehabilitation

Cancer patients face many challenges that can have a significant impact on their quality of life (QOL). When patients experience multiple functional impairments due to disease or treatment, their QOL and the efficient use of healthcare resources can be compromised. This is particularly true for patients who are nearing the end of their lives, as the physical and emotional burden of cancer can have a profound effect on both the individual and their caregivers. One approach to improving QOL in these patients is through palliative rehabilitation. Despite being an underutilized and understudied resource, palliative rehabilitation has shown promise in helping patients with advanced cancer retain their dignity and sense of control. By maximizing functional independence and reducing symptom burdens, palliative rehabilitation can provide a vital source of support for patients and their caregivers during this challenging time. Inpatient rehabilitation is one way that palliative rehabilitation can be applied in a healthcare setting. While further research is needed to fully understand the benefits of this approach, it is clear that palliative rehabilitation has the potential to play a key role in helping patients and their caregivers navigate the challenges of cancer treatment and end-of-life care. This approach is specific to the USA context but can be applied in other settings where cancer patients require such care.

Research Integrity, Governance, and Misconduct in Pakistan: Some Proposed<br /> Solutions

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Task Oriented Training For Stroke Rehabilitation: A Mini Review

Stroke is the leading global cause of death and disability and the need for stroke rehabilitation services in increasing. The usual stroke rehabilitation protocol involves a combination of therapeutic exercises, occupational therapy, speech therapy and counselling sessions depending upon the severity of the deficit and associated co-morbidities. However, there is a need for better protocols and new therapies for improving outcomes after stroke rehabilitation. The term 'task-oriented training' (TOT) refers to guided rehabilitation training of patients' limb function using goal oriented tasks, which can be used to enhance neuroplasticity in brain after injury. Task oriented training could be modified with action selection and environmental enrichment to fulfill the limitations of stroke like, holistic approach, outcome/goal based intervention, proper dosage for desirable outcomes. This mini review provides an overview of the TOT and to identify gaps and challenges in stroke rehabilitation related to integrating TOT.

Bladder Drainage Options For People With Spinal Cord Injury: A Mini-Review

Neurogenic bladder is one of the negative consequences following a spinal cord injury (SCI). SCI patients who have neurogenic bladder depend on alternative methods to drain urine from their bladder. These include indwelling catheters, reflex voiding , suprapubic tapping and intermittent catheterisation. This review summarizes evidence from the literature of five selected complications (renal failure, urinary tract infections, calculi, urethral stricture, and bladder cancer) that could result from use of the different bladder drainage methods. There is inconsistent evidence to support the superiority of intermittent over indwelling catheterisation on risk of renal impairment, urethral stricture, and renal calculi. Indwelling catheterisations are associated with higher risk of bladder calculi and cancer. Caution needs to be taken when interpreting this review, as many of its findings are from retrospective studies, and more than a decade old. Clinicians need to communicate the evidence to their patients when making the decision on method of bladder drainage.

Use of Social Media and Digital Profile of Physicians: What One Needs to Know?

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Prevalence pattern, phenotypic manifestation, and descriptive genetics of congenital limb deficiencies in Pakistan

BACKGROUND

Congenital limb deficiency (CLD) is a group of very rare disorders characterized by substantial hypoplasia or the complete absence of 1 or more bones of limbs. Congenital limb deficiency has a significant physical, clinical, and psychological burden on the affected individuals and their families. This cross-sectional study aimed to describe the prevalence pattern, phenotypic manifestations, and biodemographic factors associated with CLD in a cohort assembled from the Pakistani population from the Northwestern region.

METHODS

Through a prospective cross-sectional study, 141 individuals having 166 limbs with CLD were recruited during 2017-2021.

RESULTS

There were 77 (55%) individuals with transverse defects, 61 (43%) with longitudinal defects, and 3 (2%) with Intercalary defects. Among the patients with transverse defects, 52 had terminal amputations and 25 had symbrachydactyly. Among the longitudinal defects, thumb aplasia/hypoplasia was the most common presentation (20 patients), followed by oligodactyly (18), and radial hemimelia (18). Eighty six percent had upper-limb deficiencies, 83% had unilateral deficiencies, and 92% were sporadic in nature. The parental consanguinity was observed in 33% individuals, and 79% cases had an isolated presentation which may be indicative of the substantial role of nongenetic factors in the etiology of CLD.

CONCLUSIONS

This study demonstrates marked heterogeneity in CLD subtypes in the involvement of limbs and associated variables. There is a need to establish a national registry for CLD, molecular genetic diagnosis, and multidisciplinary medical and social rehabilitation services for these individuals.

Goal Setting In Medical Rehabilitation: A Narrative Review

Goal setting is an integral part of rehabilitation and the rehabilitation process. The aim of rehabilitation is to optimize functioning. Therefore, rehabilitation professionals and patients together have to determine mutually which aspects of functioning they should aim at. From a clinical view, a formal procedure for setting goals should help to motivate patients, ensure cooperation of rehabilitation team members, help to identify relevant blind spots and provide a system to monitor patient changes. Applying goalsetting in rehabilitation represents a purpose in its own right, as it serves to strengthen the autonomy of patients and is a valuable tool to integrate personal motives, attitudes, meanings into the rehabilitation process. There is evidence that the introduction of goal setting into rehabilitation practice could enhance health-related quality of life and emotional states, especially self-efficacy. Mixed results have been reported regarding the patient motivation as well as activities and participation outcomes.

Neuromuscular Electrical Stimulator as a Protective Treatment against Intensive Care Unit Muscle Wasting in Sepsis/Septic Shock Patients

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An Overview Of The Management And Rehabilitation Of Dysphagia

Dysphagia is a medical condition that makes it difficult for a person to eat or swallow. It is estimated that 590 million people worldwide have dysphagia. The causes are varied and include neurological disorders like stroke and motor neuron disease, head and neck cancer, neuromuscular diseases, inflammatory diseases such as dermatomyositis, dementia, cervical spinal cord injury, and anterior vertebral ossification. The assessment and screening of dysphagia consists of a questionnaire-based interview, mealtime observation, and, if deemed necessary by a screening test or instrumental examination by specialists. Treatment is based on the diagnosis, patients' cognition and information gathered by screening and clinical evaluation. Patient's function can be improved only when treatment is comprehensive and includes compensatory feeding using an adjusted swallowing diet, compensatory posture adjustment, and nutritional improvement. We present a brief overview of the assessment and management strategies for dysphagia.

The Emerging Role of Artificial Intelligence in Healthcare

Artificial intelligence (AI) is increasingly being used in the field of healthcare to improve the efficiency and accuracy of medical diagnoses, treatment plans, and decisionmaking.1 It has the potential to transform the way healthcare is delivered and improve patient outcomes. There are many examples of the use of artificial intelligence (AI) in healthcare. One way that AI is being used in healthcare is by developing machine learning algorithms that can analyze vast amounts of patient data and identify patterns and trends that may not be immediately apparent to humans.2 This can be particularly useful in identifying early signs of diseases or conditions, allowing for earlier diagnosis, treatment, prognosis evaluation, and more. Another application of AI in healthcare is through the use of natural language processing (NLP). NLP systems can analyze electronic medical records (EMR) and extract important information, allowing healthcare providers to access and interpret patient data conveniently.3 This can help healthcare providers access and interpret patient data more easily, leading to more informed decision-making and better patient care. AI can also be used to assist with tasks such as image analysis, allowing for more accurate analysis and efficient diagnosis of medical images such as CT scans or X-rays.4 In addition, AI can be used to help automate routine tasks, freeing up healthcare providers to focus on more complex and higher-level tasks that require human expertise.5 Machine learning algorithms can analyze large amounts of patient data and identify patterns and trends that may not be immediately apparent to humans.6 This can be useful in identifying early signs of diseases or conditions, leading to earlier diagnosis and treatment. AI-powered chatbots or virtual assistants can help with tasks such as appointment scheduling and medication reminders.7 Systems that can assist with the automation of routine tasks, freeing up healthcare providers to focus on more complex and higher-level tasks that require human expertise. Predictive analytics systems can forecast patient outcomes and help healthcare providers make informed decisions about treatment plans.8 Personalized medicine systems can help tailor treatment plans to individual patients based on their specific needs and characteristics. These are just a few examples of the many ways in which AI is being used in healthcare. It is important to note that AI in healthcare is still in its early stages, and the potential applications of the technology are likely to expand significantly in the coming years.

Rehabilitation Perspectives in Long COVID-19

Long COVID is a term used to describe the persistence of symptoms in people who have had COVID-19 for an extended period. It affects multiple systems including neurological (fatigue, brain fog, attention issues, memory issues), neuromuscular (sarcopenia, myositis, arthritis and myopathy), cardiovascular (myopericarditis, right ventricular dysfunction, vasculitis and aortic, arterial and venous thrombosis) and respiratory (pulmonary fibrosis, pleurisy, pulmonary embolism and pneumonitis). This results in functional impairments which adversely affect the quality of life of patients. The rehabilitation of persons who have experienced long COVID-19, also known as "long haulers," is a relatively new field of study. We have described potential rehabilitation interventions to improve functional capacity and quality of life in patients with long COVID. These rehabilitation interventions include but are not limited to, endurance, flexibility and strength training, pulmonary rehabilitation, task specific exercises to improve Activities of Daily Living (ADL), psychological rehabilitation, medical rehabilitation, pain management and management of dysphagia.

Need for Development and Validation of Sarcopenia Screening Tools in Pakistan

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Role of Vitalstim® In The Management Of Patients With Dysphagia: A MiniReview

Dysphagia defined as difficulty in swallowing, can result from multiple causes including, Stroke, head injury, Alzheimer, Dementia, Muscular dystrophy, Cerebral Palsy etc. It is associated with neuro-muscular impairments in different age groups. VitalStim® therapy is a relatively new approach to treat dysphagia. It provides neuromuscular electrical stimulation (NMES) of the involved muscles to improve the function of swallowing. This review summarizes the usefulness of VitalStim® in dysphagia, and barriers in its use in Pakistan.

Overview of gait rehabilitation in stroke

Stroke is the 2nd leading cause of death globally after ischaemic heart disease and is expected to rise more by 2030. The estimated incidence of stroke in Pakistan is about 250/100,000 individuals. Difficulty in walking is present in approximately 80% of stroke survivors. About a quarter of stroke survivors, even after receiving rehabilitation have residual gait impairments requiring assistance in activities of daily life. Almost half of stroke patients after being discharged will have episodes of fall, with majority of these falls occurring in activities like "turning". Gait is one of the key features to participate in community and occupational activities. Therefore, appropriate gait rehabilitation post stroke is crucial for functional independence and community ambulation. There are many approaches to gait rehabilitation based on different models of motor physiology and disease. Augmenting conventional therapies with novel techniques such as utilization of electromechanical means have improved gait rehabilitation in improving functions. The usage of technology in rehabilitation of patients with neurological deficits, is still novel in Pakistan. This review provides an overview of advancements in neurological and gait rehabilitation post stroke.

Cardiac Rehabilitation for Visceral Obesity: A Multidisciplinary Approach

World Health Organization data indicates a marked rise in global obesity, with approximately 30% of the world's population classified as overweight or obese. The contributory factors include unhealthy dietary habits, lack of physical activity, urbanization, and technology dependent sedentary lifestyle. Among the various management approaches, cardiac rehabilitation has evolved from an exercise-only programme for patients with cardiac diseases to a multi-disciplinary individualised intervention plan for risk factor modification, primary and secondary prevention of cardiometabolic diseases. Evidence suggests that visceral obesity is an independent risk factor of morbidity and mortality from cardiometabolic causes. There are multiple training programmes targeting visceral fat oxidation, one of which is high intensity interval training. It appears to be a promising regime, inducing metabolic adaptations in the body. This review summarizes the multidisciplinary cardiac rehabilitation services for the management of visceral adiposity and generalised obesity, its under-utilization and scarcity of local published data, highlighting the need for future research.

Development of a tool for objectively measuring somatic pain in the low back region based on a longitudinal diagnostic study conducted in Karachi, Pakistan

OBJECTIVES

This study aimed at devising an objective method for quantifying pain in the low back region using pressure pain threshold (PPT) and demographic factors as predictive variables.

METHODS

The research was conducted in two phases. Phase I was a longitudinal exploratory study conducted on 49 men aged 18-50 years with chronic low back pain (CLBP) recruited using non-probability purposive sampling. We used Visual Analogue Scale to record pain intensity and pain affect, and Disability Rating Index to record associated disability. PPT was measured on 12 different locations on the lower back using a manual algometer. These measurements were taken from each participant in 1 to 6-follow-up visits, depending on improvement in the individual's symptoms. In phase II additional 33 subjects, both men and women with varying durations of low back pain were recruited using non-probability convenience sampling. Repeated measures ordinal regression and receiver's operating characteristic curve analyses were performed to develop predictive models using STATA V.16.0 and R V.3.5.2 software. These models were given an interface using Microsoft Excel. A p value of <0.05 was considered statistically significant.

RESULTS

Higher PPT scores, increased lean body mass, lean physique and a longer duration of CLBP were associated with a reduction in CLBP intensity, affect and disability. Advancing age was associated with an increase in these outcomes. Collectively, these factors were found to predict pain intensity, affect, and disability with 63%-65% diagnostic accuracy in phase I, however, this diagnostic accuracy increased to 65%-78% in phase II.

CONCLUSION

We developed a new outcome tool 'Pain Calculator' that can objectively measure low back pain with sufficient statistical accuracy. With further refinement, this tool in the future can be configured to measure somatic pain in different regions as well, affording clinicians and researchers much-needed objectivity while recording pain levels.

TRIAL REGISTRATION NUMBER

NCT04482075.

Functional Outcomes of Patients with Primary Brain Tumors Undergoing Inpatient Rehabilitation at a Tertiary Care Rehabilitation Facility in Saudi Arabia

Rehabilitation services play a crucial role in improving the functionality and quality of life of individuals with a brain tumor; however, outcomes of inpatient rehabilitation based on tumor characteristics are not well known in the literature. This study was carried out to evaluate the effects of tumor characteristics on functional outcomes. A retrospective chart review was conducted for all adults with a diagnosis of primary brain tumor admitted for IPR between January 2014 and December 2019. Information was collected regarding demographics, characteristics of primary brain tumors, length of stay (LOS) and Functional Independence Measurement (FIM) scores. There were 46 patients, with the majority being male. The most common brain tumors were glioblastoma multiforme and meningioma. The mean LOS was 47.93 ± 26.40 days and the mean FIM gain was 78 ± 14. The type, grade and location of primary brain tumors did not show a significant correlation with the length of stay and functional gains during inpatient rehabilitation. There was a positive correlation between the FIM at admission and discharge, and a significant inverse correlation between the FIM score at admission and LOS. In-patient rehabilitation improved the functional outcomes in adult patients with primary brain tumors. Strategies to incorporate IPR in the care continuum of patients with brain tumors need to be adapted to improve regional services.

Fall risk screening and balance rehabilitation in elderly: a missing healthcare intervention in Pakistani healthcare system

Elderly are one of the fastest-growing population globally and require significant healthcare services due to age-related deterioration in physiological systems. Poor postural control due to aging results in impaired balance leading to increase in frequency of falls, poor quality of life, and rise in disability and mortality rates. In Pakistan, due to lack of awareness, and resources, fall prevention and screening programmes for the elderly are lacking. Regular fall risk screening utilizing balance assessment tools, integration of fall prevention programmes and balance rehabilitation approach as part of elderly healthcare services can serve as tools to lower the incidence of falls in the elderly population of Pakistan. Moreover, integration of latest technology as part of balance rehabilitation can also be considered. The review aims to highlight appropriate strategies for fall risk screening and balance rehabilitation in an effort to promote an important healthcare intervention for elderly in Pakistan.

An overview of injury prevention for soccer players in Pakistan: A sports rehab perspective

Soccer (football) is one of the most popular weight-bearing sports in the world, which involves activities such as jumping, running and turning. Soccer related injuries have the highest incidence in all sports and are more common in young amateur players. The most important modifiable risk factors include neuromuscular control, postural stability, hamstring strength and core dysfunction. The International Federation of Football Association introduced FIFA 11+; an injury prevention programme for reduction in the rate of injuries in amateur and young soccer players. It focusses on the training of dynamic, static and reactive neuromuscular control, proper posture, balance, agility and control of the body. This training protocol is not being used in Pakistan at amateur level who neither possess the resources, nor the knowledge or proper guidance in risk factor assessment, prevention, and subsequent sport injury management. In addition, the physicians and rehabilitation community are not much familiar with it except for those directly involved in sports rehabilitation. This review highlights the importance of including FIFA 11+ training programme in the curriculum and faculty training.

An overview of biofeedback techniques in mechanical low back pain: effects on sensory integration of balance

Low back pain is a common musculoskeletal disorder involving the lumbar spine. It affects almost 80% of the world's population and is associated with functional limitations. The reported global prevalence ranges from15-30%. Postural control involves processing the information from sensory stimulus derivative of vestibular, visual, and somatosensory systems in a coordinated manner to precisely regulate center of mass and body positioning. Failure of one or more of these systems, or incorrect processing of sensory information leads to instability or risk of fall. Low back pain can also modify the sensory input for postural control. Biofeedback can be utilized to assist "down-train" elevated muscle activity or to "up-train" weak or inhibited, muscles. Clinicians can use biofeedback to determine if patients are able to relax and evaluate psychophysiological reactions of muscles. Using biofeedback, patients can be educated about physiological processes and how biopsychosocial factors can interact causing recurrent complaints of pain.

Are antiepileptic drugs effective for the primary and secondary prevention of Seizures after stroke? A Cochrane Review summary with commentary

BACKGROUND

In post stroke patients, seizures can complicate the recovery process and lead to poor outcomes. It is unclear whether antiepileptic drugs (AEDs) can prevent seizures after a stroke.

OBJECTIVE

To summarize the evidence on the effects of AEDs on the primary and secondary prevention of post stroke seizures.

METHODS

The authors searched the Cochrane Register of Studies and MEDLINE (last search on 9 March 2021), checked the reference lists of articles retrieved and contacted the corresponding authors of the study where needed. Only randomized controlled trials were included (RCT). There were no language and time limits.

RESULTS

Two RCTs with 856 adult participants with a clinical diagnosis of stroke were included. There was moderate-certainty evidence that the AEDs were not effective for primary prevention of post stroke seizures (Relative effect, 95% CI = RR 0.65, 95% CI 0.34 to 1.26). They also did not affect the mortality rate (RR 1.03, 95% CI 0.78 to 1.36). Both studies were at low risk of bias and certainty of the evidence was low to moderate.

CONCLUSION

The evidence for routine use of AED for the primary and secondary prophylaxis of post stroke seizures is unclear. There is a need for high-quality trials to address this question using a larger sample size.

Wellness in residency: Addressing the neglected need in lower middle-income countries

The concept of wellness incorporates many domains, including mental, physical, social, and integrated well-being. However, it is not well understood in most lower middle-income countries (LMIC). The significance of practicing wellness during residency, focusing on the context of LMIC, is described here. Based on the authors' experiences of working in LMIC, the challenges faced during residency and the importance of prioritizing self-care and well-being is highlighted. Physician burnout is a global concern having a negative impact on patient care quality, patient satisfaction, and professionalism. Interventions to address wellness can be individual and organization-based. Individual interventions include mindfulness training, behavioral interventions, self-care practices, and support networks. Organizational interventions involve the establishment of wellness committees, introduction of wellness curricula, optimization of workflows, and creation of shared social spaces. There is a need for implementing wellness practices within residency programs in LMIC. By focusing on wellness, physicians can mitigate burnout, enhance their well-being, and improve patient care outcomes.

Interdisciplinary inpatient rehabilitation of acquired brain injury - Part II - a proposed model of care for Pakistan

Rehabilitation of acquired brain injury (ABI) is a complex and costly intervention in which the comprehensive rehabilitation services should be integrated with neurosciences units to provide best possible opportunities of recovery to the patients. Keeping in view the diversity and chronicity of impairments, the follow up needs to be well planned in terms of duration and patient convenience. These types of services need to be run by the government and funded by government, with parallel efforts to make national guidelines and registry to keep a track of patients suffering from ABI. In Pakistan, the burden of people with ABI is increasing. This can be attributed to the acts of terrorism and bomb blasts, rapid urbanization and increase in number of motor vehicles resulting in increased frequency of roadside accidents, lack of adequate medical and evacuation services and the absence of hyper acute neurosurgical units. We have proposed an ABI rehabilitation plan considering the local health care system, socio-cultural context and resources. The proposed ABI rehabilitation pathway will not only improve the clinical care and continued support delivered by health services to adults with ABI but will also facilitate community reintegration and support their families and care givers.

Interdisciplinary inpatient rehabilitation of acquired brain injury - Part-1: impairment based assessment and rehabilitation

The objective of this review is to describe the major impairments resulting from acquired brain injury (ABI) and their rehabilitation interventions resulting in better functional outcomes. Because of the nature of deficits and treatment cost, these patients may be lost to follow up. Comprehensive rehabilitation services integrated with neurosciences units are scarce in Pakistan. Keeping in view the diversity and chronicity of impairments, the follow up needs to be well planned in terms of duration and patient convenience. The rehabilitation needs of these patients go beyond physiotherapy alone, which is considered as the only form of rehabilitation in Pakistan. We focus only on the major impairments most seen after ABI. The rehabilitation team members providing their services and the possibilities are comprehensively explained in the review. These types of services need to be run by government and funded by government, with parallel efforts to make national guidelines and registry to keep a track of patients suffering from ABI. The proposed ABI rehabilitation pathway will not only improve the clinical care and continued support delivered by health services to adults with ABI but will also facilitate community reintegration and support their families and care givers.

The Role of Rehabilitation Services in the Optimal Management of Urinary Incontinence in Women

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The emerging role of focal muscle vibration in rehabilitation of neurological disorders

Focal muscle vibration (FMV) is an innovative approach to enhance balance and motor control in various neurological diseases. In this technique a low-amplitude/high-frequency vibratory stimulus is applied to a specific muscle using a mechanical device. The use of FMV in rehabilitation is relatively new and it promises to be an effective tool in improving rehabilitation outcomes. Over the past few years, the use of FMV in rehabilitation has increased because of certain advantages over traditional rehabilitation techniques. These include better patient adherence to the rehabilitation protocols due to its long-lasting effects, increase in muscle mass, better blood circulation, improved bone density, reduction in joints and back pain. This mini review summarizes the available evidence on the role of FMV in rehabilitation, its effects, and scope across different clinical disorders and neurological conditions such as management of spasticity, improving gait pattern in stroke, multiple sclerosis and Parkinson's disease.

Recent advances in the management of hemiplegic shoulder pain

Stroke is a debilitating neurological disorder with hemiplegia as most common presentation. Hemiplegic shoulder pain (HSP) affects a large number of stroke survivors and is associated with significant morbidity and low quality of life (QoL). The etiology is multifactorial and therefore the management is multipronged. Traditionally, oral analgesics have been advised with physical therapy and intra-articular steroid injections. This narrative review discusses emerging treatment strategies for HSP. It focuses on four key new treatments; electric stimulation, the use of robotics, intraarticular injections of novel anti-inflammatory agents, and pulsed radiofrequency treatment. Multiple studies have assessed the efficacy of these techniques and have found the efficacy and side effect profile to be comparable or superior to current management strategies for HSP. Integrating these interventions in the multidisciplinary rehabilitation programmes for stroke patients, can improve the management of HSP and reduce stroke related morbidity and disability.

Is environmental enrichment useful for stroke and other non-progressive brain injury? A Cochrane Review summary with commentary

BACKGROUND: Stroke and other traumatic brain injuries are the leading causes of global disability in adults. Environmental enrichment for neurological diseases is a relatively new concept within rehabilitation. These are interventions to enhance the level of somatic and social stimulation by providing an engaging environment. OBJECTIVE: To assess the effects of environmental enrichment on well-being, functional recovery, activity levels and quality of life in people who have stroke or non-progressive brain injury. METHODS: Multiple global databases were searched on 26 October 2020. Aim was to include only the randomized controlled trials that compared environmental enrichment with standard services. RESULTS: A single RCT study with 53 participants with stroke was included. It compared the environmental enrichment (physical, cognitive and social activities such as reading material, board and card games, gaming technology, music, artwork, and computer with Internet) with standard services in an inpatient rehabilitation setting. The evidence was of very low quality and follow up was of 3 months only. CONCLUSIONS: The current data are inconclusive and there is a need for well-designed large-scale trials to study the role of environmental enrichment in the functional recovery of neurological diseases.

Technological advancements in stroke rehabilitation

Early, coordinated, and multidisciplinary rehabilitation plays a major part in motor recovery after stroke. The conventional stroke rehabilitation primarily includes physical therapy, occupational therapy, and speech therapy. However, with these conventional methods, many stroke survivors still have a residual functional disability which impairs their ability to perform activities of daily living. This could be attributed to the insufficient therapy dose, low engagement and motivation of the patient, and lack of objective feedback to achieve significant improvements in function. Various technology-based stroke rehabilitation interventions have been developed in the last few decades which have shown promising results in improving stroke patients' functional mobility and independence. The use of technology promotes repetitive, task-specific training, active engagement of patients, integrating constructive and concurrent feedback, and accurately measuring functional improvement. This review summarizes the important technological advances in stroke rehabilitation, including exergames, telerehabilitation, robotic-assisted systems, virtual and augmented reality, wearable sensors, and smartphone applications.

Recent advances in the pelvic floor assessment and rehabilitation of Women with Pelvic Floor Dysfunction

Pelvic Floor Dysfunctions (PFDs) are a group of disorders characterized by inter-related symptoms of urology, gynaecology, colorectal or general pelvic pain. These mainly cause voiding or defecation disorders, pelvic organ prolapses, sexual dysfunctions and pelvic pain. PFDs adversely impact various domains of women's life including psychological, physical, social and sexual well-being. Pelvic Floor Rehabilitation (PFR) has been recommended as part of a multidisciplinary approach for evaluation and management of the multiple PFDs. The assessment of PFD has improved with utilization of new measurement tools and specific outcome measures for PFDs. PFR is a first-line treatment approach effective for PFDs. However, robust research is needed to test standardised assessment and physical therapy treatment protocols with long term efficacy. In this review, we discuss a range of PFDs, impairment-based classification, recent updates, and advances in the evaluation of PFDs, physical therapy tools and techniques for the treatment of PFDs.

Ergonomics and musculoskeletal disorders among health care professionals: Prevention is better than cure

Medical profession is demanding and requires long working hours, lengthy procedures, and constant posturing. Musculoskeletal disorders are common among health care professionals (HCP). The commonest musculoskeletal disorders reported include pain in the neck, back, shoulders, elbows, wrists, repetitive strain disorders, nerve injuries and chronic pain disorders. It can result in reduced performance, poor quality of life and significant disability. Ergonomics is the science of adapting the job, equipment, and the humans to each other for optimal safety and productivity. If workplace of a HCP is ergonomically inadequate it will lead to musculoskeletal disorders. The main ergonomic issues include sustained postures, repetitive tasks, forceful hand exertions, use of equipment and precision requirement. In order to prevent ergonomic related injuries, there is a need to increase awareness among HCPs regarding physical fitness, correct posturing, ergonomic adjustments in equipment and environment, and early recognition of problems specific to field.

The Analysis of Published Research on Gout and Hyperuricemia from Pakistan in National Biomedical Literature

Objective: This study analyzed the published research on gout and hyperuricemia in the national biomedical journals with an aim to highlight the research gaps in the management of gout and hyperuricemia in Pakistan. Methods: An online literature survey on global databases (Medline and Google Scholar) and local Pakistani database Pak Medinet was conducted from January to March 2018. Different keywords on gout and hyperuricemia in Pakistan were combined using Boolean operators. We included all kinds of manuscripts reporting work specifically related to gout or hyperuricemia from Pakistan and having the corresponding author or at least one author with an affiliation from a Pakistani institution. We also considered manuscript published on this topic in Pakistani journals by authors affiliated with other countries. Results: Thirty-four manuscripts were selected for review and analysis. Thirty-one manuscripts were written by local authors affiliated with institutions located in different cities of Pakistan. Five manuscripts had foreign authors, out of which two were authored by all Turkish authors, but others had Pakistani co- authors too. Most of the Manuscripts were published in the category of original research article. None of them was a randomized clinical trial (RCT). Conclusion: The number and quality of studies published on gout and hyper-uricemia from Pakistan is low. There is a need to conduct more epidemiological and interventional studies to know the actual burden of gout in the country and RCTs to compare different drug treatments for managing gout in the local population.

Multi-disciplinary rehabilitation for management of diabetes mellitus related neurological and musculoskeletal complications

Diabetes Mellitus (DM) is one of the most common metabolic disorders in the world. It can result in several neurological and musculoskeletal (MSK) conditions. These conditions adversely affect the mobility, community functioning and quality of life for the patient with DM. Rehabilitation Medicine Physicians (Physiatrists) can offer both diagnostic and therapeutic interventions for the accurate diagnosis and optimal management of neurological and MSK conditions associated with DM. These include diagnostic tests such as Nerve Conduction Studies and Electromyography, therapeutic interventions in form of pharmacological management of symptoms, prescription of appropriate physical therapy, occupational therapeutic exercise, injections, as well as psychosocial and cognitive interventions. A physiatrist can provide expert advice on musculoskeletal disorders in patients with DM, as they are formally trained in the evaluation, diagnosis, and management of MSK conditions. A multidisciplinary team for DM should include a physiatrist as one of the key members. This can help effectively address neurological and MSK disorders related to DM.

Quality of Life of the Elderly during the COVID-19 Pandemic in Asian Countries: A Cross-Sectional Study across Six Countries

Background: Few studies have explored the determinants of health-related quality of life (HRQoL) in the elderly during the COVID-19 pandemic. Identifying these factors may help implement appropriate policies to enhance HRQoL in the elderly. Therefore, we aimed to identify the predictors of physical and mental component summary (PCS and MCS) scores of HRQoL in selected six low- and middle-income Asian countries. Methods: We conducted an online survey of older people aged ≥55 years in six countries: Bangladesh, Iran, Iraq, Malaysia, Palestine, and Sri Lanka. The Stark QoL questionnaire was used to measure the PCS and MCS scores. Univariate and multiple variable analyses after adjusting for confounders were performed to identify the possible predictors of PCS and MCS. Results: A total of 1644 older people (69.1 ± 7.8 years, range 55−97 years, Female: 50.9%) responded to the survey. We documented age, country of residence, marital status, number of male children, current employment status, and health insurance, ability to pay household bills, frequency of family members visits and receiving support during COVID-19 pandemic predicted both PCS and MCS. However, gender, residence, and number of female children were associated with PCS only (all p < 0.05). Conclusion: Socio-demographic factors such as age, country of residence, marital status, number of male children, current employment status, health insurance, ability to pay household bills, frequency of family members visiting family members, and receiving support during the COVID-19 pandemic affecting both physical and mental quality of life. These results can guide formulating health care planning policies to enhance QoL during COVID-19 and future pandemics in the elderly.

Need for Clinical Guidelines for Management of Osteoporosis: Do Not Forget Role of Rehabilitation Interventions

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The emerging role of virtual reality training in rehabilitation

Virtual reality (VR) uses computer-generated simulations to create a virtual environment for users which appears, sounds, and feels like real-life objects and events. The use of VR in rehabilitation is relatively new and has demonstrated to be an effective tool in achieving desired clinical outcomes by active engagement of participants. Over the past few years, the use of VR in rehabilitation has rapidly increased because of its advantages over traditional rehabilitation techniques. These include better patient adherence to the rehabilitation protocols with high levels of engagement and motivation. This review summarises the available evidence on the role of VR in rehabilitation, its effects, and scope across different clinical conditions and outcomes. We also describe the current status of VR utilization in rehabilitation settings across Pakistan and highlight the need for further research.