Publications by authors named "Christoph Gutenbrunner"

121 Publications

Treatment of upper limb spasticity with inhibitory repetitive transcranial magnetic stimulation: A randomized placebo-controlled trial.

NeuroRehabilitation 2021 Sep 13. Epub 2021 Sep 13.

BDH-Clinic Hessisch Oldendorf, Institute for Neurorehabilitation Research (InFo), Associated Institute of Hannover Medical School, Hessisch Oldendorf, Germany.

Background: Upper limb dysfunction is a frequent complication after stroke impairing outcome. Inhibitory repetitive transcranial magnetic stimulation (rTMS) applied over the contralesional hemisphere is supposed to enhance the positive effects of conventional rehabilitative treatment.

Objective: This double-blind randomized placebo-controlled trial investigated whether inhibitory rTMS as add-on to standard therapy improves upper limb spasticity.

Methods: Twenty-eight patients (aged 44 to 80 years) with unilateral stroke in the middle cerebral artery territory were analyzed. Participants were randomly assigned to inhibitory, low-frequency (LF-) rTMS (n = 14) or sham-rTMS (n = 14). The primary outcome measure was the spasticity grade, which was assessed with the Modified Ashworth Scale (MAS). In addition, the Fugl-Meyer-Assessment (FMA) for the upper extremity (UE) and a resting-state fMRI were performed to measure motor functions and the sensorimotor network, respectively.

Results: The MAS score was reduced in the LF-rTMS group only, whereas the FMA score improved in both groups over time. Regarding the fMRI data, both groups activated typical regions of the sensorimotor network. In the LF-rTMS group, however, connectivity to the left angular gyrus increased after treatment.

Conclusion: Changes in functional connectivity in patients receiving inhibitory rTMS over the contralesional motor cortex suggest that processes of neuronal plasticity are stimulated.
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http://dx.doi.org/10.3233/NRE-210088DOI Listing
September 2021

Ramadan Fasting in Germany (17-18 h/Day): Effect on Cortisol and Brain-Derived Neurotrophic Factor in Association With Mood and Body Composition Parameters.

Front Nutr 2021 12;8:697920. Epub 2021 Aug 12.

Department of Rehabilitation Medicine, Hannover Medical School, Hannover, Germany.

Ramadan fasting (RF) is a type of diurnal intermittent fasting. Previous studies reported the benefits of RF in healthy subjects on mood and health related to quality of life (QoL). Cortisol and brain-derived neurotrophic factor (BDNF) have been shown to play a role in mood, body composition parameters, and health-related QoL. This study aimed at elucidating the mechanism of the benefit of RF, particularly cortisol and BNDF and their association with mood and QoL. Insulin growth factor-1 (IGF-1), interleukin (IL)-8, matrix metalloproteinase (MMP)-9, and myoglobin were determined. Thirty-four healthy men and women were recruited. Serum from peripheral venous blood samples was collected at five time points: 1 week before RF (T1); mid of RF (T2), last days of RF (T3), 1 week after RF (T4), and 1 month after RF (T5). The amounts of biological mediators in the serum samples were determined by enzyme-linked immunosorbent assay (ELISA) and Luminex assays. BDNF and cortisol significantly decreased at T3 ( < 0.05) and T4 ( < 0.001) compared to T1, respectively. It seems the benefits of RF for mood-related symptoms are mediated by different biological mediators, particularly cortisol and BDNF.
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http://dx.doi.org/10.3389/fnut.2021.697920DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8387581PMC
August 2021

Adaptations for rehabilitation services during the COVID-19 pandemic proposed by scientific organizations and rehabilitation professionals.

J Rehabil Med 2021 Sep 16;53(9):jrm00228. Epub 2021 Sep 16.

Health Rehabilitation Group and Academic Group of Clinical Epidemiology, University of Antioquia, Antioquia, Colombia. E-mail:

Objective: To describe adaptations in the provision of rehabilitation services proposed by scientific and professional rehabilitation organizations to avoid interruptions to patients rehabilitation process and delays in starting rehabilitation in patients with COVID-19.

Methods: A narrative review approach was used to identify the recommendations of scientific and professional organizations in the area of rehabilitation. A systematic search was performed in the main data-bases in 78 international and regional web portals of rehabilitation organizations. A total of 21 publications from these organizations were identified and selected.

Results: The results are presented in 4 categories: adequacy of inpatient services, including acute care services and intensive care unit for patients with and without COVID-19; adequacy of outpatient services, including home-based rehabilitation and tele-rehabilitation; recommendations to prevent the spread of COVID-19; and regulatory standards and positions during the COVID-19 pandemic expressed by organizations for protecting the rights of health workers and patients.

Conclusion: Health systems around the world are rapidly learning from actions aimed at the reorganization of rehabilitation services for patients who are in the process of recovery from acute or chronic conditions, and the rapid response to the rehabilitation of survivors of COVID-19, as well as from efforts in the prevention of contagion of those providing the services.
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http://dx.doi.org/10.2340/16501977-2865DOI Listing
September 2021

Scope and Practices of Physical Therapists Working With Children: Results From an International Online Survey.

Pediatr Phys Ther 2021 Aug 19. Epub 2021 Aug 19.

School of Rehabilitation (Drs Camden and Cinar and Ms Gauvin), Sherbrooke University, Sherbrooke, Quebec, Canada; Research Centre of the Sherbrooke University Hospital Centre (Drs Camden and Cinar and Mr Berbari), Sherbrooke, Quebec, Canada; School of Physiotherapy (Dr Mulligan), Otago University, Christchurch, New Zealand; Department of Rehabilitation Medicine (Drs Nugraha and Gutenbrunner), Hannover Medical School, Hannover, Germany.

Purpose: To describe the scope of practice of physical therapists (PTs) working with children worldwide.

Methods: PTs working with children in any context and country were invited via social media and email campaigns to complete an online survey containing 42 questions about work context and service delivery. Descriptive statistics were computed.

Results: Of the 1133 participants from 77 countries, most worked with children full-time (51.8%), and in government-funded work settings (57.5%). Modalities of access to services varied across countries, work settings, and children's conditions, yet 46.7% of PTs reported that most children had direct access to services. PTs provided services to children with a variety of conditions, with cerebral palsy being most reported (83.3%). Interventions focused primarily on improving body function (42.0%) and on providing face-to-face individual treatment (96.6%).

Conclusions: This study provides an international portrait of pediatric PT practice and illustrates the diversity of services in pediatric PT.
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http://dx.doi.org/10.1097/PEP.0000000000000816DOI Listing
August 2021

[Translation, Adaptation, Reliability and Validity of the German Version of the Prosthesis Mobility Questionnaire 2.0 (PMQ) on Patients with Major Lower Limb Amputation].

Rehabilitation (Stuttg) 2021 Jul 22. Epub 2021 Jul 22.

Klinik für Rehabilitationsmedizin, Medizinische Hochschule Hannover.

Purpose: The aim of this prospective validation study was to translate the Prosthesis Mobility Questionnaire 2.0 (PMQ) into German based on a guideline, following by psychometric testing for its validity and reliability using classical test theory.

Methods: The PMQ was translated into German according to ISPOR guidelines using double forward and double backward translations, finalized by pilot testing (N=10). Subsequently, assessment of the validity and reliability was performed from March 2020 to August 2020 on N=61 patients with unilateral lower limb amputation. Construct validity was determined by using the German version of the Locomotor Capabilities Index-5 (LCI-5-D), the Rivermead Mobility Index (RMI), the Timed up and go Test (TUG), and K-levels. Cronbach's alpha was calculated to check internal consistency and discriminatory power was determined by item correlations. Test-retest reliability was calculated using ICC (2,1). Based on the ICC, the minimum detectable difference (MDC) was calculated.

Results: The translation process required small changes after the pilot test. The validation study was performed on N=61 patients (56.59±13.16 years, m/f=38/23). A mean PMQ of 26.23±8.89 points was achieved. Ceilings or floor effects for total score did not appear. Construct validity showed strong positive correlations to LCI-5-D (r=0.74, p<0.001), RMI (r=0.63 p<0.001) as well as k-levels (r=0.61 p<0.001) and moderate negative correlation to TUG (r=- 0.49, p<0.001). Internal consistency was excellent with Cronbach's alpha=0.95). All items showed a value greater than r=0.40 for item-to-total score correlation. Test-retest reliability was excellent with an ICC (2,1)=0.98 with a timespan between T0 and T1 of 3.2±2.83 days. Based on this results, the MDC was 3.40 points.

Conclusion: The German version of the Prosthesis Mobility Questionnaire 2.0 is a valid, reliable patient reported outcome measure (PROM) for measuring mobility and functional ability of patients with exoprosthesis due to unilateral lower limb amputation. It can be used for a German-speaking population.
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http://dx.doi.org/10.1055/a-1506-7603DOI Listing
July 2021

ROLE OF NURSING IN REHABILITATION.

J Rehabil Med Clin Commun 2021 14;4:1000061. Epub 2021 Jun 14.

Department of Rehabilitation Medicine, Hannover Medical School, , Hannover, Germany.

Evidence shows that, in order to attain optimum outcomes, rehabilitation interventions should be delivered by multi-professional teams. A rehabilitation nurse is one of the relevant rehabilitation professionals. The model of nursing care has shifted from the traditional model (a passive role of patients) to a complex and modern concept of nursing in supporting patients to independently and actively perform self-care. This paper briefly introduces the role of nurses in rehabilitation, from the point of view of rehabilitation service delivery, which is relevant in all phases and types of rehabilitation care, including acute rehabilitation, post-acute rehabilitation, long-term rehabilitation, nursing home and geriatric care, and in community- based rehabilitation service.
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http://dx.doi.org/10.2340/20030711-1000061DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8215228PMC
June 2021

Health inequalities and income for people with spinal cord injury. A comparison between and within countries.

SSM Popul Health 2021 Sep 26;15:100854. Epub 2021 Jun 26.

Swiss Paraplegic Research, Guido A. Zäch Institute, Nottwil, Switzerland.

Income and health are related in a bi-directional manner, whereby level of income affects health and vice versa. People in poorer households tend to experience worse health status and higher mortality rates than people in wealthier households, and, at the same time, having poor health could restrict workability leading to less income. This gap exists in almost every country, and it is more pronounced in more unequal countries and in vulnerable populations, such as people experiencing disability. The goal of this paper is to estimate the health-income gap in people with a Spinal Cord Injury (SCI), which is a chronic health condition often associated with multiple comorbidities that leads to disability. As data on mortality is inexistent, to estimate the health-income gap for persons with SCI, this paper uses two health outcomes: the number of years a person has lived with the injury, and a comorbidity index. Data was obtained from the International Spinal Cord Injury survey (InSCI), which is the first worldwide survey on community-dwelling persons with SCI. To compare across countries, the health outcomes were adjusted through hierarchical models, accounting for country fixed-effects, individual characteristics such as age and gender, and injury characteristics (cause, type and degree). Our results suggest that for the years living with SCI, the gap varies from 1 to 6 years between the lowest and the highest income groups. The main driver of such a difference is the cause of injury, where injuries caused by work accidents showed the biggest gap. Similarly, for the comorbidity index, persons with SCI in poorer deciles reported significantly more comorbidities, forty times more, than people in richer deciles.
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http://dx.doi.org/10.1016/j.ssmph.2021.100854DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8259327PMC
September 2021

Which factors have an association to the Quality of Life (QoL) of people with acquired Spinal Cord Injury (SCI)? A cross-sectional explorative observational study.

Spinal Cord 2021 Aug 8;59(8):925-932. Epub 2021 Jul 8.

Department of Rehabilitation Medicine, Hannover Medical School, Hanover, Germany.

Study Design: Cross-sectional explorative observational study.

Objectives: To identify factors which have an association to the self-perceived Quality of Life (QoL) for persons with acquired spinal cord injury (SCI).

Setting: Eight specialized SCI-centers in Germany. The GerSCI survey is the German part of the International Spinal Cord Injury Survey (InSCI).

Methods: Self-disclosure questionnaire, created from the InSCI group, translated and adapted for Germany. The questionnaire collects a very broad range of data and, and due to its design as a self-report, is particularly suitable for the analysis on QoL. Because of the content, which is binding for all participating states, it allows a direct comparability of the results. Included in Germany were 1479 persons with acquired SCI aged 18 years and older.

Results: Various factors were identified with high associations to QoL, including changeable and unchangeable ones, such as those of particular importance: pain, sleep problems, sexual dysfunction, age, and time since onset of SCI. Some results confirmed reports of previous studies, others were surprising.

Conclusion: this study provides an important basis for the planned analysis of the InSCI participating countries in the 6 WHO regions. Germany was able to contribute the largest study population. The concrete study design of InSCI allows us to directly compare data and helps us to improve ourselves within the framework of a "learning health system". Medical measures can be orientated towards the found results, in order to ensure the best possible care and support by the therapeutic team, individually adapted to the person, place of residence and impairment.
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http://dx.doi.org/10.1038/s41393-021-00663-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8338547PMC
August 2021

A prospective controlled study on Ramadan fasting in the healthy young males in summer in Germany: effect on cytokines.

J Complement Integr Med 2020 Dec 25;18(2):425-431. Epub 2020 Dec 25.

Department Rehabilitation Medicine, Hannover Medical School, Carl-Neuberg-Str.1, 30625 Hannover, Germany.

Short Communication: During the Ramadan fasting (RF) month, participants restrict some activities during day time, particularly consumption of food and beverages. In Germany, Muslims fast about 18-19 h a day when Ramadan falls in the summer. This longer period of restriction could lead to the changes of the body physiology, anthropometric parameters and biological mediators.

Objectives: This study aimed to determine the effect of Ramadan fasting on cytokines (Interleukin (IL)-1β. IL-6, IL-8, IL-10, IL-12, tumor necrosis factor (TNF)-α) during RF in Germany. Correlations of cytokines with anthropometric parameters were also determined.

Methods: Fifty healthy adult males were recruited and divided into two equal groups: fasting group (FG) and non-fasting group (NFG). FG was evaluated at T1: one week before, T2: mid-, T3: last days of, and T4: one week after Ramadan. The NFG were evaluated only at T1 and T3.

Results: In FG significant alterations of IL-1β was observed. Insignificant differences were found between the FG and NFG at T1 and T3 concerning the measured cytokines. Circulating IL-1β increased significantly from T2 to T4 and from T3 to T4. At T3, TNF-α was correlated significantly with anthropometric parameters such as the body weight, the skeletal muscle mass and the fat free mass, whilst IL-12 was correlated significantly with the skeletal muscle mass, the fat free mass and the body water mass at T4.

Conclusions: Significant Alterations of IL-1β during RF in FG were observed. Anthropometric parameters correlate with TNF-α and IL-12 levels during at T3 and T4, respectively.
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http://dx.doi.org/10.1515/jcim-2019-0209DOI Listing
December 2020

Long term outcome of functional independence and quality of life after traumatic SCI in Germany.

Spinal Cord 2021 Aug 25;59(8):902-909. Epub 2021 Jun 25.

Klinik Hohe Warte, Hospital Bayreuth, Bayreuth, Germany.

Study Design: Multicenter observational study.

Objective: To describe the long-term outcome of functional independence and quality of life (QoL) for individuals with traumatic and ischemic SCI beyond the first year after injury.

Setting: A multicenter study in Germany.

Methods: Participants of the European multicenter study about spinal cord injury (EMSCI) of three German SCI centers were included and followed over time by the German spinal cord injury cohort study (GerSCI). Individuals' most recent spinal cord independence measure (SCIM) scores assessed by a clinician were followed up by a self-report (SCIM-SR) and correlated to selected items of the WHO short survey of quality of life (WHO-QoL-BREF).

Results: Data for 359 individuals were obtained. The average time passed the last clinical SCIM examination was 81.47 (SD 51.70) months. In total, 187 of the 359 received questionnaires contained a completely evaluable SCIM-SR. SCIM scores remained stable with the exception of reported management of bladder and bowel resulting in a slight decrease of SCIM-SR of -2.45 points (SD 16.81). SCIM-SR scores showed a significant correlation with the selected items of the WHO-QoL-BREF (p < 0.01) with moderate to strong influence.

Conclusion: SCIM score stability over time suggests a successful transfer of acquired independence skills obtained during primary rehabilitation into the community setting paralleled by positively related QoL measurements but bladder and bowel management may need special attention.
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http://dx.doi.org/10.1038/s41393-021-00659-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8338549PMC
August 2021

Rasch validation and comparison of the German versions of the Locomotor Capabilities Index-5 and Prosthetic Mobility Questionnaire 2.0 in lower-limb prosthesis users.

Int J Rehabil Res 2021 Sep;44(3):233-240

Physical Medicine and Rehabilitation Department, Istituti Clinici Scientifci Maugeri, IRCCS, Institute of Tradate (VA), Italy.

This study aimed to compare, through Rasch analysis, the psychometric properties of the Locomotor Capabilities Index (LCI-5) and Prosthetic Mobility Questionnaire (PMQ 2.0) in German lower-limb prosthesis users. The questionnaires were concurrently administered to a convenience sample of 98 consecutively recruited individuals with lower limb amputation (LLA) (male/female = 61/37; mean age 57 ± 14 years). LCI-5 showed disordered rating scale thresholds (one response option in three items required collapsing); local dependence between two items (resolved by creating a testlet); underfit of one item ('Get up from the floor'); and presence of a second weak dimension. PMQ 2.0 showed a correctly functioning rating scale; good fit of the data to the model (apart from some overfit); local dependence between two items (absorbed by creating a testlet); and essential unidimensionality. At scale co-calibration onto a common interval-scaled metric, PMQ 2.0 was better targeted than LCI-5 (i.e. the extent of item difficulty was more appropriate for the sample) and its operational range allowed a more precise measurement of higher locomotor abilities. The correlation between LCI-5 and PMQ 2.0 scores was rho =  0.78. In conclusion, LCI-5 revealed some drawbacks, confirming a previous Rasch study; refinement of its rating scale and item selection seems therefore warranted. The PMQ 2.0 demonstrated good overall measurement quality, in line with previous Italian and Slovene studies. The operational range of the PMQ 2.0 makes it more suitable than LCI-5 for assessing people with high locomotor abilities.
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http://dx.doi.org/10.1097/MRR.0000000000000478DOI Listing
September 2021

The Flexor Pollicis Longus Reflex: Interrater and Intrarater Reliability in Comparison With Established Muscle Stretch Reflexes.

Am J Phys Med Rehabil 2021 06;100(6):539-545

From the Department of Rehabilitation Medicine, Hannover Medical School, Hannover, Germany (LMG, CS, CG, AR); and University of Applied Sciences and Art, Hildesheim, Germany (TS-K).

Objective: The aim of this study was to investigate the interrater reliability and intrarater reliability of the flexor pollicis longus muscle stretch reflex (FPLR) and compare it with clinically established reflexes.

Design: A total of 71 healthy volunteers participated. The FPLR, biceps reflex, brachioradialis reflex, and patellar tendon reflex of each participant were tested bilaterally and rated by eight examiners (four experienced, four inexperienced). For intrarater reliability evaluation, five examiners rated the reflexes of four volunteers at four different points in time.

Results: Analysis of the interrater reliability with Gwet's AC1 demonstrated almost perfect agreement for FPLR (Gwet's AC1 = 0.90), biceps reflex (Gwet's AC1 = 0.90), and patellar tendon reflex (Gwet's AC1 = 0.95) when using binary data (reflex present vs. absent). Only fair agreement was found for the brachioradialis reflex (Gwet's AC1 = 0.56). Experienced raters had a higher agreement than inexperienced raters did when rating the biceps reflex and the patellar tendon reflex. The intrarater reliability was almost perfect for the patellar tendon reflex (Gwet's AC1 = 0.94), followed by the FPLR (Gwet's AC1 = 0.83) with substantial agreement and the biceps reflex (Gwet's AC1 = 0.57) with moderate agreement.

Conclusion: The FPLR is a reliable diagnostic neuromuscular test and may therefore be useful in the clinical examination for C8/T1 nerve root lesions or pathologies of the interosseous anterior nerve.

To Claim Cme Credits: Complete the self-assessment activity and evaluation online at http://www.physiatry.org/JournalCME.

Cme Objectives: Upon completion of this article, the reader should be able to: (1) Elicit the flexor pollicis longus muscle stretch reflex; (2) Discuss the disadvantage of kappa statistics in assessing the interrater reliability when the prevalence of the studied trait is very high or very low; and (3) Name the spinal nerves involved in the innervation of the flexor pollicis longus muscle.

Level: Advanced.

Accreditation: The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.The Association of Academic Physiatrists designates this Journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.
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http://dx.doi.org/10.1097/PHM.0000000000001731DOI Listing
June 2021

Towards standardized reporting of service organization in rehabilitation for clinical trials.

J Rehabil Med 2021 Jun 14;53(6):jrm00207. Epub 2021 Jun 14.

Department of Rehabilitation Medicine, Hannover Medical School, Carl-Neuberg-Str.1, DE-30625 Hannover, Germany. E-mail:

Meta-analysis of clinical trials in rehabilitation is often inconclusive, even when similar interventions are investigated. A possible reason for this is the influence of the settings in which rehabilitation services are delivered. Examples show that factors related to service organization in rehabilitation can influence study outcomes. This, in particular, is relevant, as contextual factors in rehabilitation are known to influence the participation and functioning of persons with disability. The Consolidated Statement of Reporting Trials (CONSORT) group and other initiatives published standards for reporting relevant factors for clinical trials. However, description of the rehabilitation setting of factors related to rehabilitation service provision is under-represented. Systematic reviews show that, on the one hand, these factors are scarcely reported, and only a few studies systematically evaluated the influence of factors related to service organization on rehabilitation outcomes. The International Classification of Service Organization in Rehabilitation (ICSO-R) provides a framework to systematically describe rehabilitation services. It contains 40 categories and sub-categories for the domains "provider" and "service delivery". Therefore, it is important and relevant to develop a minimum reporting set for factors relevant to service organization for rehabilitation trials. This paper sets out a methodological approach for this purpose, including literature reviews, Delphi survey focus group discussion, and consensus conference.
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http://dx.doi.org/10.2340/16501977-2842DOI Listing
June 2021

The p38/MK2 Axis in Monocytes of Fibromyalgia Syndrome Patients: An Explorative Study.

Medicina (Kaunas) 2021 Apr 19;57(4). Epub 2021 Apr 19.

Department of Rehabilitation Medicine, Hannover Medical School, Carl-Neuberg-Str.1, 30625 Hannover, Germany.

: The aetiology and pathomechanism of fibromyalgia syndrome 12 (FMS) as one of chronic pain syndromes still need to be further elucidated. Mitogen-activated protein kinase (MAPK) pathway has been proposed as a novel approach in pain management. Since the major symptom of fibromyalgia syndrome (FMS) patients is pain, it became of interest whether MAPK pathways, such as the stress-activated p38 MAPK/MK2 axis, are activated in FMS patients. Therefore, this study aimed at determining p38 MAPK/MK2 in FMS patients. : Phosphorylation of MAPK-activated protein kinases 2 (MK2), a direct target of p38 MAPK, was measured in monocytes of FMS and healthy controls (HCs) to monitor the activity of this pathway. : The mean level of phosphorylated MK2 was fivefold higher in FMS patients as compared to HCs ( < 0.001). Subgroup analysis revealed that antidepressants did not influence the activity of MK2 in FMS patients. : This result indicates that the p38/MK2 pathway could be involved in the pathomechanism of FMS, could act as a clinical marker for FMS, and could be a possible target for pain management in FMS patients.
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http://dx.doi.org/10.3390/medicina57040396DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8072914PMC
April 2021

Brain-Derived Neurotrophic Factor and Immune Cells in Osteoarthritis, Chronic Low Back Pain, and Chronic Widespread Pain Patients: Association with Anxiety and Depression.

Medicina (Kaunas) 2021 Apr 1;57(4). Epub 2021 Apr 1.

Department of Rehabilitation Medicine, Hannover Medical School, Carl-Neuberg-Str.1, 30625 Hannover, Germany.

: Musculoskeletal dysfunction can induce several types of chronic pain syndromes. It is of particular interest to elucidate the pathomechanism of different forms of chronic pain. It is possible that patients who have developed chronic widespread pain (CWP) may endure different pathomechanisms as compared to those who suffer from local pain (osteoarthritis, OA) and regional pain (chronic low back pain, cLBP), especially with regard to pain regulation and its related biomediators. The aim of this study was to determine the differences in pathomechanisms among these patients by measuring pain-related biomediators, particularly brain-derived neurotrophic factor (BDNF). Additionally, subpopulations of immune cells were determined in parallel. : Patients and healthy subjects (HSs) were recruited (age and gender-matched). BDNF was measured from serum samples of patients and HSs and the data of body composition parameters were recorded. Additionally, both patients and HSs were asked to fill in questionnaires related to pain intensity, anxiety, and depression. : Our results highlight that the levels of both free and total BDNF are significantly lower in pain patients compared to HSs, with values of 0.041 and 0.024, respectively. The number of CD3 CD56 natural killer (NK) cells shows significant differences between the groups. Comparing all chronic pain patients with HSs reveals a significantly lower number of CD4 CD8 T cells ( 0.031), CD3 CD56 NK cells ( 0.049) and CD20 CD3 cells ( = 0.007). : To conclude, it seems that a general conformity between the pathomechanisms of different chronic pain diseases exists, although there are unique findings only in specific chronic pain patients.
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http://dx.doi.org/10.3390/medicina57040327DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8065931PMC
April 2021

Phase-Adapted Rehabilitation for Acute Coronavirus Disease-19 Patients and Patient With Long-term Sequelae of Coronavirus Disease-19.

Am J Phys Med Rehabil 2021 06;100(6):533-538

From the Department of Rehabilitation Medicine, Hannover Medical School, Hannover, Germany.

Abstract: Since the beginning of the COVID-19 pandemic in early 2020, many papers have highlighted the need for the rehabilitation of patients with SARS-CoV-2 infection. Most papers refer to the need for respiratory rehabilitation in the acute phase; however, the fact that the infection also affects other organ systems has to be considered in rehabilitation interventions. Long-term symptoms in many cases severely limit activity and participation and alter quality of life, leading to rehabilitation needs. This article proposes a phase-adapted model of linking the acute, postacute, and long-term symptoms of COVID-19 with the well-established matrix of acute, postacute, and long-term rehabilitation services. A review of currently available recommendations for phase-adapted rehabilitation strategies, including the relevance of prehabilitation within this context, is provided.
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http://dx.doi.org/10.1097/PHM.0000000000001762DOI Listing
June 2021

"Fit for work and life": an innovative concept to improve health and work ability of employees, integrating prevention, therapy and rehabilitation.

J Rehabil Med 2021 May 31;53(5):jrm00199. Epub 2021 May 31.

Department of Rehabilitation Medicine, Coordination Centre for Rehabilitation Research, Hannover Medical School, Carl-Neuberg-Str. 1, DE-30625 Hannover, Germany.

Objectives: To set up a comprehensive health programme for employees, with needs-based allocation to preventive and rehabilitative measures; and to evaluate the effects of the programme on work ability and sick leave.

Design: Prospective single-group observational study.

Methods: Employees of a university hospital were invited to participate in needs-based interventions of preventive or rehabilitative character. Allocation followed screening questionnaires, anamnesis and clinical examination. The selection of a preventive or rehabilitative measure appropriate to the needs of the patient followed screening questionnaires, anamnesis and clinical examination. Preventive offers can include back training courses, water gymnastics or stress management exercises. Rehabilitative measures can include 3-6 weeks in- or outpatient rehabilitation or one week intensive outpatient rehabilitation. The main outcome parameters were work ability and sick leave duration.

Results: At this time of the project included 1,547 participants, who applied voluntarily to enter the programme. The mean age of participants was 44.3 years (standard deviation (SD) 10.3 years), and 72.0% were female. Needs-based allocation to a prevention (n=1,218) or a rehabilitation group (n=329) was effective, and enabled formation of 2 groups with different needs. Overall, more than half of the employees participating in the programme reported sick leave within the last 3 months. Participants in the preventive measures group reported significantly lower duration of sick leave than those in the rehabilitation group. Employees in the rehabilitation group had significantly lower work ability (Work Ability Index (WAI) 30.4 vs 36.6), but higher effects at 6-month follow-up (WAI 33.4 (standardized effect size (SES) 0.51) vs 37.9 (SES 0.17)). In the prevention group mean sick leave reduced significantly from 1.9 to 1.3 weeks (p < 0.001) during the previous 3-month period, whereas in the rehabilitation group it reduced from 2.7 to 1.5 (p < 0.001) weeks.

Conclusion: Implementation of the comprehensive health programme was successful, using the multimodal infrastructure of a university hospital. Allocation to suitable interventions in occupational health programmes following screening, anamnesis and clinical examination is an appropriate way to meet participants' needs. The programme resulted in improved work ability and less sick leave.
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http://dx.doi.org/10.2340/16501977-2822DOI Listing
May 2021

Assessment of rehabilitation needs in patients after COVID-19: Development of the COVID-19-rehabilitation needs survey.

J Rehabil Med 2021 Apr 27;53(4):jrm00183. Epub 2021 Apr 27.

Institute for Physiotherapy, University Hospital, Jena, Germany.

Objective: COVID-19 can result in a broad spectrum of dysfunctions, some of which may persist for long periods, requiring long-term rehabilitation. A comprehensive screening tool is therefore necessary to identify these needs. To date, no data exist on satisfaction with medical and therapeutic interventions for COVID-19 in terms of quality and quantity. The aim of this study is to develop a survey for use with COVID-19 patients during and after the end of the acute phase of the disease.

Methods: Following the definition of dimensions by a group of experts, and a literature search, proven survey instruments were searched for suitable items. In addition, specific questions were developed based on symptoms, and answer options were created with regard to to the complexity of the questions.

Results: The COVID-19 Rehabilitation Needs Survey (C19-RehabNeS) consists of the established 36-item Short Form Survey (SF-36) together with the newly developed COVID-19-Rehabilitation Needs Questionnaire (C19-RehabNeQ) (11 further dimensions, respectively 57 items).

Conclusion: C19-RehabNeS is a comprehensive survey to assess functional limitations and rehabilitation needs during and after infection with SARS-CoV-2 (COVID-19). The strength of this survey is that it combines the assessment of important rehabilitation needs with assessment of satisfaction with the health services, treatment and therapy during the pandemic (C19-RehabNeQ) and assessment of patients' quality of life (SF-36). The C19-RehabNeS survey also enables collection of systematic information on patients with Post-COVID-19 syndrome (Long-COVID-19).
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http://dx.doi.org/10.2340/16501977-2818DOI Listing
April 2021

Auditory Stimulation Modulates Resting-State Functional Connectivity in Unresponsive Wakefulness Syndrome Patients.

Front Neurosci 2021 16;15:554194. Epub 2021 Feb 16.

BDH-Klinik Hessisch Oldendorf, Hessisch Oldendorf, Germany.

Passive listening to music is associated with several psychological and physical benefits in both, healthy and diseased populations. In this fMRI study, we examined whether preferred music has effects on the functional connectivity within resting-state networks related to consciousness. Thirteen patients in unresponsive wakefulness syndrome (UWS) and 18 healthy controls (HC) were enrolled. Both groups were exposed to different auditory stimulation (scanner noise, preferred music, and aversive auditory stimulation). Functional connectivity was analyzed using a seed-based approach. In HC, no differences were found between the three conditions, indicating that their networks are already working at high level. UWS patients showed impaired functional connectivity within all resting-state networks. In addition, functional connectivity of the auditory network was modulated by preferred music and aversive auditory stimulation. Hence, both conditions have the potential to modulate brain activity of UWS patients.
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http://dx.doi.org/10.3389/fnins.2021.554194DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7921457PMC
February 2021

Describing community-based rehabilitation services in Indonesia by using The International Classification of Service Organization in Rehabilitation 2.0.

J Rehabil Med 2021 Mar 22;53(3):jrm00166. Epub 2021 Mar 22.

Department of Rehabilitation Medicine , Hannover Medical School, Carl-Neuberg-Str.1, DE-30625 Hannover, Germany. E-mail:

Objective: Describing rehabilitation services in a standardized way is a challenge. The International Classification of Service Organizations in Rehabil-itation (ICSO-R) 2.0 was published for this purpose. The ICSO-R was criticized for being tested mainly in high-income countries, and because the testing in lower-income countries did not include community-based rehabilitation services. Therefore, this study was performed to describe community-based rehabilitation services by using ICSO-R 2.0.

Methods: The ICSO-R 2.0 was used to describe 8 community-based rehabilitation services located in 3 cities in 3 different provinces in Indonesia: 6 community-based rehabilitation services in Bandung, West Java; 1 in Tanah Datar, West Sumatra; and 1 in Gowa, South Sulawesi.

Results: All the community-based rehabilitation services were owned by the government, as a public body, and in the context of the community. The 6 community-based rehabilitation services in Bandung, West Java, are under the government city of Bandung, while the other 2, from Tanah Datar and Gowa, are integrated within primary healthcare centres. Social welfare supports all 6 community-based rehabilitation services in Bandung. The other 2 community-based rehabilitation services are supported by their respective primary healthcare centres.

Conclusion: The ICSO-R 2.0 is a feasible tool to describe rehabilitation services, including community-based rehabilitation.
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http://dx.doi.org/10.2340/16501977-2804DOI Listing
March 2021

Teaching functioning, disability and rehabilitation to first year medical students.

J Rehabil Med 2021 Feb 25;53(2):jrm00158. Epub 2021 Feb 25.

Department of Rehabilitation Medicine, Coordination Centre for Rehabilitation Research, Hannover Medical School, Carl-Neuberg-Str. 1, DE-30625 Hannover, Germany.

Background: Many patients have disabilities; it is therefore essential that medical education includes comprehensive teaching on disability and rehabilitation. In 2006 Hannover Medical School implemented an introductory course in the curriculum for medical students, on how to communicate with persons with disability and the need for rehabilitation. The course, entitled "Introduction to medicine", has the main goals of teaching the strategy and systematic approach of medicine to solving patients' problems.

Methods: This paper describes the content, methods and outcomes of 1 of the 4 main themes of the "Introduction to medicine" course; the theme "Pain and disability", which is covered in the second week of the course.

Results: Evaluation of the "Pain and disability" module found that students' ratings for the category "patient involvement" were very high (93%), whereas their ratings for the category "examination of student knowledge" were low. The overall rating of the module was "good" (10.8 out of 15 points), but not "very good".

Conclusion: The concept of the "Pain and disability" module is feasible and successful, even though it is scheduled early in the first year of the curriculum and approximately 350 students participate. Factors related to this success are: a mixture of teaching knowledge, supporting students' understanding, and applying communication and physical examination skills.
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http://dx.doi.org/10.2340/16501977-2797DOI Listing
February 2021

Combination of acupuncture and medical training therapy on tension type headache: Results of a randomised controlled pilot study.

Cephalalgia 2021 Jul 9;41(8):879-893. Epub 2021 Feb 9.

Department for Rehabilitation Medicine, Hannover Medical School, Hannover, Germany.

Objectives: The aim of this study was to compare the effects of acupuncture and medical training therapy alone and in combination with those of usual care on the pain sensation of patients with frequent episodic and chronic tension-type headache.

Design: This was a prospective single-centre randomised controlled trial with four balanced treatment arms. The allocation was carried out by pre-generated randomisation lists in the ratio 1:1:1:1 with different permutation block sizes.

Setting: The study was undertaken in the outpatient clinic of Rehabilitation Medicine of the Hannover Medical School. Ninety-six adult patients with tension-type headache were included and randomised into usual care (n = 24), acupuncture (n = 24), medical training (n = 24), and combination of acupuncture and medical training (n = 24). One patient was excluded from analysis because of withdrawing her/his consent, leaving 95 patients for intention to treat analysis. Each therapy arm consisted of 6 weeks of treatment with 12 interventions. Follow-up was at 3 and 6 months.

Main Outcome Measures: Pain intensity (average, maximum and minimum), frequency of headache, responder rate (50% frequency reduction), duration of headache and use of headache medication. The combination of acupuncture and medical training therapy significantly reduced mean pain intensity compared to usual care (mean = -38%, standard deviation = 25%,  = 0.012). Comparable reductions were observed for maximal pain intensity (-25%, standard deviation = 20%, 0.014) and for minimal pain intensity (-35%, standard deviation = 31%, 0.03). In contrast, neither acupuncture nor medical training therapy differed significantly from usual care. No between-group differences were found in headache frequency, mean duration of headache episodes, and pain medication intake. At 3 months, the majority of all patients showed a reduction of at least 50% in headache frequency. At 6 months, significantly higher responder rates were found in all intervention groups compared to usual care.

Conclusions: In contrast to monotherapy, only the combination of acupuncture and medical training therapy was significantly superior in reduction of pain intensity compared to usual care. Registered on 11 February 2019. German Clinical Trials Register, DRKS00016723.
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http://dx.doi.org/10.1177/0333102421989620DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8217893PMC
July 2021

Five years after development of the national disability, health and rehabilitation plan for Ukraine: Achievements and challenges.

J Rehabil Med 2021 Mar 3;53(3):jrm00160. Epub 2021 Mar 3.

Department of Physical and Rehabilitation Medicine and Sports Medicine, Shupyk National Medical Academy for Postgraduate Education, Kyiv, Ukraine. E-mail:

In 2015, technical consultation to support development of the National Disability, Health and Rehabilitation Plan in Ukraine was carried out by the Rehabilitation Advisory Team of the International Society of Physical and Rehabilitation Medicine. Recommendations for actions and projects to improve rehabilitation services within the healthcare system in Ukraine were developed, proposed and implemented. The achieve-ments in the subsequent 5 years include establishing, training and enabling employment at health-care facilities for new rehabilitation professionals (physical and rehabilitation medicine physi-cians, physical therapists, occupational therapists), commencing implementation of the International Classification of Functioning, Disability and Health (ICF), and increasing rehabilitation knowledge among Ukrainian communities and decision-makers. The main challenges include inappropriate healthcare legislation for developing modern rehabilitation services, gaps in the clinical environment and quality control for training rehabilitation professionals, and the slow pace of implementation of the ICF. A gen-eral facilitator is the ongoing healthcare reform in Ukraine, especially its continuation to secondary and tertiary healthcare levels. Future high-priority activ-ities will include amendments to basic healthcare legislation, and introducing a bio-psycho-social approach for the provision of rehabilitation services at all healthcare levels and all rehabilitation treatment phases, starting with the most debilitating health conditions. It will be important to continue collaboration with European and international partners.
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http://dx.doi.org/10.2340/16501977-2792DOI Listing
March 2021

The influence of the CRS-R score on functional outcome in patients with severe brain injury receiving early rehabilitation.

BMC Neurol 2021 Jan 30;21(1):44. Epub 2021 Jan 30.

Institute for Neurorehabilitative Research, Associated Institute of the Hannover Medical School, BDH-Clinic Hessisch Oldendorf, Hessisch Oldendorf, Germany.

Background: The aim of the study was to determine the role of the Coma Recovery Scale-Revised (CRS-R) in the prediction of functional status at the end of neurological early rehabilitative treatment.

Methods: Patients consecutively admitted to intensive or intermediate care units of a neurological rehabilitation center were enrolled in the study. Consciousness and functional status were assessed with the Coma Recovery Scale-Revised (CRS-R) and the Early Rehabilitation Barthel Index (ERBI), respectively. Both assessments were carried out weekly within the first month and at the end of early rehabilitation. Patient and clinical data were entered into a binary logistic regression model to predict functional status at discharge.

Results: 327 patients (112 females, 215 males) with a median age of 63 years (IQR = 53-75) and a median disease duration of 18 days (IQR = 12-28) were included. Most patients suffered from stroke (59 %), followed by traumatic brain injury (31 %), and hypoxic ischemic encephalopathy (10 %). Upon admission, 12 % were diagnosed as comatose, 31 % as unresponsive wakefulness syndrome (UWS), 35 % as minimally conscious state (MCS) and 22 % already emerged from MCS (eMCS). Of all patients undergoing complete early rehabilitative treatment (n = 180), 72 % showed improvements in level of consciousness (LOC). In this group, age, initial CRS-R score and gains in CRS-R score after four weeks independently predicted functional outcome at discharge.

Conclusions: The study confirms the relevance of the CRS-R score for functional outcome prediction. High CRS-R scores and young age facilitate functional improvements and increase the probability to continue treatment in subsequent rehabilitation phases. Moreover, results indicate that recovery might occur over a period of time that extends beyond acute care.
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http://dx.doi.org/10.1186/s12883-021-02063-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7847163PMC
January 2021

Promoting factors and barriers to participation in working life for people with spinal cord injury.

J Occup Med Toxicol 2020 Dec 17;15(1):37. Epub 2020 Dec 17.

Department of Rehabilitation Medicine, Hannover Medical School, Carl-Neuberg Str. 1, 30625, Hanover, Germany.

Background: It is still difficult for people with physical impairments to be and remain equally integrated into the labour market. For this reason, the question of occupational activity has explicitly been examined by the German Spinal Cord Injury Survey (GerSCI) in order to identify barriers and facilitators for labour market participation.

Methods: Cross-sectional explorative observational study. The GerSCI survey is the German part of the International Spinal Cord Injury Survey (InSCI). Using survey data from persons recruited at eight specialised SCI-centres in Germany.

Participants: 1.479 persons with Spinal Cord Injury (SCI) aged 18 years and older.

Results: In a self-disclosure questionnaire, persons with SCI show themselves as a professionally well-educated and highly motivated group with most of them aiming at gainful employment and considering themselves fit for work. Many changeable and non-changeable factors have been found, which showed a high correlation with the return to work after acquired SCI.

Conclusion: Education and pain belong to the most critical factors and thereby possible approaches to increase the level of employment, which is essential and highly relevant not only for earning money but also for self-confidence and social integration. SCI has many dimensions in itself; support also should be multidimensional. Study results might help to improve participation.
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http://dx.doi.org/10.1186/s12995-020-00288-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7745479PMC
December 2020

Contribution of the scientific field of Physical and Rehabilitation Medicine to improvements in health-related rehabilitation at all levels of the healthcare system: A discussion paper.

J Rehabil Med 2021 Feb 23;53(2):jrm00155. Epub 2021 Feb 23.

Department of Rehabilitation Medicine , Hannover Medical School, Carl-Neuberg-Str.1, DE-30625 Hannover, Germany. E-mail:

Rehabilitation is an important health strategy that should be implemented at all levels of the healthcare system and at all levels of care. Scientific evidence is vital to strengthen rehabilitation; therefore, research in the scientific field of Physical and Rehabilitation Medicine (PRM) should be implemented and linked to all levels of the healthcare system. PRM research can be categorized into 5 areas: (i) biosciences in rehabilitation; (ii) biomedical rehabilitation sciences and engineering; (iii) clinical PRM sciences; (iv) integrative rehabilitation sciences; and (v) human function-ing sciences. At the level of the healthcare system, rehabilitation can be divided into micro-, meso- and macro-levels. This paper discusses the contribution of the five above research areas to health-related rehabilitation at the different levels of the healthcare system. The contribution of PRM research can have synergistic value and facilitate improvements and implementation of scientific evidence in rehabilitation at all levels of healthcare. From a broader perspective, improved understanding of the contribution of each area of the scientific field of PRM and the priorities for the healthcare system that are set by relevant stakeholders will contribute to the advancement and rapid attainment of overall goals.
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http://dx.doi.org/10.2340/16501977-2773DOI Listing
February 2021

Rehabilitation Service Assessment and Workforce Capacity Building in Albania-A Civil Society Approach.

Int J Environ Res Public Health 2020 10 6;17(19). Epub 2020 Oct 6.

Department of Rehabilitation Medicine, Hannover Medical School, 30625 Hannover, Germany.

Background: Rehabilitation is an important health strategy. Due to the lack of rehabilitation professionals (e.g., no physical and rehabilitation medicine, occupational therapist, and others) and lack of rehabilitation services (e.g., no multi-profession rehabilitation services in hospital, no post-acute rehabilitation services, no community-based rehabilitation services), the need to strengthen rehabilitation in Albania was pronounced. Therefore, this project aimed at rehabilitation service assessment and workforce capacity building in Albania.

Methods: The World Health Organization's Template for Rehabilitation Information Collection was used to collect available data related to rehabilitation services. Additionally, two site visits to different rehabilitation centers including interviews with relevant stakeholders were performed. A stakeholders' workshop to prioritize recommendations was also performed before finalizing the report.

Results: In Albania, rehabilitation service delivery, rehabilitation workforces, and financing in rehabilitation need to be strengthened.

Conclusions: The project achieved the intended objectives. Additionally progress has been occurring in the development and implementation of the Physical and Rehabilitation Medicine specialization at the University of Medicine, Tirana.
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http://dx.doi.org/10.3390/ijerph17197300DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7579078PMC
October 2020

COVID-19 pandemic in Indonesia: Situation and challenges of rehabilitation medicine in Indonesia.

Acta Med Indones 2020 Jul;52(3):299-305

Department of Rehabilitation Medicine, Hannover Medical School, Hannover.

AbstrakCOVID-19 telah menjadi pandemik di Indonesia sejak ditemukannya kasus pertama pada tanggal 2 Maret 2020 di Depok. Peningkatan kasus perhari semakin tinggi sejak akhir Agustus 2020 yang mencapai lebih dari 2000 kasus per hari. Sistem kesehatan di Indonesia perlu ditingkatkan dalam hal kapasitas, termasuk rehabilitasi medik yang harus dilibatkan dari fase akut hingga jangka panjang dalam penanganan pasien COVID-19. Rehabilitasi medik juga diperlukan untuk pasien lain yang bukan COVID-19. Pentingnya keterlibatan, pelayanan rehabilitasi medik dan implementasinya dimasa pandemic COVID-19 memerlukan strategi tersendiri yang harus dilakukan baik oleh pekerja kesehatannya, rumah sakit dan kebijakan pemerintah. Hal ini diperlukan untuk percepatan peningkatan kesehatan pasien, percepatan pemulangan dan menghindari readmisi pasien, dan juga pengoptimalan program kembali bekerja untuk pasien yang sembuh dari COVID-19.AbstractCOVID-19 has become a pandemic in Indonesia since the first cases have been positively diagnosed on 2 March 2020 in Depok. The cases have been increased gradually since the end of August 2020 that has reached 1000 cases per day. The health system in Indonesia needs to be improved in terms of capacity, including rehabilitation medicine that should be involved in all health phases (from acute to long-term) in managing patients with COVID-19. Rehabilitation is also still needed for other non-COVID-19 patients. The importance of involvement and implementation of rehabilitation services during the COVID-19 pandemic will need special strategies that should be done by rehabilitation professionals, hospitals, and government. These are necessary to accelerate the improvement of patients' health, discharge, and avoid re-admission, as well as optimize return-to-work for patients who are recovered from COVID-19.
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July 2020

Polymorphisms of brain-derived neurotrophic factor genes are associated with anxiety and body mass index in fibromyalgia syndrome patients.

BMC Res Notes 2020 Aug 28;13(1):402. Epub 2020 Aug 28.

Department of Rehabilitation Medicine, Hannover Medical School, Hannover, Germany.

Objective: Fibromyalgia syndrome has been associated with familial clusters although the specific genetic predisposition is not clear. Accordingly, studies concerning genetic factors associated with this disease are important. Brain-derived neurotrophic factor (BDNF) has been shown to play a role in patients with fibromyalgia syndrome, particularly in mediating manifestations of pain and mood-related symptoms. Research on genetic factors, including genetic variations or single nucleotide polymorphisms, especially related to BDNF in fibromyalgia is very limited. Therefore, this study was aiming at determining the association of polymorphisms of BDNF, particularly rs2049046 (A>T) and rs7124442 (A>G), with body mass index (BMI) and mood-related symptoms in FMS.

Results: In fibromyalgia syndrome cases, BDNF polymorphisms were associated with body mass index and anxiety score, specifically rs7124442 (A>G) (Fisher's exact test χ; p < 0.05; odds ratio (OR): 1.02) and rs2049046 (A>T) (Fisher's exact test χ; p < 0.05; OR: 0.55), respectively. Additionally, patients with fibromyalgia syndrome who have AA (95% CI (8.71, 11.63)) and AT (95% CI (9.32, 11.74)) alleles of rs2049046 showed higher score of anxiety compared to patients with TT (95% CI (3.98, 8.20) allele (ANOVA test; p < 0.01). These results suggest that BDNF polymorphisms (rs7124442 and rs2049046) are associated with body mass index and anxiety symptoms in patients with fibromyalgia syndrome.
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http://dx.doi.org/10.1186/s13104-020-05226-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7456381PMC
August 2020
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