[The Swiss approach for cardiac rehabilitation]

Structured cardiac rehabilitation goes back to the late 1960s also in Switzerland and in the beginning was only available in rehabilitation clinics. In 1972 the first ambulatory rehabilitation programs became available to patients in Zurich and Bern. In the following years, in addition to the increasing number of rehabilitation centers for inpatients, more and more ambulatory rehabilitation programs were developed, especially in the larger Midlands population area in German and French-speaking Switzerland. In 1985 the Swiss Working Group of Cardiac Rehabilitation (SAKR) was initiated as an official working group of the Swiss Society of Cardiology and one of its first tasks was to establish a list of the institutions for cardiac rehabilitation in Switzerland. At that time there were 42 rehabilitation programs for a population of approx. 6.5 million, 21 for inpatients and 21 ambulatory; however, 90% of the patients were in inpatient programs. In 1992 the SAKR group defined the quality criteria which were to be applied for official recognition of institutions for cardiac rehabilitation in Switzerland. Due to these criteria, plus the fact that an increasing number of rehabilitation clinics in the mountains had been closed down, the number of inpatient rehabilitation centers decreased from 21 to 11 between 1989 and 2011, whereas the number of ambulatory programs increased from 21 to 51. The ambulatory rehabilitation centers are partially organized by local medical groups; however, most have integrated their activities into the local hospitals. The trend shows a developing preference for ambulatory rehabilitation. More and more elderly, polymorbid patients, however, will still need care in inpatient programs.

Depression and anxiety symptoms affect change in exercise capacity during cardiac rehabilitation

BACKGROUND: To study whether symptoms of depression and anxiety would affect changes in exercise capacity and body mass index (BMI) during rehabilitation. DESIGN: Comprehensive cardiac outpatient rehabilitation intervention program. METHODS: We investigated exercise capacity, BMI, and symptoms of depression and anxiety before and after cardiac rehabilitation in 114 patients with coronary artery disease. The Hospital Anxiety and Depression Scale (HADS) was applied to assess symptoms of depression (HADS-D) and anxiety (HADS-A). RESULTS: Exercise capacity increased (127+/-47 vs. 144+/-51 watts, P<0.001) and symptoms of depression (4.0+/-3.6 vs. 2.7+/-2.7, P<0.001) and anxiety (5.4+/-4.4 vs. 4.1+/-3.6, P<0.001) decreased with the program, whereas BMI did not change. After controlling for covariates, HADS-D (r=-0.19, P=0.47) and HADS-A (r=0.17, P<0.09) correlated with change in exercise capacity. Change in HADS-A also correlated with that in exercise capacity (r=0.18, P<0.06). Changes in depression and anxiety were not significantly related to those in BMI. CONCLUSION: Symptoms of depression and anxiety affected change in exercise capacity during cardiac rehabilitation. Depressive symptoms may impair improvement in exercise capacity, thereby mitigating the cardiovascular benefit achieved by cardiac rehabilitation programs.

Clinical primary flexor tendon repair and rehabilitation: The Bern Experience

In this chapter we present our experience with treatment of zone 2 flexor tendon repair using a six-strand repair technique combined with postoperative place-and-hold exercise. The six-strand Lim/Tsai repair technique combined with place-and-hold exercises demonstrated better digital function compared to a two-strand repair without place-and-hold exercises. Range of motion in the Lim/Tsai repair group appeared to be increased without a higher rate of ruptures but with a shorter rehabilitation period. The fact that the two groups differed in both suture techniques and rehabilitation programs made it impossible to know whether the better results in the group of Lim/Tsai were due to the six-strand repair or the place-and-hold exercises or both. Despite the obvious benefit of early active mobilization, an active motion protocol may not always be possible to apply in a substantial number of patients due to concomitant injuries, the quality of the surgical repair or patient factors (swelling, pain, limited compliance). Since August 2006 a staged rehabilitation program (“stop and go”) was introduced within our unit using early active controlled flexion (green), place-and-hold (yellow), or passive flexion exercises (red) introduced by Kleinert-Duran. Our experience using the six-strand suture repair technique and “stop and go” is outlined.

Can imagined whole-body rotations improve vestibular compensation?

Unilateral damage to the labyrinth and the vestibular nerve cause rotational vertigo, postural imbalance, oculomotor disorders and spatial disorientation. Electrophysiological investigations in animals revealed that such deficits are partly due to imbalanced spontaneous activity and sensitivity to motion in neurons located in the ipsilesional and contralesional vestibular nuclei. Neurophysiological reorganizations taking place in the vestibular nuclei are the basis of the decline of the symptoms over time, a phenomenon known as vestibular compensation. Vestibular compensation is facilitated by motor activity and sensory experience, and current rehabilitation programs favor physical activity during the acute stage of a unilateral vestibular loss. Unfortunately, vestibular-defective patients tend to develop strategies in order to avoid movements causing imbalance and nausea (in particular body movements towards the lesioned side), which impedes vestibular compensation. Neuroanatomical evidence suggests a cortical control of postural and oculomotor reflexes based on corticofugal projections to the vestibular nuclei and, therefore, the possibility to manipulate vestibular functions through top-down mechanisms. Based on evidence from neuroimaging studies showing that imagined whole-body movements can activate part of the vestibular cortex, we propose that mental imagery of whole-body rotations to the lesioned and to the healthy side will help rebalancing the activity in the ipsilesional and contralesional vestibular nuclei. Whether imagined whole-body rotations can improve vestibular compensation could be tested in a randomized controlled study in such patients beneficiating, or not, from a mental imagery training. If validated, this hypothesis will help developing a method contributing to reduce postural instability and falls in vestibular-defective patients. Imagined whole-body rotations thus could provide a simple, safe, home-based and self-administered therapeutic method with the potential to overcome the inconvenience related to physical movements.

What Ethanol metabolites as biological markers tell us about alcohol use

Alcohol and tobacco related disorders are the two leading and most expensive causes of illness in central Europe. In addition to self reports and questionnaires, biomarkers are of relevance in diagnosis and therapy of alcohol use disorders.Traditional biomarkers such as gamma glutamyl transpeptidase or mean corpuscualr volume are indirect biomarkers and are subject to influence of age, gender and non alcohol related diseases, among others.Direct ethanol metabolites such as ethyl glucuronide (EtG), ethyl sulphate (EtS) and phosphatidylethanol (PEth) are direct metabolites of ethanol, that are positive after intake of ethyl alcohol. They represent useful diagnostic tools for identifying alcohol use even more accurately than traditional biomarkers. Each of these drinking indicators remains positive in serum and urine for a characteristic time spectrum after the cessation of ethanol intake-EtG and EtS in urine up to 7 days, EtG in hair for months after ethanol has left the body. Applications include clinical routine use, emergency room settings, proof of abstinence in alcohol rehabilitation programs, driving under influence offenders, workplace testing, assessment of alcohol intake in the context of liver transplantation and fetal alcohol syndrome.