Psychiatry

EDITORIAL
	Obsessive-compulsive disorder: Mimicking journey of psychiatry	p. 1
	Om Prakash Singh DOI:10.4103/psychiatry.IndianJPsychiatry_3_19
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GUEST EDITORIAL
	Recent advances in obsessive compulsive and related disorders	p. 2
	Janardhanan C Narayanaswamy, Shyam Sundar Arumugham, TS Jaisoorya, Y C Janardhan Reddy DOI:10.4103/psychiatry.IndianJPsychiatry_587_18
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REVIEW ARTICLES
	Obsessive-compulsive disorder and global mental health	p. 4
	Dan J Stein DOI:10.4103/psychiatry.IndianJPsychiatry_515_18   The discipline of global mental health has emphasized the importance of the treatment gap in mental disorders, and of addressing this gap via changes in health policy, an emphasis on human rights, and innovations such as task-shifting. Although global mental health research has focused on both common mental disorders such as depression, and serious mental disorders such as schizophrenia, it has paid relatively little attention to obsessive-compulsive and related disorders (OCRDs). Nevertheless, international collaborations have recently paid a good deal of attention to the nosology and neurobiology of OCRDs, and given the prevalence and morbidity of these conditions, further work along these lines should be encouraged. This article provides a brief overview of recent international collaborations on OCRDs, and outlines future directions for such work.
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	Neuroimaging findings in obsessive–compulsive disorder: A narrative review to elucidate neurobiological underpinnings	p. 9
	Nandita Hazari, Janardhanan C Narayanaswamy, Ganesan Venkatasubramanian DOI:10.4103/psychiatry.IndianJPsychiatry_525_18   Obsessive compulsive disorder (OCD) is a common psychiatric illness and significant research has been ongoing to understand its neurobiological basis. Neuroimaging studies right from the 1980s have revealed significant differences between OCD patients and healthy controls. Initial imaging findings showing hyperactivity in the prefrontal cortex (mainly orbitofrontal cortex), anterior cingulate cortex and caudate nucleus led to the postulation of the cortico-striato-thalamo-cortical (CSTC) model for the neurobiology of OCD. However, in the last two decades emerging evidence suggests the involvement of widespread associative networks, including regions of the parietal cortex, limbic areas (including amygdala) and cerebellum. This narrative review discusses findings from structural [Magnetic Resonance Imaging (MRI), Diffusion Tensor Imaging(DTI)], functional [(functional MRI (fMRI), Single photon emission computed tomography (SPECT), Positron emission tomography (PET), functional near-infrared spectroscopy (fNIRS)], combined structural and functional imaging studies and meta-analyses. Subsequently, we collate these findings to describe the neurobiology of OCD including CSTC circuit, limbic system, parietal cortex, cerebellum, default mode network and salience network. In future, neuroimaging may emerge as a valuable tool for personalised medicine in OCD treatment.
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	Neurocognitive deficits in obsessive–compulsive disorder: A selective review	p. 30
	Satish Suhas, Naren P Rao DOI:10.4103/psychiatry.IndianJPsychiatry_517_18   Obsessive–compulsive disorder (OCD) is a debilitating mental illness characterized by an early onset and chronic course. Evidence from several lines of research suggests significant neuropsychological deficits in patients with OCD; executive dysfunction and nonverbal memory deficits have been reported consistently in OCD. These deficits persist despite controlling potential confounders such as comorbidity, severity of illness, and medications. Neuropsychological impairments are independent of illness severity, thus suggesting that the neuropsychological deficits are trait markers of the disease. In addition, these deficits are seen in first-degree relatives of individuals with OCD. These reports suggest that neuropsychological deficits are potential endophenotype markers in OCD. Neuropsychological studies in pediatric OCD are limited; they show impairments of small effect size across multiple domains but with doubtful clinical significance. Preliminary evidence shows that different symptom dimensions of OCD may have unique neuropsychological deficits suggestive of discrete but overlapping neuroanatomical regions for individual symptom dimensions. Overall, neuropsychological deficits further support the role of frontostriatal circuits in the neurobiology of OCD. In addition, emerging literature also suggests the important role of other areas, in particular parietal cortex. Preliminary evidence suggests the possible role of neuropsychological deficits to be markers of treatment response but needs to be examined in future. Longitudinal studies with examination of patients at different time points and examination of their potential utility as predictors of treatment response are needed in future.
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	Genetics of obsessive-compulsive disorder	p. 37
	Abhishek Purty, Gerald Nestadt, Jack F Samuels, Biju Viswanath DOI:10.4103/psychiatry.IndianJPsychiatry_518_18   Obsessive-compulsive disorder (OCD) has been seen to run in families and genetics help to understand its heritability. In this review, we summarize older studies which focused on establishing the familial nature of OCD, including its various dimensions of symptoms, and we focus on recent findings from studies using both the candidate gene approach and genome-wide association study (GWAS) approach. The family studies and twin studies establish the heritability of OCD. Candidate gene approaches have implicated genes in the serotonergic, glutamatergic, and dopaminergic pathways. GWAS has not produced significant results possibly due to the small sample size. Newer techniques such as gene expression studies in brain tissue, stem cell technology, and epigenetic studies may shed more light on the complex genetic basis of OCD.
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	Course and outcome of obsessive–compulsive disorder	p. 43
	Eesha Sharma, Suresh Bada Math DOI:10.4103/psychiatry.IndianJPsychiatry_521_18   Obsessive–compulsive disorder (OCD) is generally believed to follow a chronic waxing and waning course. The onset of illness has a bimodal peak – in early adolescence and in early adulthood. Consultation and initiation of treatment are often delayed for several years. Studies over the past 2–3 decades have found that the long-term outcomes in OCD are not necessarily bleak and that at least half the treatment-seeking patients with OCD show symptomatic remission over long term. A short duration illness, of low severity that is treated early and intensively, with continued maintenance treatment over long term possibly has a good outcome. Recent studies have also identified neuroimaging and neuropsychological correlates of good outcome, but these need further replication. This paper presents an overview of conceptual issues and studies on long-term outcome of OCD and predictors of outcome.
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	Antipsychotic augmentation in the treatment of obsessive-compulsive disorder	p. 51
	Abel Thamby, TS Jaisoorya DOI:10.4103/psychiatry.IndianJPsychiatry_519_18   Most studies suggest that obsessive-compulsive disorder runs a chronic course. Only 40%–70% of patients respond to first-line treatment with selective serotonin reuptake inhibitors (SSRIs). The most common pharmacological strategy used in clinical practice for partial responders to SSRIs is augmentation with an atypical antipsychotic. This article aims to review the efficacy, tolerability, and comparative efficacy of antipsychotics as augmenting agents in patients who showed inadequate response to SSRIs. In addition to case reports and case series, 15 randomized controls trials, 6 meta-analyses, and 3 expert guidelines have been examined. The findings suggest that one in three SSRI nonresponders improve with antipsychotic augmentation. The presence of comorbid tics and/or schizotypal disorder may predict a better response to antipsychotic augmentation. Among antipsychotics, risperidone, and aripiprazole have the best evidence, with haloperidol being considered second in-line owing to its unfavorable side effect profile. Guidelines recommend that antipsychotics be administered at a low-to-medium dosage for a duration not exceeding 3 months, with mandatory discontinuation if there is no response. Larger studies and head-to-head trials are needed to further explore this treatment strategy.
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	Glutamatergic augmentation strategies in obsessive–compulsive disorder	p. 58
	Karthik Sheshachala, Janardhanan C Narayanaswamy DOI:10.4103/psychiatry.IndianJPsychiatry_520_18   Proven treatment strategies for obsessive– compulsive disorder (OCD) include pharmacotherapy with serotonin reuptake inhibitors and cognitive behavior therapy (CBT). A significant proportion of patients (25%–30%) fail to respond to these treatment options, necessitating the need for additional treatment options to improve treatment outcomes and quality of life in patients with OCD. Augmentation strategies using various glutamatergic agents have been explored, with diverse outcomes. The aim of this review is to give an overview of the glutamatergic system in the brain with a focus on glutamatergic abnormalities in OCD and to review the existing evidence for various glutamatergic agents used for augmentation.
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	Noninvasive brain stimulation in obsessive–compulsive disorder	p. 66
	Venkataram Shivakumar, Damodharan Dinakaran, Janardhanan C Narayanaswamy, Ganesan Venkatasubramanian DOI:10.4103/psychiatry.IndianJPsychiatry_522_18   Obsessive–compulsive disorder (OCD) is a complex neuropsychiatric disorder with a chronic course, contributing to significant socio-occupational dysfunction. Forty percent of patients remain treatment refractive despite mainstream treatment options such as serotonin-reuptake inhibitors and cognitive behavior therapy. Noninvasive brain stimulation approaches such as transcranial magnetic stimulation (TMS) and transcranial direct current stimulation (tDCS) have piqued interest as add-on treatment options in OCD. This review focuses on summarizing the TMS and tDCS studies in OCD with respect to their study design and stimulation parameters and key findings. We also briefly discuss the limitations and future directions noninvasive brain stimulation in OCD.
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	Ablative neurosurgery and deep brain stimulation for obsessive-compulsive disorder	p. 77
	Srinivas Balachander, Shyam Sundar Arumugham, Dwarakanath Srinivas DOI:10.4103/psychiatry.IndianJPsychiatry_523_18   Despite advancements in pharmacotherapeutic and behavioral interventions, a substantial proportion of patients with obsessive-compulsive disorder (OCD) continue to have disabling and treatment-refractory illness. Neurosurgical interventions, including ablative procedures and deep brain stimulation (DBS), have emerged as potential treatment options in this population. We review the recent literature on contemporary surgical options for OCD, focusing on clinical aspects such as patient selection, presurgical assessment, and safety and effectiveness of these procedures. Given the invasiveness and limited evidence, these procedures have been performed in carefully selected patients with severe, chronic, and treatment-refractory illness. Along with informed consent, an independent review by a multidisciplinary team is mandated in many centers. Both ablative procedures and DBS have been found to be helpful in around half the patients, with improvement observed months after the procedure. Various targets have been proposed for either procedure, based on the dominant corticostriatal model of OCD. There is no strong evidence to recommend one procedure over the other. Hence, the choice of procedure is often based on the factors such as affordability, expertise, and reversibility of adverse effects. Surgery is not recommended as a standalone treatment but should be provided as part of a comprehensive package including medications and psychotherapeutic interventions. Available evidence suggest that the benefits of the procedure outweigh the risks in a treatment-refractory population. Advances in neurosurgical techniques and increasing knowledge of neurobiology are likely to bring about further progress in the efficacy, safety, and acceptability of the procedures.
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	Exposure and response prevention for obsessive-compulsive disorder: A review and new directions	p. 85
	Dianne M Hezel, H Blair Simpson DOI:10.4103/psychiatry.IndianJPsychiatry_516_18   Obsessive-compulsive disorder (OCD) is characterized by distressing thoughts and repetitive behaviors that are interfering, time-consuming, and difficult to control. Although OCD was once thought to be untreatable, the last few decades have seen great success in reducing symptoms with exposure and response prevention (ERP), which is now considered to be the first-line psychotherapy for the disorder. Despite these significant therapeutic advances, there remain a number of challenges in treating OCD. In this review, we will describe the theoretical underpinnings and elements of ERP, examine the evidence for its effectiveness, and discuss new directions for enhancing it as a therapy for OCD.
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	Family accommodation in psychopathology: A synthesized review	p. 93
	Yaara Shimshoni, Basavaraj Shrinivasa, Anish V Cherian, Eli R Lebowitz DOI:10.4103/psychiatry.IndianJPsychiatry_530_18   Family accommodation describes changes that family members make to their own behavior, to help their relative who is dealing with psychopathology, and to avoid or alleviate distress related to the disorder. Research on family accommodation has expanded greatly in the past few years. The aim of this study was to provide a synthesized review of recent findings on family accommodation in psychopathology. Electronic databases were searched for available, peer-reviewed, English language papers, published between September 2015 and March 2018, cross-referencing psychiatric disorders with accommodation and other family-related terms. Ninety-one papers were identified and reviewed, of which 69 were included. In obsessive-compulsive disorder and anxiety disorders family accommodation has been linked to symptom severity, functional impairment, caregiver burden, and poorer treatment outcomes. Several randomized controlled trials explored the efficacy of treatments aimed at reducing family accommodation. A growing number of studies have reported family accommodation in eating disorders where it is associated with greater symptom severity and caregiver burden. Family accommodation has also been studied in other disorders, including autism spectrum disorders, tic disorders, and posttraumatic stress disorder. Research on family accommodation in psychopathology is advancing steadily, expanding across disorders. The study highlights the importance of addressing family accommodation in the assessment and treatment of various disorders.
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	New-wave behavioral therapies in obsessive-compulsive disorder: Moving toward integrated behavioral therapies	p. 104
	M Manjula, Paulomi M Sudhir DOI:10.4103/psychiatry.IndianJPsychiatry_531_18   New-wave behavioral therapies in obsessive-compulsive disorders (OCDs) comprise of third-wave therapies and newer cognitive therapies (CTs). This review covers outcome studies published in English until December 2017. A total of forty articles on mindfulness-based CT, metacognitive therapy, acceptance and commitment therapy, and danger ideation reduction therapy in the form of single-case studies, case series, open-label trials, two-group comparison studies, and randomized controlled studies were included. Results show that studies on these therapies are limited in number. Methodological limitations including lack of active control groups, randomized controlled trials, small sample sizes, and short follow-up periods were also noted. However, the available literature demonstrates the feasibility and utility of these therapies in addressing the issues unresolved by exposure and response prevention (ERP) and cognitive behavior therapy (CBT). These therapies were often combined with traditional ERP and CBT based on the profile and response of the client; hence, it is unclear whether they can be used as standalone therapies in the larger segment of the OCD population. Supplementary use of these strategies alongside established therapies could provide better utilization of resources. In view of the need for such integration, further research is warranted. The use of sound methodologies and establishing the mechanism of action of these therapies would assist in choosing the techniques for integration.
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	The role of personality disorders in obsessive-compulsive disorder	p. 114
	Abel Thamby, Sumant Khanna DOI:10.4103/psychiatry.IndianJPsychiatry_526_18   Personality disorders are a common comorbidity in obsessive-compulsive disorder (OCD). The effect of comorbidity on the symptom presentation, course, and treatment outcome of OCD is being discussed here. OCD and obsessive-compulsive personality disorder (OCPD) though similar in their symptom presentation, are distinct constructs. Schizotypal disorder, OCPD, and two or more comorbid personality disorders have been found to be consistently associated with a poor course of illness and treatment response. Further research is needed to determine treatment strategies to handle the personality pathology in OCD.
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	Challenges in the diagnosis and treatment of pediatric obsessive–compulsive disorder	p. 119
	Clara Westwell-Roper, S Evelyn Stewart DOI:10.4103/psychiatry.IndianJPsychiatry_524_18   Obsessive–compulsive disorder (OCD) affects 1%–3% of children worldwide and has a profound impact on quality of life for patients and families. Although our understanding of the underlying etiology remains limited, data from neuroimaging and genetic studies as well as the efficacy of serotonergic medications suggest the disorder is associated with the fundamental alterations in the function of cortico-striato-thalamocortical circuits. Significant delays to diagnosis are common, ultimately leading to more severe functional impairment with long-term developmental consequences. The clinical assessment requires a detailed history of specific OCD symptoms as well as psychiatric and medical comorbidities. Standardized assessment tools may aid in evaluating and tracking symptom severity and both individual and family functioning. In the majority of children, an interdisciplinary approach that combines cognitive behavioral therapy with a serotonin reuptake inhibitor leads to meaningful symptom improvement, although some patients experience a chronic, episodic course. There are limited data to guide the management of treatment-refractory illness in children, although atypical antipsychotics and glutamate-modulating agents may be used cautiously as augmenting agents. This review outlines a clinical approach to the diagnosis and management of OCD, highlighting associated challenges, and limitations to our current knowledge.
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	Understanding and treating body dysmorphic disorder	p. 131
	Aoife Rajyaluxmi Singh, David Veale DOI:10.4103/psychiatry.IndianJPsychiatry_528_18   Body dysmorphic disorder (BDD), also known as dysmorphophobia, is a condition that consists of a distressing or impairing preoccupation with imagined or slight defects in appearance, associated repetitive behaviors and where insight regarding the appearance beliefs is often poor. Despite the fact it is relatively common, occurs around the world and can have a significant impact on a sufferer's functioning, levels of distress, and risk of suicide, the diagnosis is often missed. In this review, we outline the clinical features of BDD including as characterized in the newly published World Health Organization's International Classification of Diseases 11, review the prevalence of BDD within different settings, and highlight the reasons why BDD may be underdiagnosed even within psychiatric settings. We additionally review the cultural considerations for BDD and finally discuss the evidence-based treatment approaches for BDD, particularly the use of serotonin reuptake inhibitor medication and cognitive behavioral therapy.
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	Trichotillomania (hair pulling disorder)	p. 136
	Jon E Grant DOI:10.4103/psychiatry.IndianJPsychiatry_529_18   Trichotillomania is characterized by the repetitive pulling out of one's own hair leading to hair loss and possibly functional impairment. Trichotillomania has been documented in the medical literature since the 19th century. Prevalence studies suggest that trichotillomania is a common disorder (point prevalence estimates of 0.5%–2.0%). Although grouped with the obsessive-compulsive disorder (OCD) in the diagnostic and statistical manual of mental disorders-5, trichotillomania is distinct from OCD in many respects. For example, the treatment of trichotillomania generally employs habit reversal therapy and medication (n-acetylcysteine or olanzapine), both of which are quite different from those used to treat OCD. Conversely, some first-line treatments used for OCD (e.g., selective serotonin reuptake inhibitors) appear ineffective for trichotillomania. This article presents what is known about trichotillomania and the evidence for a variety of treatment interventions.
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	Obsessive–compulsive disorder comorbid with schizophrenia and bipolar disorder	p. 140
	Lavanya P Sharma, Y C Janardhan Reddy DOI:10.4103/psychiatry.IndianJPsychiatry_527_18   Obsessive Compulsive Disorder (OCD) and Obsessive Compulsive Symptoms (OCS) are known to be highly comorbid with bipolar disorder and schizophrenia. Comorbid OCD/OCS influences the course of schizophrenia and bipolar disorder. There is also some evidence to suggest that a diagnosis of OCD may be associated with elevated risk for later development of psychosis and bipolar disorder. Comorbid OCD/OCS is associated with a greater severity of schizophrenia phenotype and poorer prognosis. In addition, certain atypical antipsychotics, clozapine in particular are known to induce or worsen OCS in schizophrenia. OCD when comorbid with bipolar disorder mostly runs an episodic course with worsening and improvement of OCD/OCS in depressive and in manic/hypomanic phases respectively. There is limited systematic data on the treatment of OCD in schizophrenia and bipolar disorder. When OCD presents in the context of schizophrenia, management may include treatment with atypical antipsychotics with limited serotonergic properties, changing the antipsychotic, reduction in the dose of the antipsychotic, addition of cognitive-behavior therapy (CBT), or a specific serotonin reuptake inhibitor (SSRI). When OCD is comorbid with bipolar disorder, mood stabilization is the priority. CBT may be preferred over SSRIs to treat OCD/OCS that persist in between the mood episodes because SSRIs may induce a switch or worsen the course of bipolar disorder. SSRIs when indicated have to be used judiciously under the cover of adequate mood stabilization.
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Physical and Rehabilitation Medicine

EDITORIAL
	From the editor-in-chief	p. 1
	Gerard E Francisco DOI:10.4103/ijprm.ijprm_9_18
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SPECIAL REPORT
	ISPRM-France 2018: A winning and very promising experience	p. 2
	Isabelle Laffont, J Lains, W Frontera, A Yelnik, A Thevenon DOI:10.4103/jisprm.ijprm_11_18
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FROM THE ISPRM PRESIDENT
	The scientific article and the future of physical and rehabilitation medicine	p. 4
	Walter R Frontera DOI:10.4103/ijprm.ijprm_10_18   Scientific research is the process by which new information and/or knowledge is generated. This knowledge can serve the purpose of supporting the practice of a medical specialty like physical and rehabilitation medicine (PRM). The research process consists of various steps including the dissemination of the findings in the form of a scientific article. Progress in science and medicine is communicated to others through the scientific article. The number of journals and articles in science in general and in the field of physical and rehabilitation medicine in particular has been increasing in the last few decades. This trend is expected to continue because of the expansion of research (including clinical trials) in the field and other activities such as the initiation of Cochrane Rehabilitation. Authors should understand the sections of a scientific article, the peer-review process, the hierarchy of levels of evidence, new rules regarding scientific reporting, and the need to prevent scientific misconduct through education.
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REVIEW ARTICLES
	Management of fatigue in neurological disorders: Implications for rehabilitation	p. 9
	Fary Khan, Bhasker Amatya DOI:10.4103/ijprm.ijprm_5_18   This review systematically evaluates existing evidence for the effectiveness and safety of different rehabilitation interventions for managing fatigue in persons with multiple sclerosis (MS), stroke, traumatic brain injury (TBI), and Parkinson's disease (PD) for improved patient outcomes. A comprehensive literature search was conducted using medical and health science electronic (MEDLINE, EMBASE, PubMed, and the Cochrane Library) databases for published articles up to March 1, 2018. Both reviewers applied inclusion criteria to select potential studies and extracted data independently. Overall, 56 studies (22 systematic reviews/meta-analyses, 32 randomized clinical trials, 2 controlled clinical trials) fulfilled the inclusion criteria for this review. Although existing best-evidence for many interventions is still sparse, the overall findings suggest "strong" evidence for physical activity, cognitive-educational programs, and energy conservation strategies in MS; "moderate" evidence for multidisciplinary rehabilitation in MS; home-based physical activities in stroke and TBI; hydrotherapy in MS and TBI, group-education in stroke and self-management programs in TBI; and mindfulness intervention in MS, stroke, and TBI. There was "low" evidence for exercise in PD and other physical modalities such as yoga and cooling therapy in MS, pulsed electromagnetic devices in MS and stroke; light therapy, and biofeedback in TBI. Effect of other interventions was inconclusive. Despite the available range of rehabilitation interventions for management of fatigue in neurological conditions, there is lack of high-quality evidence for many modalities. More robust research is needed with appropriate study design, timing and intensity of modalities, and associated costs.
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	Strengthening rehabilitation in health systems worldwide by implementing information on functioning in rehabilitation practice, quality management, and policy: 2018 status report	p. 37
	Francesca Gimigliano, Melissa Selb, Masahiko Mukaino, Cristiana Baffone, Jerome Bickenbach, Julia Engkasan Patrick, Christoph Gutenbrunner, Jianan Li, Stefano Negrini, Gerold Stucki, Mauro Zampolini, Jorge Lains DOI:10.4103/jisprm.ijprm_13_18   The link between rehabilitation, functioning, and the International Classification of Functioning, Disability and Health (ICF) is nothing new. This is reflected not only in the numerous peer-reviewed papers on applying the ICF in rehabilitation but also in the indispensable role of functioning and the ICF in developing the conceptual descriptions of rehabilitation as a health strategy and of physical and rehabilitation medicine (PRM) as a medical specialty. Since the World Health Organization's (WHO's) Rehabilitation 2030 Call for Action in 2017, functioning and the ICF have gained an even more prominent role in rehabilitation. This paper provides an overview of the current efforts toward strengthening rehabilitation in health systems throughout the world by applying information on functioning in rehabilitation practice, Clinical Quality Management for Rehabilitation (CQM-R), and policy, using the ICF as a reference framework. These initiatives are led by rehabilitation and rehabilitation-related societies and academic institutions in various countries and regions of the world. This paper briefly describes them and puts them into the context of WHO's call for strengthening rehabilitation. It concludes by highlighting lessons learned from these initiatives, introducing Cochrane Rehabilitation as a conduit for promoting the use of ICF in evidence gathering and calling for collaboration from new partners who have not yet been active in promoting ICF implementation. This call for collaboration from the International Society of PRM strives to diversify the representation of contributors and experiences in implementing the ICF in rehabilitation practice, CQM-R, and policy.
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ORIGINAL ARTICLES
	Limitations of long-standing non-malignant pain in functioning, activity and quality of life: A gender comparison	p. 49
	Jan-Rickard Norrefalk, Kristian Borg DOI:10.4103/ijprm.ijprm_1_18   Background: Long-standing non-malignant pain (LSNMP) leads to limitations of function and activity as well as decreased quality of life (QoL). Aim: The aim of this study is to describe the subjective experience and to compare the gender differences of functional, activity, and QoL limitations in patients with LSNMP. Methods: Three hundred patients, 207 women and 93 men, with a median duration of pain of 49 months referred to a Pain Management Centre filled out the Functional Barometer questionnaire, adapted to the International Classification of Functioning, Disability and Health (ICF). Results: All patients reported that pain was a moderate, major or total problem. In the ICF item variables, lifting/carrying things, endurance, keeping posture, muscle strength, leisure time, sleeping and energy were indicated as major or total limitations due to pain. Women had significantly more limitations in comparison to men regarding concentration, ordinary housework stress and psychological demands, keeping posture, lifting/carrying things, gastrointestinal functions and contact with friends. Conclusion: Targeting limitations and possibilities in function, activity and QoL are of importance when tailoring an individual treatment and rehabilitation plan. Gender differences are of importance to recognize.
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	Phenol nerve block for ankle plantar flexor and invertor spasticity in upper motor neuron lesions: A case series	p. 55
	Fahim Anwar, Harry Mee, Shruthika Ramanathan DOI:10.4103/ijprm.ijprm_2_18   Aim: The study aims to evaluate the effectiveness of tibial nerve block with phenol on ankle plantarflexion and inversion spasticity caused by the upper motor neuron lesions. Materials and Methods: A single-center retrospective study was undertaken to assess the effectiveness of tibial nerve block on the spasticity of ankle plantar flexors and invertors in upper motor neuron lesions. Forty-four patients with ankle plantar flexion and inversion spasticity were included in the study. Clinical outcomes were measured before tibial nerve block at 6 and 24 weeks following the treatment. The outcome measures included Modified Ashworth Scale (MAS), the passive range of motion of the ankle dorsiflexion with the knee in a flexed position and with the knee in an extended position. The patients were advised to continue with the pharmacological and nonpharmacological interventions such as medications, splinting, and stretching. Friedman test of differences among repeated measures was conducted from data at 0, 6, and 24 weeks. Results: There was a statistically significant difference between the baseline MAS and ankle passive range of dorsiflexion motions (both with the knee flexed and extended) measured at 6 and 24 weeks following the phenol nerve block of the tibial nerve. Conclusions: This study highlights that phenol nerve block of the tibial nerve helps to reduce the spasticity of the ankles when combined with other pharmacological and nonpharmacological interventions such as splinting and stretching.
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	How to assess the level of dependency in an integrated health care system. The andorran experience	p. 61
	Anna Boada-Pladellorens, Mercè Avellanet DOI:10.4103/ijprm.ijprm_4_18   Background: Disability becomes increasingly common with advancing age. Physical medicine and rehabilitation (PMR) aim to enhance the functional ability and decrease dependency and disabilities. In Andorra, there is a genuine dependence classification called Grau de Dependència Andorrà (GDA), which rates 0 (no dependence) to 5 (total dependence). It is used to allocate therapeutic and economic resources at the national public skilled nursing facility (El Cedre). To improve patient experience and achieve greater efficiency from health system (integrated care), this paper aims to reevaluate the actual level of dependence of people staying in El Cedre with several validated scales. Moreover, this study aims to measure patient's dependency against GDA levels and to provide the rehabilitation resources needed for improved healthcare. Methods: We conducted a cross-sectional descriptive study in which a PMR physician evaluated all residents using a functional dependence scale (Barthel Index), a cognitive impairment scale (Pfeiffer test), assessment of independent living skills (Lawton instrumental activities of daily living scale), and assessment of gait dependence (Rankin modified scale score and functional ambulation classification). In addition, patients underwent a physical musculoskeletal examination. The residents, their relatives, and the staff, including the rehabilitation team, were part of the assessment. Results: We evaluated 143 patients (120 inpatient and 23 in day hospitals) of which 48 were men and 95 were women. Considering previous GDA classification, almost 70% of patients had at least high dependence. However, there are no data specified on which kind of disability patients were suffering from. Comparing PMR evaluation to GDA results, we found no correlation between GDA level and rehabilitation requirements. As a result, we adapted groups to differentiate those participants with predominantly cognitive impairment from those with mostly physical impairment. We identified more than a half of participants (52.4%) suffering from cognitive impairment in comparison with the 19.5%, whose main disability came from physical impairment. The vast majority (72.02%) had moderate-to-high disability. Furthermore, up to 61.55% needed one or more people to walk. Results were reported to hospital executive department, assisting with El Cedre's management. Conclusions: PMR evaluation in a skilled nursing facility resulted in a change in allocating therapeutic resources, establishing properly the rehabilitation goals. To entirely evaluate disability, it is necessary to use both instruments of cognitive and physical assessment.
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	Gait among patients with myotonic dystrophy type 1: A three-dimensional motion analysis study	p. 65
	Vincent Tiffreau, Christine Detrembleur, Peter Van Den Bergh, Anne Renders, Virginie Kinet, André Thevenon, Etienne Allart, Thierry Lejeune DOI:10.4103/ijprm.ijprm_8_18   Objective: The objective was to characterize the gait abnormalities in myotonic dystrophy type 1 patients. Material and Methods: Outcomes variables were kinematic and kinetic parameters, timing of muscles, mechanical work and energy cost, and the motor function measure. Results:Despite a high cadence and a low ankle range of motion ratio, ankle extension power, and first extension moment of the knee during the stance, the mechanical work and energy cost were normal. The duration of electromyography activation of the gastrocnemius lateralis (GL) muscle was abnormally long. Conclusion: The hypothesis of a myotonic activity of the GL during the swing phase should be investigated.
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GUIDELINES
	Minimum technical standards and recommendations for traumatic brain injury rehabilitation teams in sudden-onset disasters	p. 72
	Bhasker Amatya, Vandana Vasudevan, Nina Zhang, Seema Chopra, Irina Astrakhantseva, Fary Khan DOI:10.4103/ijprm.ijprm_3_18   Current advances in disaster response and management have improved survival rates of disaster victims, resulting in overwhelming number of survivors with injuries relative to mortality. These include complex and long-term disabling injuries, such as traumatic brain injury (TBI), spinal cord injury, peripheral nerve injury, musculoskeletal injuries and others. Despite lack of accurate data on TBI in sudden-onset disasters (SODs), it remains a common neurological consequence of armed conflict worldwide. TBI is complex and survivors often have long-term physical, cognitive and behavioural disabilities, residual neurological deficits, medical complications and lifestyle consequences. These necessitate comprehensive interdisciplinary management, including medical, surgical and rehabilitation. The goal of rehabilitation in disaster settings is to improve functional independence and successful reintegration into the community, with an emphasis on patient education and self-management. Rehabilitation of TBI survivors should commence from early-response phase during disasters to minimise disability, prevent secondary injury and should be continued long-term in the community. Specialized rehabilitation teams in any SODs are deployed based on the skill-base and response required to meet specific local needs at the request of host health authorities. These interdisciplinary teams (specialized cells) need to be integrated into emergency disaster response and management plans. This report extends the previously published guidelines for WHO Emergency Medical Teams (EMTs) to establishe minimum standards for development and deployment of TBI specialized rehabilitation team in SODs. Overview of rehabilitation input for TBI survivors by EMT type, and specific recommendations and considerations for the management of the TBI victims for EMTs are provided. These include: deployment decision-making process; elements of making rapid assessment of existing TBI care capacity; leadership & operational support; outreach services; medical and surgical input; human resources, skill mix, team competencies and team configuration; equipment including consumables and pharmacological supplies; discharge & referral; data collection, management and health care records; and exit strategy.
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Abdominal Wall and Hernia Surgery

ORIGINAL ARTICLES
	Comparison of intraperitoneal ventralex ST patch versus onlay mesh repair in small and medium primer umbilical hernia	p. 1
	Birol Agca, Yalin Iscan DOI:10.4103/ijawhs.ijawhs_24_18   PURPOSE: Although the size of the hernia plays an active role in the use of the mesh, the counter-view is that the use of the mesh should be preferred regardless of the size of the hernia. In our study, the clinical results of two different mesh types applied under elective conditions to small-and medium-sized umbilical hernia cases were examined. PATIENTS AND METHODS: Between January 2015 and May 2018, intraperitoneal Ventralex ST repair and onlayprolene mesh repair were performed in 88 primary small and medium umbilical hernia cases. Demographic data, duration of surgery, length of hospital stay postoperative complications, and recurrence were recorded. RESULTS: Eighty-eight patients were analyzed including 54 males and 34 females – a mean age of 50.3 years. The duration of the surgery in Ventralex ST group was 35.9 ± 4.1 min. (P < 0.05). Comparing to the visual analog scale (VAS) values of the 1st day, the decrease in VAS values in both groups on the 7th day was statistically significant (P < 0.05). The rates of early and late postoperative complications, such as seroma, hematoma, wound infection, and recurrence, were similar between the procedures. The mean follow-up period was 23 months (with range 7–46 months), and no recurrence was observed in both groups. CONCLUSION: We think that the Ventralex ST mesh performed with open surgical technique under elective conditions for primitive umbilical hernias can be safely used because of its quick applicability and low rates of complication and recurrence.
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	Peritoneal closure using self-anchoring-barbed absorbable sutures during laparoscopic transabdominal preperitoneal inguinal hernioplasty: How to make it more safe?	p. 7
	Axel Gilbert, Fawaz Abo-Alhassan, Pablo Ortega-Deballon, Nicolas Cheynel, Patrick Rat, Olivier Facy DOI:10.4103/ijawhs.ijawhs_30_18   CONTEXT: Peritoneal closure with a barbed suture during laparoscopic transabdominal preperitoneal (TAPP) inguinal hernia repair is a controversial subject due to the risk of postoperative intestinal adhesions and occlusions formed by this type of suture. This risk, however, was only reported in several case reports. The purpose of this study is to determine the incidence of postoperative intestinal obstructions related to the use of barbed suture materials in laparoscopic hernia repair (TAPP). PATIENTS AND METHODS: We included all patients that underwent laparoscopic TAPP inguinal hernia repair between October 2012 and October 2017. All peritoneal closures were accomplished using absorbable barbed sutures. Operative data were collected in a dedicated database and analyzed retrospectively. RESULTS: Only 3 out of the 320 patients included (0.9%) presented with an early postoperative intestinal obstruction and required further surgery. Two of the three patients (0.6%) were found to have intestinal incarceration in the peritoneal defects initially created during the hernia repair. However, the last patient had an intestinal volvulus due to adhesions formed with the barbed suture. None of the patient characteristics collected were significant risk factors for developing postoperative intestinal obstructions. CONCLUSION: In this study, peritoneal closure using barbed suture material did not increase the risk of early postoperative intestinal obstruction, in comparison to other suture materials reported in the literature. The use of barbed absorbable sutures for peritoneal closure during laparoscopic TAPP seems to be safe when sutures are cut short and covered by the peritoneum.
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	Local anesthesia for open mesh repair of recurrences after previous total extraperitoneal inguinal hernia repair	p. 12
	Keerthi Rajapaksha DOI:10.4103/ijawhs.ijawhs_26_18   INTRODUCTION: Optimum treatment for recurrences after laparoscopic repair of inguinal hernia (IH) is debatable. Guidelines recommend open repair under general anesthesia (GA), whereas emerging studies show relaparoscopy as a feasible option. Both require GA and incur extra cost. Does open surgery under local anesthesia (LA) is an option for recurrent hernia following laparoscopic surgery? METHODS: This is a retrospective review of medical reports of four patients who underwent open mesh repair under LA for recurrences after previous laparoscopic IH repair between May 2015 and August 2018. RESULTS: All the patients were male with a mean age of 50 years and 3 months (range 36–64 years). All the patients have primarily underwent total extraperitoneal (TEP) repair. Inadequate deperitonealization at the deep ring (n = 2), mesh migration (n = 1), and missed indirect sac were the causes for recurrences. All the patients underwent tension-free Lichtenstein repair under LA. The mean operative time was 25 min (range, 18–32 min). Tissue planes were well preserved and separation of cord structures from hernia sac and preservation of ilioinguinal nerve were possible in all cases. No conversions to GA. None of the patients had long-term morbidity or recurrences during the mean follow-up period of 1 year and 7 months (range, 1 month–2 years). All the cases were performed as day-case procedures. CONCLUSION: Open mesh repair under LA is a safe and effective option for recurrences after previous TEP repair of IH.
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	A single-blind, randomized controlled study to compare Desarda technique with Lichtenstein technique by evaluating short- and long-term outcomes after 3 years of follow-up in primary inguinal hernias	p. 16
	Hemanth Vupputuri, Satish Kumar R, Priya Subramani, Venugopal K DOI:10.4103/ijawhs.ijawhs_21_18   BACKGROUND: Lichtenstein tension-free repair is associated with postoperative complications and dysfunctions; hence, there is a need to look for a new hernia repair techniques while retaining its advantages. Desarda technique is a physiologic repair and essentially restores physiology of the inguinal canal. This single-blind, randomized controlled study was conducted to compare Desarda with Lichtenstein technique evaluating short- and long-term outcomes after 3 years of follow-up in primary inguinal hernias. MATERIALS AND METHODS: One hundred and twenty-three adult male patients with primary inguinal hernia (both direct and indirect) were randomly allocated intraoperatively to Lichtenstein repair, Mesh (M) Group or Desarda repair, nonmesh (NM) Group. Baseline characteristics were recorded before the surgery. Short- and long-term outcomes and patients responses on patient global impression of change (PGIC) and Prolo scale after surgery were recorded. RESULTS: Sixty-two patients were assigned to NM and 61 to M group. Surgery time was significantly higher for M group (P < 0.001). Postsurgical pain was significantly higher (P < 0.001) in M than NM group whereas complications were comparable. The total mean duration of follow-up for M was 35.2 months while for NM was 35.7 months. The recurrence rate was not significantly different; however, chronic groin pain was significantly higher in M compared to NM (P = 0.05). After surgery, PGIC score was consistently higher in NM group with better functionality in NM group. CONCLUSIONS: After 3 years of follow-up, Lichtenstein technique and Desarda technique results were similar. After considering the pros and cons of both the methods, a tailor-made approach is required while choosing a procedure for hernia repair.
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COMMENTARY
	Outside of guidelines: Successful Desarda technique for primary inguinal hernias	p. 23
	Ralph Lorenz DOI:10.4103/ijawhs.ijawhs_1_19
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TECHNIQUE REPORT
	Laparoscopic total extraperitoneal superior and inferior lumbar hernias repair without traumatic fixation: Two case reports	p. 25
	Junsheng Li, Xiangyu Shao, Tao Cheng DOI:10.4103/ijawhs.ijawhs_23_18   BACKGROUND: The lumbar area is limited by the bone structures (superiorly by the 12th rib and inferiorly by the iliac crest); furthermore, several important nerves, including the genitofemoral nerve, lateral femoral cutaneous nerve, and ilioinguinal and iliohypogastric nerves, are all exposed in this area after retroperitoneal dissection during lumbar hernia repair, which render the risk and challenge for lumbar hernia repair and mesh fixation. In addition, the superior and inferior lumbar hernias, although had the same name of lumbar hernia, are quite different according to the anatomical location, and there is no standard and preferred method for lumbar hernia repair. In the present study, we present our techniques of total extraperitoneal (TEP) superior and inferior lumbar hernia repair. METHODS: The TEP approaches were performed in the superior and inferior lumbar hernias. Due to the different anatomic locations of the superior and inferior lumbar hernias, the trocar sites were also different. In the present procedure, with the use of self-gripping mesh, the traumatic fixation was avoided.RESULTS: After TEP lumbar hernia repair, both patients had minimal postoperative pain and were discharged 1 day and 3 days after operation without complications, respectively. CONCLUSION: Different pathways and trocar arrangement are necessary according to the different locations of superior and inferior lumbar hernias. The use of self-gripping mesh in the retroperitoneal space avoids the traumatic fixation, and TEP could be a promising technique for primary lumbar hernia repair.
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CASE REPORT
	Laparoscopic reconstruction of traumatic lumbar hernia: A case report	p. 30
	Martynas Luksta, Marius Kryzauskas, Marius Paskonis, Kestutis Strupas DOI:10.4103/ijawhs.ijawhs_22_18   The traumatic lumbar hernia is an uncommon condition after blunt trauma. There are reported <100 cases in the English literature. Although open repair of traumatic lumbar hernia is a standard treatment, there is a possibility to use minimally invasive techniques in the laparoscopic era. We report the case of a 36-year-old male patient with a history of a blunt abdominal trauma. Seven months later, the patient was complaining of the enlarging mass and a chronic pain in a right lumbar area. A computed tomography scan revealed the traumatic lumbar hernia, with the hepatic flexure of the colon and a greater omentum inside the hernia sac. A laparoscopic intraperitoneal onlay method was chosen and the reconstruction with mesh was performed. The postoperative period was uneventful. The patient was discharged on the 3rd-day postoperatively. The laparoscopic approach can be safe and feasible for treating the traumatic lumbar hernia.
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