Clinical Rehabilitation

We performed a systematic review and meta-analysis of randomized controlled trials to investigate the differences in the efficacies between strengthening and aerobic exercises for pain relief in people with knee osteoarthritis.

This search was applied to Medline, Cochrane Central Register of Controlled Trials, the Physiotherapy Evidence Database, and the Cumulative Index to Nursing and Allied Health Literature. All literature published from each source’s earliest date to March 2013 was included.

Trials comparing the effects of exercise intervention with those of either non-intervention or psycho-educational intervention were collected. Meta-analysis was performed for trials in which therapeutic exercise was carried out with more than three sessions per week up to eight weeks, for pain in people with knee osteoarthritis. All trials were categorised into three subgroups (non-weight-bearing strengthening exercise, weight-bearing strengthening exercise, and aerobic exercise). Subgroup analyses were also performed.

Data from eight studies were integrated. Overall effect of exercise was significant with a large effect size (standardised mean difference (SMD): −0.94; 95% confidence interval −1.31 to −0.57). Subgroup analyses showed a larger SMD for non-weight-bearing strengthening exercise (−1.42 [−2.09 to −0.75]) compared with weight-bearing strengthening exercise (−0.70 [−1.05 to −0.35]), and aerobic exercise (−0.45 [−0.77 to −0.13]).

Muscle strengthening exercises with or without weight-bearing and aerobic exercises are effective for pain relief in people with knee osteoarthritis. In particular, for pain relief by short-term exercise intervention, the most effective exercise among the three types is non-weight–bearing strengthening exercise.

To investigate the short- and medium-term efficacy of counselling services provided remotely by telephone, video or internet, in managing mental health outcomes following spinal cord injury.

A search of electronic databases, critical reviews and published meta-analyses was conducted.

Seven independent studies (N = 272 participants) met the inclusion criteria. The majority of these studies utilized telephone-based counselling, with limited research examining psychological interventions delivered by videoconferencing (N_study = 1) or online (N_study = 1).

There is some evidence that telecounselling can significantly improve an individual’s management of common comorbidities following spinal cord injury, including pain and sleep difficulties (d = 0.45). Medium-term treatment effects were difficult to evaluate, with very few studies providing these data, although participants have reported gains in quality of life 12 months after treatment (d = 0.88). The main clinical advantages are time efficiency and consumer satisfaction.

The results highlight the need for further evidence, particularly randomized controlled trials, to establish the benefits and clinical viability of telecounselling.

A systematic review and meta-analysis using the Grades of Recommendation, Assessment, Development and Evaluation (GRADE) approach to evaluate Botulinum Toxin Type A efficacy on spasticity and pain in the upper/lower limb in adults.

Pubmed, Cinahl, Amed, Embase and Cochrane Databases. English language. 1989 to April 2013.

All randomized controlled trials on adults with spasticity of any origin in the upper or lower limb, treated with a single dose of Botulinum Toxin A, with outcome measures for pain or spasticity. Quality was assessed by GRADE, which uses a transparent, structured process for developing and presenting summaries of evidence, including its quality, for systematic reviews.

A total of 37 studies were reviewed. A meta-analysis was carried out on 10 for pain and 21 for spasticity. Evidence quality was low/very low for pain. No significant effect was found in the upper limb (standardised mean difference (SMD) = 0.44, confidence interval (CI) –0.02 to 0.90, Z = 1.88, P=0.06), and no effect was found in the lower limb (risk ratio (RR) = 1.01 CI 0.19 to 5.36, Z = 0.02, P=0.99).

Evidence quality for spasticity was moderate. Significant effects were found for Botulinum Toxin in the upper limb (weighted mean difference (WMD) = 0.88, CI 0.63 to 1.14, Z = 6.86, P<0.00001), and the lower limb (RR=2.42, CI 1.60 to 3.65, Z=4.18, P<0.0001).

The use of Botulinum Toxin A is supported for upper and lower limb spasticity. Further evidence is needed for spasticity-related pain. Evidence quality is reduced by inadequate study design.

To assess the treatment integrity of behavioural therapy for low mood in stroke patients with aphasia.

Participants were recruited to a multicentre randomized controlled trial (Communication and Low Mood; CALM trial) comparing behavioural therapy with a usual care control group.

Of the 51 participants randomly allocated to receive behavioural therapy, 44 participants completed treatment.

Participants were assessed on measures of disability, language and mood. The number and length of therapy sessions, and therapist was recorded. Allocation of time to therapy components was compared across three phases of therapy. Associations between levels of disability, aphasia, mood and the therapy patients received were determined. Therapy content was compared between centres and at the beginning and end of the trial.

The mean number of therapy sessions was 9.1 (range 3–18, SD 2.6) and the mean duration of sessions was 58 minutes (range 30–89 minutes, SD 10.7). Allocation of time to each therapy component significantly differed across the three phases of therapy (P < 0.05). There were no significant associations (P > 0.05) between the length and number of sessions and patients’ aphasia, mood or disability, suggesting similar levels of therapy were provided regardless of patients’ characteristics. The content of therapy showed some differences between centres (P < 0.01) and there was programme drift in some components of therapy.

The results support the ability of the therapists to deliver behavioural therapy according to the treatment manual. However there were differences between centres and over time in some components of therapy.

To investigate the long-term effects of motivational interviewing on clinical outcomes, psychological outcomes, health-related quality of life among cardiac rehabilitation patients with poor motivation.

A randomized controlled trial with blind data collectors.

Cardiac rehabilitation centre.

A total of 146 cardiac rehabilitation patients with poor motivation.

All participants received usual care, including exercise and education, while those in the experimental group also received 10 sessions of motivational interviewing, each lasting 30–45 minutes.

Clinical and psychological outcomes and health-related quality of life were assessed at baseline and at six, nine and 12 months for both groups.

There was no significant difference between the two groups at baseline on demographic and clinical outcomes except for monthly family income (p = 0.034). Patients in the experimental group had higher increases in health-related quality of life (SF-36) scores in bodily pain (88.7 SD 16.7 vs. 87.6 SD 18.7 at month 12, p = 0.044) and role limitation owing to emotional problems (86.9 SD 19.2 vs. 78.6 SD 21.8 at month 9, p = 0.019; 85.8 SD 18.9 vs. 76.9 SD 23.9 at month 12, p = 0.022). No statistically significant group difference was found among other outcomes.

The long-term effect of motivational interviewing on clinical and psychological outcomes and health-related quality of life in studied patients is limited.

To investigate the effect of action observational training on walking ability with chronic stroke patients.

A double-blind randomized controlled trial.

Inpatient rehabilitation hospital.

Thirty chronic stroke patients.

Patients in both groups underwent treadmill training for 30 minutes. The action observational training group (n = 15) watched a video of treadmill walking actions taken at various speeds before treadmill training for 10 minutes. The control group (n = 15) watched a nature video unrelated to gait training for the same amount of time. All participants received training five times a week for a period of four weeks.

Timed up and go test, 10-metre walk test, 6-minute walk test and maximal flexed knee angle in the swing phase during walking.

There were significant improvements in timed up and go test (–4.47 vs. –2.47 seconds), 10-m walk test (0.35 vs. 0.16 m/s), 6-minute walk test (93.13 vs. 32.53 m) and maximal flexed knee angle in the swing phase during walking (7.11 vs. 4.58 degrees) in the action observational training group compared with the control group (P < 0.05). Small to huge effect sizes of 1.27, 0.57, 2.34 and 0.37 were observed for timed up and go test, 10-m walk test, 6-minute walk test, and maximal flexed knee angle in the swing phase during walking, respectively.

These results suggest that action observational training is an effective method for improvement of the walking ability in chronic stroke patients.

The primary aim was to investigate the comparative effects of massage therapy and exercise therapy on patients with multiple sclerosis. The secondary aim was to investigate whether combination of both massage and exercise has an additive effect.

Randomized controlled pilot trial with repeated measurements and blinded assessments.

Local Multiple Sclerosis Society.

A total of 48 patients with multiple sclerosis were randomly assigned to four equal subgroups labelled as massage therapy, exercise therapy, combined massage–exercise therapy and control group.

The treatment group received 15 sessions of supervised intervention for five weeks. The massage therapy group received a standard Swedish massage. The exercise therapy group was given a combined set of strength, stretch, endurance and balance exercises. Patients in the massage–exercise therapy received a combined set of massage and exercise treatments. Patients in the control group were asked to continue their standard medical care.

Pain, fatigue, spasticity, balance, gait and quality of life were assessed before and after intervention.

Massage therapy resulted in significantly larger improvement in pain reduction (mean change 2.75 points, P = 0.001), dynamic balance (mean change, 3.69 seconds, P = 0.009) and walking speed (mean change, 7.84 seconds, P = 0.007) than exercise therapy. Patients involved in the combined massage–exercise therapy showed significantly larger improvement in pain reduction than those in the exercise therapy (mean change, 1.67 points, P = 0.001).

Massage therapy could be more effective than exercise therapy. Moreover, the combination of massage and exercise therapy may be a little more effective than exercise therapy alone.

To investigate the long-term dosage evolution and complication rate of intrathecal baclofen use in multiple sclerosis and spinal cord injury patients, based on a large population with a long follow-up.

Retrospective data analysis

Academic hospital

Patients with multiple sclerosis (n = 81) or spinal cord injury (n = 49) having an intrathecal baclofen pump implanted at the University Hospitals Leuven between 1988 and 2009.

Medical records review of included patients in August 2010.

Complications linked to intrathecal baclofen therapy. Daily baclofen dosage after 3 and 6 months, and yearly thereafter. Data on dosage evolution were analysed using a mixed-effect linear model.

In 130 patients with a mean follow-up of 63 months, comprising 797 pump years, 104 complications were recorded. This corresponds to a complication rate of 0.011 per month, equally divided among both groups. Seventy-eight of these complications were catheter related. The mean dosage of baclofen stabilizes two years after implantation at 323 µg/day in the multiple sclerosis population. In spinal cord injury patients the daily dose only stabilizes after five years at a significantly higher dosage (504 µg/day). No significant increase in dosage is seen in the long term.

In multiple sclerosis and spinal cord injury patients, intrathecal baclofen therapy has a complication rate of 1% per month. Complications are mainly due to catheter-related problems (74%). The intrathecal baclofen dosage stabilizes in the long term, indicating that long-term tolerance, defined as progressive diminution of the susceptibility to the effects of a drug, is not present.