Clinical Rehabilitation

Older adults with dementia are at a high risk of falls. Standard interventions have not been shown to be effective in this patient population potentially due to poor consideration of dementia-specific risk factors. An intervention is required that addresses the particular needs of older people with dementia in a community setting.

We followed guidelines for the development of an intervention, which recommend a structured approach considering theory, evidence and practical issues. The process used 15 information sources. Data from literature reviews, clinician workshops, expert opinion meetings, patient-relative interviews, focus groups with people with dementia and clinicians, a cross-sectional survey of risk factors, a pre-post intervention study and case studies were included. Data were synthesized using triangulation to produce an intervention suitable for feasibility testing. Practical consideration of how an intervention could be delivered and implemented were considered from the outset.

Elements of the intervention included individually tailored, dementia-appropriate, balance, strength and dual-task exercises, functional training, and activities aimed at improving environmental access, delivered using a motivational approach to support adherence and long-term continuation of activity. We focussed on promoting safe activity rather than risk or prevention of falls.

We used a systematic process to develop a dementia-specific intervention to promote activity and independence while reducing falls risk in older adults with mild dementia.

This systematic review aimed to examine the effects of dual-task balance and mobility training in people with stroke.

An extensive electronic databases literature search was conducted using MEDLINE, PubMed, EBSCO, The Cochrane Library, Web of Science, SCOPUS, and Wiley Online Library. Randomized controlled studies that assessed the effects of dual-task training in stroke patients were included for the review (last search in December 2017). The methodological quality was evaluated using the Cochrane Collaboration recommendation, and level of evidence was determined according to the criteria described by the Oxford Center for Evidence-Based Medicine.

About 13 articles involving 457 participants were included in this systematic review. All had substantial risk of bias and thus provided level IIb evidence only. Dual-task mobility training was found to induce more improvement in single-task walking function (standardized effect size = 0.14–2.24), when compared with single-task mobility training. Its effect on dual-task walking function was not consistent. Cognitive-motor balance training was effective in improving single-task balance function (standardized effect size = 0.27–1.82), but its effect on dual-task balance ability was not studied. The beneficial effect of dual-task training on cognitive function was provided by one study only and thus inconclusive.

There is some evidence that dual-task training can improve single-task walking and balance function in individuals with stroke. However, any firm recommendation cannot be made due to the weak methodology of the studies reviewed.

To assess whether the addition of an education programme for primary caregivers to rehabilitation improves daily functioning in children with cerebral palsy.

A randomized, single-blind, controlled study.

This study was conducted in a rehabilitation centre in Salvador, Brazil.

A total of 63 boys and girls with cerebral palsy, at 1–12 years of age, with Gross Motor Function Classification Systems I–V, were randomly assigned to two groups: educational programme for primary caregivers and conventional rehabilitation (n = 29) or conventional rehabilitation alone (n = 31).

Each group received 12 sessions of 30 minutes of conventional rehabilitation and 12 sessions of 45 minutes to intervention group.

Gross Motor Function Classification System, Gross Motor Function Measure and daily functioning with the Pediatric Evaluation of Disability Inventory were assessed by a blinded assessor. The clinical outcomes were obtained at the completion of treatment (12 weeks).

Of the 63 patients included, 60 (mean ± SD age: 4.6 ± 2.74 years) completed the protocol. The combined education and rehabilitation, as compared with conventional rehabilitation alone, yielded significantly greater benefit in the self-care domain of the Functional Skills Scale (mean change 1.74 versus 5; P = 0.001), self-care (mean change 5.52 versus 13.99; P = 0.017) and the mobility domain of the Caregiver Assistance Scale of Pediatric Evaluation of Disability Inventory (mean change 0.87 versus 17.88; P = 0.002).

Self-care and mobility improved in children with cerebral palsy with the addition to conventional rehabilitation of an educational programme for primary caregivers.

To assess the effects of early self-managed focal sensorimotor training compared to functional exercise training after total knee replacement on functional mobility and sensorimotor function.

A single-blind controlled clinical trial.

University Hospital of Rion, Greece.

A total of 52 participants following total knee replacement.

The primary outcome was the Timed Up and Go Test and the secondary outcomes were balance, joint position error, the Knee Outcome Survey Activities of Daily Living Scale, and pain. Patients were assessed on three separate occasions (presurgery, 8 weeks post surgery, and 14 weeks post surgery).

Participants were randomized to either focal sensorimotor exercise training (experimental group) or functional exercise training (control group). Both groups received a 12-week home-based programme prescribed for 3–5 sessions/week (35–45 minutes).

Consistently greater improvements (F_2,98 = 4.3 to 24.8; P < 0.05) in group mean scores favour the experimental group compared to the control group: Timed Up and Go (7.8 ± 2.9 seconds vs. 4.6 ± 2.6 seconds); balance (2.1 ± 0.9° vs. 0.7 ± 1.2°); joint position error (13.8 ± 7.3° vs. 6.2 ± 9.1°); Knee Outcome Survey Activities of Daily Living Scale (44.2 ± 11.3 vs. 26.1 ± 11.4); and pain (5.9 ± 1.3 cm vs. 4.6 ± 1.1 cm). Patterns of improvement for the experimental group over time were represented by a relative effect size range of 1.3–6.5.

Overall, the magnitude of improvements in functional mobility and sensorimotor function endorses using focal sensorimotor training as an effective mode of rehabilitation following knee replacement.

This study aimed to investigate the effect of continuous progressive resistance training on body composition, functional capacity and self-reported quality of life in end-stage renal disease patients.

A randomized controlled trial.

The study included 52 hemodialysis patients (aged 55.7 ± 14.03 years) randomized into exercise (progressive resistance training (PRT), n = 28) or control (CON, n = 24) groups.

Patients randomized into the PRT group received prescribed strength exercises in two sets of 15–20 repetitions, in a repetition maximum training zone regime, thrice a week for 12 weeks, during hemodialysis. Patients randomized into the CON group received a sham-exercise with active mobilization of the arms and legs without load and progression.

Body composition using dual-energy X-ray absorptiometry (DXA), strength using handgrip dynamometry (HGS), repeated sit-to-stand test (STT), 6-minute walk test, flexibility and the SF-36 questionnaire (quality of life (QoL)) were assessed at baseline and at 12 weeks.

Leg lean mass (P = 0.04, effect size (ES) of 0.56), bone mineral content (P = 0.02, ES of 0.65), leg strength in STT repetitions (P = 0.01, ES of 0.66) and flexibility (P < 0.01, ES of 1.03) were significantly improved in the PRT group compared to the CON group. Walking capacity, HGS and QoL were not different between the groups.

12 weeks of PRT with a repetition maximum training zone regime provided significant load to increase leg lean mass and STT performance as well as bone mineral content, compared to the CON, which continued to deteriorate. There was lack of efficacy on walking test, HGS and QoL.

To determine the feasibility and short-term efficacy of caregiver-directed constraint-induced movement therapy to improve upper limb function in young children with hemiplegic cerebral palsy.

Randomized controlled trial with masked assessment.

Community paediatric therapy services.

Pre-school children with hemiplegic cerebral palsy.

Caregiver-directed constraint-induced movement therapy administered using either 24-hour short-arm restraint device (prolonged) or intermittent holding restraint during therapy (manual).

Primary measures include Assisting Hand Assessment (AHA) at 10 weeks. Secondary measures include adverse events, Quality of Upper Extremity Skills Test and Pediatric Quality of Life Inventory. Feasibility measures include recruitment, retention, data completeness and adherence.

About 62/81 (72%) of eligible patients in 16 centres were randomized (prolonged restraint n = 30; manual restraint n = 32) with 97% retention at 10 weeks. The mean change at 10 weeks on the AHA logit-based 0–100 unit was 9.0 (95% confidence interval (CI): 5.7, 12.4; P < 0.001) for prolonged restraint and 5.3 (95% CI: 1.3, 9.4; P = 0.01) for manual restraint with a mean group difference of 3.7 (95% CI: −1.5, 8.8; P = 0.156) (AHA smallest detectable difference = 5 units). No serious related adverse events were reported. There were no differences in secondary outcomes. More daily therapy was delivered with prolonged restraint (60 vs 30 minutes; P < 0.001). AHA data were complete at baseline and 10 weeks.

Caregiver-directed constraint-induced movement therapy is feasible and associated with improvement in upper limb function at 10 weeks. More therapy was delivered with prolonged than with manual restraint, warranting further testing of this intervention in a longer term trial.

To compare the cost effectiveness of two occupational therapy–led discharge planning interventions from the HOME trial.

An economic evaluation was conducted within the superiority randomized HOME trial to assess the difference in costs and health-related outcomes associated with the enhanced program and the in-hospital consultation. Total costs of health and community service utilization were used to calculate incremental cost-effectiveness ratios, activities of daily living and quality-adjusted life years.

Medical and acute care wards of Australian hospitals (n=5).

A total of 400 people ≥ 70 years of age.

Participants were randomized to either (1) an enhanced program (HOME), involving pre/post discharge visits and two follow-up phone calls, or (2) an in-hospital consultation using the home and community environment assessment and the Lawton Instrumental Activities of Daily Living assessment.

Nottingham Extended Activities of Daily Living (global measure of activities of daily living) and SF-12V2, transformed into SF-6D (quality-adjusted life year) measured at baseline and three months post discharge.

The cost of the enhanced program was higher than that of the in-hospital consultation. However, a higher proportion of patients showed improvement in activities of daily living in the enhanced program with an incremental cost-effectiveness ratio of $61,906.00 per person with clinically meaningful improvement.

Health services would not save money by implementing the enhanced program as a routine intervention in medical and acute care wards. Future research should incorporate longer time horizons and consider which patient groups would benefit from home visits.

To investigate the effect of a nutrition intervention program for geriatric nutritional at-risk patients.

A randomized controlled trial.

Department of geriatric medicine in a university hospital and in the primary healthcare sector, Copenhagen.

Geriatric patients (N = 144) at nutritional risk.

The intervention consisted of an individual dietary plan for home, including pre-discharge advice on nutritional intake, combined with three follow-up visits after discharge (one, four, and eight weeks).

Change in body weight, Barthel Index, hand-grip strength and self-rated health from baseline (discharge) to three months after discharge, readmission, and mortality (90 and 120 days).

The mean (SD) age in total sample was 87.2 (6.2) years. Sample size in the intervention group (IG) was N = 72, and in the control group (CG), N = 72. IG had a mean (SD) weight gain of 0.9 (4.2) kg compared to a weight loss of 0.8 (3.6) kg in the CG (P = 0.032). In addition, an improvement in self-rated health was seen in the IG compared to CG (IG: 23 (47%) vs. CG: 12 (24%); P = 0.021). No significant difference between groups was found in functional status, mortality, or readmission rates.

An individual dietary plan based on everyday food, combined with three follow-up visits (one, four, and eight weeks) after discharge, led to an improvement in nutritional status and self-rated health in geriatric patients.

To synthesize the evidence regarding the diagnostic value of simple ancillary tests post cerebrospinal fluid drainage in normal pressure hydrocephalus.

MEDLINE, CINAHL, PsycINFO, Scopus, Web of Science, and Cochrane library databases; last searched on 12 September 2017.

This review was performed applying the steps of the PRISMA statement. The QUADAS 2 tool was used to assess the risk of bias. Prospective and retrospective trials were systematically reviewed, and data on diagnostic accuracy were extracted. Meta-analysis (where possible) was performed. Hierarchical summary receiver operating characteristic package was used to calculate pooled estimates of included diagnostic studies.

Seventeen trials (with 812 subjects in total) were identified for inclusion in the meta-analyses for the 18-meter walk test, video-recorded gait performance, cognitive test, and Timed Up and Go Test. The summary estimates of sensitivity and specificity for the 18-meter walk test was 0.83 (95% CI 0.57 to 0.99) and 0.67 (95% CI 0.33 to 0.95), video-recorded gait performance was 0.85 (95% CI 0.47 to 0.99) and 0.68 (95% CI 0.33 to 0.96), cognitive test was 0.82 (95% CI 0.41–0.99) and 0.75 (95% CI 0.39–0.99), and Timed Up and Go Test was 0.89 (95% CI 0.79–0.95) and 0.63 (95% CI 0.24–0.90), respectively.

This review highlights the diagnostic value of the 18-meter walk test, video-recorded gait performance, cognitive test, and Timed Up and Go Test in predicting shunt outcomes among adults with normal pressure hydrocephalus.

The three objectives of this scoping review were to (1) identify key conceptual/theoretical frameworks and the extent to which they are used to inform goal setting related to rehabilitation goal setting with children with motor disabilities, (2) describe research that has evaluated goal setting processes and outcomes, and (3) summarize the purposes of goal setting described in paediatric rehabilitation literature.

The scoping review process described by Arksey and O’Malley was used to guide article selection and data extraction.

A total of 62 articles were included in the final review. While the concept of family-centered care was well represented, theoretical frameworks specific to goal setting (i.e. goal setting theory described by Locke and Latham, mastery motivation, social cognitive, personal construct, and self-determination theories) were rarely addressed. No articles reviewed addressed prominent behavior change theory. With the exception of the description of tools specifically designed for use with children, the role of the child in the goal setting process was generally absent or not well described. Few studies (n = 6) discussed the linkage between goals and intervention strategies explicitly. Only two studies in the review evaluated outcomes associated with goal setting. The primary purpose for goal setting identified in the literature was to develop goals that are meaningful to families (n = 49).

The results highlight significant gaps in the literature explicating a sound theoretical basis for goal setting in paediatric rehabilitation and research evaluating the effects of goal qualities and goal setting processes on the achievement of meaningful outcomes.

To explore the mediating effect of loneliness on the relationship between pain interference and depressive symptoms and to determine whether this mechanism is contingent on employment status.

Cross-sectional study.

A total of 876 adult caregivers of adolescents living in extremely impoverished conditions.

Mediation and moderated mediation analyses using standard path-analytic approaches.

The mean age of the sample was 39.0 (SD = 12.8) years and 80.7% (n = 707) identified as female. Almost half (48.9%, n = 425) of the participants did not report any pain, while 32.5% (n = 285) reported non-disabling pain, and 19.0% (n = 166) reported disabling pain. The mean depressive symptoms score was 16.20 (SD = 10.6), and the mean loneliness score was 40.09 (SD = 10.5). Loneliness mediated the effect of both non-disabling and disabling pain on depressive symptoms. However, the indirect effect of pain interference on depressive symptoms through loneliness was more pronounced among participants reporting disabling pain (coefficient, 2.11; Boot 95% confidence interval (CI) (1.25–3.01)) than non-disabling pain (coefficient, 0.99; Boot 95% CI (0.25–1.76)). Moderated mediation results showed that the indirect effect of pain interference on depressive symptoms, via loneliness varied in magnitude as a function of employment status among participants reporting disabling pain but not those reporting non-disabling pain.

Loneliness provides an important link in the relationship between depressive symptoms and pain interference. Furthermore, employment status is an important factor to consider, especially among individuals reporting disabling pain with comorbid depressive symptoms.

Physical exercise interventions for the management of knee osteoarthritis are well known to be effective and accessible forms of rehabilitation and symptom management. However, without adequate reporting of these interventions, accurate replication and clinical use is negatively impacted.

The main objective of this article was to assess content reporting using The Consensus on Exercise Reporting Template list and 2016 American College of Sports Medicine guidelines among moderate- to high-quality exercise interventions randomized controlled trials (total score of ≥6/10 on the PEDro scale) involving individuals with knee osteoarthritis.

The Consensus on Exercise Reporting Template mean total score for all 47 included randomized controlled trials was 4.42 out of 19, demonstrating generally low quality of reporting. The Consensus on Exercise Reporting Template list and the 2016 American College of Sports Medicine guidelines scores were moderately correlated (based on 95% confidence interval, intraclass correlation coefficient = 0.508) for aerobic interventions only.

The content analysis of exercise interventions in knee osteoarthritis demonstrated low scores for moderate- to high-quality trials. Improved standardized reporting is recommended to ensure knowledge transfer and replication of effective exercise programs for individuals with knee osteoarthritis.

To understand the circumstances surrounding the worst fall experienced by power wheelchair users in the past year and to examine injuries sustained and recovery methods.

A qualitative study using a semi-structured interview.

Community.

A self-selected volunteer sample of 19 power wheelchair users who utilize their device for at least 75% of mobility. The most common disability represented was cerebral palsy (n = 8). The mean (SD) age of participants was 41.9 (7.6) years, who lived with their disability for a mean (SD) of 20.5 (8.62) years and used their current device for a mean (SD) of 3.9 (1.9) years.

None.

A semi-structured interview examined the circumstances surrounding the worst fall experienced in the past year, injuries sustained and recovery techniques used.

Upon examination of the circumstances of the worst fall, four main themes emerged: (1) action-related fall contributors, (2) location of falls, (3) fall attributions and (4) time of fall. Each fall described was found to involve multiple factors. As a result of the fall, participants also reported the occurrence of physical injuries and a fear of falling. Physical injuries ranged from skin abrasion and bruises to fractures and head injuries. Participants also reported that fear of falling diminished their desire to participation in activities they enjoyed doing. Finally, most participants reported the need for physical assistance to recover from a fall.

Participant descriptions provide an in-depth description of the circumstances and aftermath of falls experienced by power wheelchair users.