Clinical Rehabilitation

Rehabilitation services in the UK are inadequate, with insufficient capacity or flexibility to meet the needs of patients after Covid-19.

Rehabilitation developed in a piecemeal way, focused on specific problems: spinal cord injury, burns, polio, stroke, back pain, equipment and adaptations etc. Rehabilitation is also provided using other names (e.g. intermediate care). Patients with complex needs do not fit easily within this system.

After Covid-19, patients have problems that cross existing condition-specific and/or treatment-specific services. Covid-19 has exposed the lack of any coherent organisational principle underlying development or commissioning of rehabilitation services. Consequently, in order to have their needs met, patients either have to engage with two or more separate services or they receive good management for some problems and sub-optimal management for other problems.

The multitude of small specific services need to coalesce into an integrated service able to meet all the needs of any patient referred. Second, rehabilitation needs to be fully integrated into all healthcare services.

The purpose of healthcare is to ‘improve our health and well-being . . . to stay as well as we can to the end of our lives’. (NHS constitution) All healthcare services need to consider patients holistically, giving equal attention to disease, disability, and distress. Rehabilitation, acute care, mental health and palliative care services need to work in parallel to achieve this purpose. Healthcare providers, supported by commissioners and rehabilitation experts, could achieve structural and organisational change, meeting the needs of patients.

To assess the effectiveness of diacutaneous fibrolysis in reducing musculoskeletal disorders symptoms such as pain, range of motion and functionality.

A systematic review of MEDLINE, Cochrane, PEDro and Science Direct was conducted until September 2020.

Computerized search strategy was performed to identify randomized controlled trials applying diacutaneous fibrolysis, on subjects with musculoskeletal disorders. Eligible articles and data extraction were conducted independently by two reviewers. Methodology quality and risk of bias were assessed by Risk of Bias 2 tool from the Cochrane Collaboration and Physiotherapy Evidence Database. Outcomes assessed were pain intensity, range of motion and functionality.

Search strategy identified 98 potential randomized control trials and six studies involving 386 participants, were finally included. Diacutaneous fibrolysis intervention added to usual physiotherapy treatment was compared to control group. Pain intensity immediately after treatment showed a pooled Standard Mean Difference (SMD) of –0.58 with 95% confidence interval (CI) from –1.12 to –0.04, and in the longest follow-up SMD was –0.63 with 95% CI (–1.21 to –0.05). Functionality showed a pooled SMD of –1.02 with 95% CI (–1.67 to –0.36) immediately after intervention and a SMD of –0.84 with 95% CI (–1.54 to –0.14). Range of motion could not be included in the quantitative synthesis.

Diacutaneous fibrolysis is an effective treatment, when combined with conventional physiotheraphy, reducing pain immediately after treatment and long term follow-up and improving function in both, short and long term in musculoskeletal disorders.

To determine the effectiveness of Baduanjin exercise in improving cognition and memory in patients with mild cognitive impairment.

Relevant English- and Chinese-language studies published until 15^th September 2020 were retrieved from the PubMed, Web of Science, Cochrane Library, Embase, EBSCOhost, OVID, National Knowledge Infrastructure, WANFANG DATA, VIP Information, and SinoMed databases.

Randomized controlled trials assessing Baduanjin exercise in patients with mild cognitive impairment were included. Two researchers independently identified eligible studies and extracted data. Risk-of-bias assessment was performed using the Cochrane Risk of Bias Tool.

This study included 16 randomized controlled trials (1054 participants) from China that used Chinese versions of standardized tests. Most studies had no significant bias, and only one study had a high risk of bias in the random allocation category. Compared with conventional therapy alone, Baduanjin plus conventional therapy significantly improved the Montreal Cognitive Assessment and Mini-Mental State Examination scores after 6 months of treatment (P < 0.00001 for both), significantly decreased the tau/Aβ_1–42 ratio in the cerebrospinal fluid (P < 0.00001), and significantly improved some dimensional scores on the Wechsler Memory Scale and the auditory verbal learning test scores at 6 months (P < 0.05 for all).

Compared with conventional therapy, Baduanjin plus conventional therapy significantly improved cognitive and memory function in patients with mild cognitive impairment.

To determine the effectiveness of proprioceptive training on knee function and proprioception following anterior cruciate ligament reconstruction.

PubMed, EMBASE, The Cochrane Library, Ovid, EBMSCO-host, ScienceDirect, CNKI, VIP, WanFang Data and CBM were searched until 2nd October 2020.

Trials with proprioceptive training for patients with anterior cruciate ligament reconstruction were included. Study screening, data extraction, risk of bias and quality assessments were performed independently by two researchers. We performed a stratified analysis based on the quality of the study. Sensitivity analyses were performed if the heterogeneity was high.

Seventeen trials with 878 participants were included, and 12/17 with low quality. After stratified analysis, the pooled effect of high-quality studies showed significant improvement for proprioceptive training group in range of motion (P < 0.05, I² = 0%), but no differences in Cincinnati knee rating system score (P > 0.05, I² = 83%), hop test (P>0.05, I² = 0%) and proprioception (P = 0.17, I² = 77%) compared to conventional training group; while the pooled effect of low-quality studies showed significant differences in knee functional improvement (P < 0.00001, I² = 69%), but no difference in proprioception (P > 0.05, I² = 84%) between two groups. The pooled effect of all studies showed a significant benefit in both function and proprioception.

The effects of proprioceptive training on knee functional and proprioceptive improvement after anterior cruciate ligament reconstruction is mixed. It is more likely that proprioceptive training in high-quality studies has few detectable effects and that low-quality studies show an effect because of an unconscious bias. A large well designed high-quality study needs to be undertaken in the future.

To evaluate effects of stationary cycling exercise on pain, function and stiffness in individuals with knee osteoarthritis.

Systematic search conducted in seven databases (PubMed, Embase, Cochrane Library, Web of Science, EBSCO, PEDro, and CNKI) from inception to September 2020.

Included studies were randomized-controlled trials involving stationary cycling exercise conducted on individuals with knee osteoarthritis. End-trial weighted mean difference (WMD) and 95% confidence interval (CI) were analyzed, and random-effects models were used. Methodological quality and risk bias were assessed by using the Physiotherapy Evidence Database scale and Cochrane Collaboration tool, respectively.

Eleven studies with 724 participants were found, of which the final meta-analysis was performed with eight. Compared to a control (no exercise), stationary cycling exercise resulted in reduced pain (WMD 12.86, 95% CI 6.90–18.81) and improved sport performance (WMD 8.06, 95% CI 0.92–15.20); although most of the meta-analysis results were statistically significant, improvements in stiffness (WMD 11.47, 95% CI 4.69–18.25), function (WMD 8.28, 95% CI 2.44–14.11), symptoms (WMD 4.15, 95% CI −1.87 to 10.18), daily living (WMD 6.43, 95% CI 3.19 to 9.66) and quality of life (WMD 0.99, 95% CI −4.27 to 6.25) for individuals with knee osteoarthritis were not greater than the minimal clinically important difference values for each of these outcome measures.

Stationary cycling exercise relieves pain and improves sport function in individuals with knee osteoarthritis, but may not be as clinically effective for improving stiffness, daily activity, and quality of life.

To investigate the effects of rehabilitation methods on leg muscle function and functional performance in cystic fibrosis.

A literature search was conducted in PubMed (MEDLINE), Scopus and the Cochrane Library from inception to October 12, 2020. A secondary hand search through reference lists from identified articles was conducted.

Three authors independently checked the full-text copies for eligibility of relevant articles. Randomized controlled trials were included. Methodological quality was assessed using the Physiotherapy Evidence Database scale. The PRISMA guidelines were followed. Results suggestive of leg muscle function (e.g. strength, power, endurance, and fatigue) and functional performance were reported.

The search identified 8 studies (233 patients). The overall quality of these articles was good. Rehabilitation modalities investigated were physical exercises (aerobic, anaerobic and resistance training) (n = 7) and neuromuscular electrical stimulation (n = 1). Most studies (n = 4) reported on the effects of combined aerobic and resistance training and showed improvement on leg strength when exercises were supervised. Aerobic training alone or the use of neuromuscular electrical stimulation also enhanced leg strength, whereas anaerobic training did not. Two studies evaluated leg fatigue and found no improvement compared to standard care. One study assessed the effect of exercises on functional performance and found no improvement when compared to standard care. No studies emphasized the impact of rehabilitation methods on leg muscle endurance or power.

Combined aerobic and resistance training enhances leg muscle strength in cystic fibrosis. There is insufficient data on other leg muscle outcomes, nor on alternative rehabilitation strategies.

To assess the feasibility of a multi-site randomised controlled trial to evaluate the effect of functional electrical stimulation on bradykinesia in people with Parkinson’s disease.

A two-arm assessor blinded randomised controlled trial with an 18 weeks intervention period and 4 weeks post-intervention follow-up.

Two UK hospitals; a therapy outpatient department in a district general hospital and a specialist neuroscience centre.

A total of 64 participants with idiopathic Parkinson’s disease and slow gait <1.25 ms⁻¹.

Functional electrical stimulation delivered to the common peroneal nerve while walking in addition to standard care compared with standard care alone.

Feasibility aims included the determination of sample size, recruitment and retention rates, acceptability of the protocol and confirmation of the primary outcome measure. The outcome measures were 10 m walking speed, Unified Parkinson’s Disease Rating Scale (UPDRS), Mini Balance Evaluation Systems Test, Parkinson’s Disease Questionnaire-39, EuroQol 5-dimension 5-level, New Freezing of Gait questionnaire, Falls Efficacy Score International and falls diary. Participants opinion on the study design and relevance of outcome measures were evaluated using an embedded qualitative study.

There was a mean difference between groups of 0.14 ms⁻¹ (CI 0.03, 0.26) at week 18 in favour of the treatment group, which was maintained at week 22, 0.10 ms⁻¹ (CI –0.05, 0.25). There was a mean difference in UPDRS motor examination score of –3.65 (CI –4.35, 0.54) at week 18 which was lost at week 22 –0.91 (CI –2.19, 2.26).

The study design and intervention were feasible and supportive for a definitive trial. While both the study protocol and intervention were acceptable, recommendations for modifications are made.

To investigate if adding Kinesio tape to therapeutic exercise is an effective treatment to improve clinical outcomes compared to therapeutic exercise alone and no intervention, in patients with shoulder impingement syndrome.

Three-arm randomized controlled trial

Outpatient setting

One hundred and twenty patients (mean (SD): age 37.8 (5.4)) with shoulder impingement syndrome.

Patients were randomly assigned to eight-weeks therapeutic exercise alone, therapeutic exercise with Kinesio tape, and control group.

Pain was measured with a numerical rating scale and disability and scapular kinematics were measured with a relative questionnaire and motion analysis software respectively, at baseline and after eight-weeks intervention.

There was significant differences in therapeutic exercise with Kinesio tape group vs. therapeutic exercise alone and control group respectively for pain (d = –0.34, P = 0.042; and d = –1.53, P = 0.001), disability (d = –0.46, P = 0.024; and d = –2.18, P = 0.001), scapular upward rotation at sagittal plane (d = 0.33, P = 0.033; and d = 0.68, P = 0.001), scapular plane (d = 0.18, P = 0.045; and d = 0.43, P = 0.001), scapular tilt at sagittal plane (d = 0.55, P = 0.043; and d = 1.39, P = 0.001), and scapular plane (d = 0.29, P = 0.034; and d = 0.58, P = 0.001). Therapeutic exercise alone was superior over control group in all significant outcomes (P < 0.05).

Although therapeutic exercises alone showed positive effect on clinical outcomes, adding Kinesio tape to therapeutic exercises had more significant effects with larger effect sizes. Adding Kinesio tape to therapeutic exercise may be of some assistance to clinicians in improving clinical outcomes in patients with shoulder impingement syndrome.

To determine the feasibility and safety of aerobic training with an arm crank ergometer and its effectiveness in improving functional capacity and gait in patients with recent hip fracture.

Randomized, controlled, assessor-blinded pilot study, with intention-to-treat analysis.

Inpatients, rehabilitation department.

40 patients with hip fracture surgically treated.

Training group performed aerobic exercise with an arm crank ergometer (15 sessions, 30 minutes/day) at an intensity of 64% to 76% of maximum heart rate, in addition to conventional inpatient rehabilitation.

Primary outcome was the feasibility (including eligibility rate, recruitment rate, number of drop-outs and adverse events, adherence). Secondary measures were the Timed Up and Go test, ability to walk independently, muscle torque of knee extensors of fractured and non-fractured leg, Functional Independence Measure.

Mostly due to pre-existing disability and fracture type, only 40/301 (13%) patients were eligible (age 84.6 ± 7.6 years, 75% female); all agreed to participate and 90% completed the trial, without adverse events. Adherence to aerobic exercise was good, with high attendance at sessions (93%), a strong compliance to exercise duration (95%) but lower compliance to the prescribed intensity (73%). After the program, more patients were able to walk independently in the training group (n = 18) compared to control (n = 13) (P < 0.05). Also the muscle torque of fractured leg knee extensors was higher in the training group (P < 0.05).

Aerobic training in addition to conventional rehabilitation after a hip fracture is feasible and safe and it was effective in improving gait performance and strength of fractured leg.

NCT04025866.

To determine the level of evidence of the measurement properties (validity, reliability, and responsiveness) and interpretability of the step tests available for assessing the exercise capacity in patients with chronic obstructive pulmonary disease.

The data sources Web of Science, MEDLINE, PubMed, PEDro, CENTRAL of Cochrane Library, and Scopus were searched up to June 26, 2020.

Studies of any design that reported results for any measurement property of the step tests for assessing the exercise capacity in COPD patients were selected. One reviewer extracted the data, and two reviewers independently rated the level of evidence by using the Consensus-Based Standards for the Selection of Health Measurements Instruments recommendations.

Thirty-one studies were included in the data synthesis. Chester Step Test, Modified Incremental Step Test, two-, three-, four-, and six-Minute Step Test, Paced Step Test, and six-Minute Stepper Test were identified. A step test protocol was also found. The level of evidence of their results for the measurement properties was mostly determined as “low” to “very low.” The best level of evidence found was for the six-minute stepper test: “high” on construct validity (r = 0.56–0.71); and “moderate” on criterion validity (r = 0.36–0.69), and responsiveness (r = 0.26–0.34).

The general level of evidence of the measurement properties of the step tests is “low” to “very low” for assessing exercise capacity in patients with chronic obstructive pulmonary disease, which can limit their application in clinical practice. The six-minute Stepper Test is currently the most appropriate step test available.

To evaluate the performance of telehealth as a screening tool for spasticity compared to direct patient assessment in the long-term care setting.

Cross-sectional, observational study.

Two long-term care facilities: a 140-bed veterans’ home and a 44-bed state home for individuals with intellectual and developmental disabilities.

Sixty-one adult residents of two long-term care facilities (aged 70.1 ± 16.2 years) were included in this analysis. Spasticity was identified in 43% of subjects (Modified Ashworth Scale rating mode = 2). Contributing diagnoses included traumatic brain injury, spinal cord injury, birth trauma, stroke, cerebral palsy, and multiple sclerosis.

Movement disorders neurologists conducted in-person examinations to determine whether spasticity was present (reference standard) and also evaluated subjects with spasticity using the Modified Ashworth Scale. Telehealth screening examinations, facilitated by a bedside nurse, were conducted remotely by two teleneurologists using a three-question screening tool. Telehealth screening determinations of spasticity were compared to the reference standard determination to calculate sensitivity, specificity, and the area under the curve (AUC) in receiver operating characteristics. Teleneurologist agreement was evaluated using Cohen’s kappa.

Teleneurologist 1 had a specificity of 89% and sensitivity of 65% to identify the likely presence of spasticity (n = 61; AUC = 0.770). Teleneurologist 2 showed 100% specificity and 82% sensitivity (n = 16; AUC = 0.909). There was almost perfect agreement between the two examiners at 94% (kappa = 0.875, 95% CI: 0.640–1.000).

Telehealth may provide a useful, efficient method of identifying residents of long-term care facilities that likely need referral for spasticity evaluation.

To (1) determine agreement between behavioural mapping and accelerometry for measuring mobility levels in an acute medical inpatient setting and to (2) explore and compare the required resources and costs for both methods.

Observational cross-sectional study

Tertiary referral teaching hospital in Brisbane, Australia.

Adult patients admitted to two acute medical wards.

Mobility levels were recorded by behavioural mapping, and thigh and chest-worn accelerometers (ActivPAL). The level of agreement between the two methods was evaluated using the Intraclass Correlation Coefficients for each mobility level (i.e. lying, sitting, upright, standing and walking).

Nineteen patients (10 male (53%); mean(SD) age of 72(14) years) were included in the agreement analysis. The Intraclass Correlation Coefficients were high for ‘lying’ (ICC = 0.87), ‘sitting’ (ICC = 0.84) and ‘upright’ (ICC = 0.93), indicating good to excellent agreement between the two methods. For these mobility levels, mean differences between the two methods were small (<2%), with large standard deviations (up to 18%). Agreement was poor for ‘standing’ (ICC = 0.00) and ‘walking’ (ICC = 0.35). Both methods were labour-intensive, with labour costs of A$1,285/€798 (34 hours) for behavioural mapping and A$1,055/€655 (28 hours) for accelerometry. No further costs were involved in behavioural mapping, but clinical backfill was required. Accelerometry involved a financial investment for accelerometers (A$11,100/€6,894 for 22 ActivPAL devices).

Agreement between behavioural mapping and accelerometry was good for measuring ‘lying’, ‘sitting’ and ‘upright’, but poor for ‘standing’ and ‘walking’ in an acute inpatient setting. Both behavioural mapping and accelerometry were labour-intensive, with high costs for the accelerometry equipment.

To explore the correlations among the Longshi Scale, the Barthel Index, and the modified Rankin Scale and the differentiate ability of the Longshi Scale and the modified Rankin Scale to Barthel Index scores.

Prospective study.

The inpatient rehabilitation units of three teaching hospitals in China.

A total of 343 stroke inpatients were recruited through convenience sampling.

Pictorial-based Longshi Scale, Barthel Index, and modified Rankin Scale.

The Longshi Scale was highly and moderately correlated with the Barthel Index and modified Rankin Scale, respectively. The median frequency distribution of the Barthel Index was slightly overlapped between Longshi Scale grades 2 and 3 but was considerably overlapped among modified Rankin Scale grades 1, 2, and 3. The Kruskal-Wallis and multiple comparison tests showed that, among the modified Rankin Scale grades, the median Barthel Index scores did not differentiate between grades 1 and 2 (χ² = 20.643, P = 1.000), between grades 1 and 3 (χ² = 60.404, P = 0.070), and between grades 2 and 3 (χ² = 39.760, P = 0.232). Among the Longshi Scale grades, the median Barthel Index scores did not differentiate between grades 2 and 3 (χ² = 48.778, P = 1.000), between grades 3 and 4 (χ² = 57.094, P = 1.000), and between grades 5 and 6 (χ² = 24.709, P = 1.000).

Using the Barthel Index as reference, the proposed Longshi Scale has better ability than the modified Rankin Scale in differentiating stroke patients’ disability, especially for those with higher level of activities of daily living.

To explore the experiences of children and families after a child’s traumatic injury (Injury Severity Score >8).

Qualitative interview study.

Two children’s major trauma centres in England.

32 participants: 13 children with traumatic injuries, their parents/guardians (n = 14) and five parents whose injured child did not participate.

Semi-structured interviews exploring the emotional, social, practical and physical impacts of children’s injuries, analysed by thematic analysis.

Interviews were conducted a median of 8.5 months (IQR 9.3) post-injury. Injuries affected the head, chest, abdomen, spine, limbs or multiple body parts. Injured children struggled with changes to their appearance, physical activity restrictions and late onset physical symptoms, which developed after hospital discharge when activity levels increased. Social participation was affected by activity restrictions, concerns about their appearance and interruptions to friendships. Psychological impacts, particularly post-traumatic stress type symptoms often affected both children and parents. Parents’ responsibilities suddenly increased, which affected family relationships and roles, their ability to work and carry out daily tasks. Rapid hospital discharge was wanted, but participants often felt vulnerable on return home. They valued continued contact with a healthcare professional and practical supports from family and friends, which enabled resumption of their usual lives.

Injured children experience changes to their appearance, friendships, physical activity levels and develop new physical and mental health symptoms after hospital discharge. Such challenges can be addressed by the provision of advice about potential symptoms, alternative activities during recovery, strategies to build resilience and how to access services after hospital discharge.