Clinical Rehabilitation

In this paper, we aim to provide a comprehensive description of the multicomponent self-management intervention for adults with epilepsy, ZMILE.

Acquiring self-management skills has been shown to play a vital role in enabling patients with epilepsy overcoming (health-related) struggles in daily life and coping with limitations their condition poses on them. ZMILE is a course consisting of education (to increase concordance to treatment), goal-setting (proactive coping), and self-monitoring.

The course is guided by two nurse practitioners and each patient is allowed to bring one family member or friend. Self-monitoring plays an important role and can be done through e-Health tools or written diaries.

During and after the course, patients are required to work toward a personally defined goal using a five-step approach by means of pro-active coping. Moreover, patients are expected to use self-monitoring tools to reflect on their own behavior and identify ways to optimize medication intake when required.

ZMILE is provided in an outpatient setting over five weekly group sessions and one booster session. From the start, patients are encouraged to set individual goals. Each group session will have a different theme but part of every session is reflecting on personal goals and to learn from eachother.

The ZMILE-intervention has been evaluated and may be a promising intervention in terms of effectiveness and feasibility for adults with epilepsy, relatives, and professionals. We present the adapted version which can be implemented in clinical practice.

To assess the effect of speech and language therapy (SLT) on Hypokinetic dysarthria (HD) in Parkinson’s disease.

Systematic review and meta-analysis of randomized controlled trials.

We performed a literature search of randomized controlled trials using PubMed, Web of Science, Science Direct and Cochrane database (last search October 2020). Quality assessment and risk of bias were assessed using the Downs and Black scale and the Cochrane tool. The data were pooled and a meta-analysis was completed for sound pressure levels, perceptual intelligibility and inflection of voice fundamental frequency.

We selected 15 high to moderate quality studies, which included 619 patients with Parkinson’s disease. After pooling the data, 7 studies, which compared different speech language therapies to no treatment, control groups and 3 of their variables, (sound pressure level, semitone standard deviation and perceptual intelligibility) were included in the analysis.

Results showed significant differences in favor of SLT for sound pressure level sustained phonation tasks (standard mean difference = 1.79; 95% confidence interval = 0.86, 2.72; p ⩽ 0.0001). Significant results were also observed for sound pressure level and semitone standard deviation in reading tasks (standard mean difference = 1.32; 95% confidence interval = 1.03, 1.61; p ⩽ 0.0001). Additionally, sound pressure levels in monologue tasks showed similar results when SLT was compared to other treatments (standard mean difference = 0.87; 95% confidence interval = 0.46, 1.28; p ⩽ 0.0001).

This meta-analysis suggests a beneficial effect of SLT for reducing Hypokinetic Dysarthria in Parkinson’s disease, improving perceptual intelligibility, sound pressure level and semitone standard deviation.

To identify the adherence interventions used with people receiving treatments to prevent or manage scarring, the effectiveness of these interventions, and the theoretical frameworks on which these interventions were based.

Databases (PubMed, Embase, Web of Science, CINAHL, PsychINFO and OTseeker) were searched (09.10.2020) with no date or language restrictions. Grey literature databases, clinical trial registries and references lists of key papers were also searched.

Eligible randomised controlled trials included people using treatments for scarring following skin wounds, interventions that may improve adherence, and outcomes measuring adherence. Risk of bias (selection, performance, detection, attrition, reporting) and certainty of evidence (inconsistency, imprecision, indirectness, publication bias) were assessed.

Four randomised trials were included with 224 participants (17 children) with burn scars. Interventions involved educational (three trials) or technology-based components (four trials) and ranged in length from two weeks to six months. All four trials reported greater adherence rates in the intervention group compared with standard practice [standardised mean difference = 1.50 (95% confidence interval (CI) = 0.91–2.08); 2.01 (95% CI 1.05–2.98); odds ratio = 0.28 (95% CI = 0.11–0.69)]. One trial did not report original data. The certainty of evidence was very low.

Adherence interventions using education or technology for people receiving burn scar treatment may improve adherence. Further studies are needed particularly in children, with a focus on including outcomes of importance to patients (e.g. quality of life) and identifying core components of effective adherence interventions using theoretical frameworks.

To systematically assess the effectiveness of core-based exercise for correcting a spinal deformity and improving quality of life in people with scoliosis.

The PubMed, Embase, Cochrane Library, Cumulative Index of Nursing and Allied Health Literature (CINAHL), and Web of Science databases were searched from inception up to September 30, 2020.

Clinical controlled trials were eligible if they compared the effectiveness of core-based exercise to other nonsurgical interventions in people with scoliosis. The revised Cochrane risk of bias assessment tool for randomized trials and the methodological index for non-randomized studies scale were used to assess the risk of bias. The outcomes included the Cobb angle, the angle of trunk rotation and quality of life. RevMan 5.3 was used, and intergroup differences were determined by calculating mean differences (MD) and 95% confidence intervals (CIs).

After screening 1348 studies, nine studies with 325 participants met the inclusion criteria. The exercise group had significantly lower Cobb angles (MD = −2.08, 95% CI: −3.89 to −0.28, P = 0.02) and significantly better quality of life as measured by the Scoliosis Research Society-22 questionnaire (MD = 0.25, 95% CI: 0.02 to 0.49, P = 0.03) than the control groups. However, no significant difference was observed regarding the angle of trunk rotation between groups (MD = −0.69, 95% CI: −2.61 to 1.22, P = 0.48). Furthermore, no serious adverse events were reported. The overall quality of evidence ranged from low to very low.

Core-based exercise may have a beneficial role in reducing the Cobb angle and improving quality of life in people with scoliosis in the short term.

CRD42020160509 (Available at http://www.crd.york.ac.uk/prospero/)

To evaluate effectiveness of positive expiratory pressure blow-bottle device compared to expiratory positive airway pressure and conventional physiotherapy on pulmonary function in postoperative cardiac surgery patients in intensive care unit.

A randomized controlled trial.

Tertiary care.

48 patients (16 in each group; aged 64.5 ± 9.1 years, 38 male) submitted to cardiac surgery.

Patients were randomized into conventional physiotherapy (G1), positive expiratory pressure blow-bottle device (G2) or expiratory positive airway pressure, both associated with conventional physiotherapy (G3). G2 and G3 performed three sets of 10 repetitions in each session for each technique.

Pulmonary function (primary); respiratory muscle strength, radiological changes, pulmonary complications, length of intensive care unit and hospital stay (secondary) assessed preoperatively and on the 3rd postoperative day.

Pulmonary function (except for forced expiratory volume in one second/ forced vital capacity % predicted) and respiratory muscle strength showed significant reduction from the preoperative to the 3rd postoperative in all groups (P < 0.001), with no difference between groups (P > 0.05). Regarding radiological changes, length of intensive care unit stay and length of hospital stay, there was no significant difference between groups (P > 0.05).

Both positive expiratory pressure techniques associated with conventional physiotherapy were similar, but there was no difference regarding the use of positive expiratory pressure compared to conventional physiotherapy.

NCT03639974.

https://clinicaltrials.gov/ct2/show/NCT03639974

The aim of this study was to determine whether perioperative breathing training reduces the incidence of postoperative pulmonary complications in patients undergoing laparoscopic colorectal surgery.

A randomized controlled trial.

University hospital.

A total of 240 patients undergoing laparoscopic colorectal surgery participated in this study.

The enrolled patients were randomized into an intervention or control group. Patients in the intervention group received perioperative breathing training, including deep breathing and coughing exercise, balloon-blowing exercise, and pursed lip breathing exercise. The control group received standard perioperative care without any breathing training.

The primary endpoint was the incidence of postoperative pulmonary complications. The secondary objectives were to evaluate the effect of perioperative breathing training on arterial oxygenation, incidence of other postoperative complications, patient satisfaction, length of stay, and hospital charges.

The incidence of postoperative pulmonary complications in the breathing training group was lower than that in the control group (5/120 [4%] vs 14/120 [12%]; RR 0.357, 95%CI 0.133–0.960; P = 0.031). In addition, PaO₂ and arterial oxygenation index on the first and fourth days after surgery were significantly higher in the breathing training group than in the control group (P < 0.001). In addition, patients with breathing training had shorter length of stay (6d [IQR 5–7] vs 8d [IQR 7–9]), lower hospital charges (7761 ± 1679 vs 8212 ± 1326), and higher patient satisfaction (9.46 ± 0.65 vs 9.21 ± 0.47) than those without.

Perioperative breathing training may reduce the incidence of postoperative pulmonary complications and preserve of arterial oxygenation after laparoscopic colorectal surgery.

To examine the cost-effectiveness of self-managed computerised word finding therapy as an add-on to usual care for people with aphasia post-stroke.

Cost-effectiveness modelling over a life-time period, taking a UK National Health Service (NHS) and personal social service perspective.

Based on the Big CACTUS randomised controlled trial, conducted in 21 UK NHS speech and language therapy departments.

Big CACTUS included 278 people with long-standing aphasia post-stroke.

Computerised word finding therapy plus usual care; usual care alone; usual care plus attention control.

Incremental cost-effectiveness ratios (ICER) were calculated, comparing the cost per quality adjusted life year (QALY) gained for each intervention. Credible intervals (CrI) for costs and QALYs, and probabilities of cost-effectiveness, were obtained using probabilistic sensitivity analysis. Subgroup and scenario analyses investigated cost-effectiveness in different subsets of the population, and the sensitivity of results to key model inputs.

Adding computerised word finding therapy to usual care had an ICER of £42,686 per QALY gained compared with usual care alone (incremental QALY gain: 0.02 per patient (95% CrI: −0.05 to 0.10); incremental costs: £732.73 per patient (95% CrI: £674.23 to £798.05)). ICERs for subgroups with mild or moderate word finding difficulties were £22,371 and £21,262 per QALY gained respectively.

Computerised word finding therapy represents a low cost add-on to usual care, but QALY gains and estimates of cost-effectiveness are uncertain. Computerised therapy is more likely to be cost-effective for people with mild or moderate, as opposed to severe, word finding difficulties.

To explore effects of repetitive transcranial magnetic stimulation (rTMS) combined with transcranial direct current stimulation (tDCS) on motor function and cortex excitability in subacute stroke patients.

Randomized controlled trial.

Inpatient hospitals.

Sixty-five participants were randomly assigned to four groups: sham, 1Hz rTMS, cathodic tDCS combined with 1Hz rTMS (tDCS^-/rTMS^-) and anodic tDCS combined with 1Hz rTMS (tDCS⁺/rTMS^-).

Four interventions were used, including sham, 1Hz rTMS, and cathodal or anodal tDCS, followed by 1Hz rTMS over contralesional motor cortex, which continued for four weeks.

Outcome measures were motor function and cortical excitability, evaluated by Fugl-Meyer Assessment, National Institutes of Health Stroke Scale and Barthel Index, resting Motion Threshold, Motor Evoked Potentials and Central Motor Conduction Time, assessed at baseline, four weeks and eight weeks.

At four weeks after interventions, Fugl-Meyer Assessment lower limb change score in tDCS⁺/rTMS^- group was significantly larger than other three groups (P < 0.001). There were significant differences in bilateral Motor Evoked Potentials changes between tDCS⁺/rTMS^- group and sham group (P < 0.05). At eight weeks, compared to other groups, National Institutes of Health Stroke Scale (P = 0.003), Barthel Index (P = 0.002), FMA lower limb score (P < 0.001), and bilateral resting Motion Threshold, Motor Evoked Potentials (P < 0.05) showed significant changes in tDCS⁺/rTMS^- group. Furthermore, Fugl-Meyer Assessment lower limb change score was associated with increased ipsilesional Motor Evoked Potentials (r = 0.703 P < 0.001) in tDCS+/rTMS- group.

1Hz rTMS combined with anode tDCS stimulation protocol could be a preferable rehabilitative strategy for motor recovery in subacute stroke patients.

To investigate the feasibility and acceptability of a home-based exercise program monitored using telehealth for people with Parkinson’s disease.

Pilot randomised control trial.

University physiotherapy clinic, participants’ homes.

Forty people with mild to moderate Parkinson’s disease, mean age 72 (6.9).

In Block 1 (5 weeks) all participants completed predominantly centre-based exercise plus a self-management program. Participants were then randomised to continue the centre-based exercise (n = 20) or to a home-based program with telehealth (n = 20) for Block 2 (5 weeks). The exercises targeted balance and gait.

The primary outcomes were the feasibility and acceptability of the intervention. Secondary outcomes were balance, gait speed and freezing of gait.

Adherence was high in Block 1 (93%), and Block 2 (centre-based group = 93%, home-based group = 84%). In Block 2, the physiotherapist spent 6.4 hours providing telehealth to the home-based group (mean 10 (4) minutes per participant) and 32.5 hours delivering the centre-based exercise classes (98 minutes per participant). Participants reported that exercise was helpful, they could follow the home program and they would recommend exercising at home or in a group. However, exercising at home was less satisfying and there was a mixed response to the acceptability of the self-management program. There was no difference between groups in any of the secondary outcome measures (preferred walking speed mean difference −0.04 (95% CI: −0.12 to 0.05).

Home-based exercise monitored using telehealth for people with Parkinson’s disease is feasible and acceptable.

To determine the clinical results of custom-made foot orthoses versus placebo flat cushioning insoles combined with an extracorporeal shock wave therapy on pain and foot functionality in patients with plantar fasciitis.

A randomised controlled clinical trial with follow-up at six months. Faculty of Podiatry and Centre Clinical private of Physiotherapy, Seville, Spain.

Patients with plantar fasciitis were randomly assigned to either group A (n = 42), which received custom-made foot orthoses, or group B (n = 41), which received placebo insoles. All the participants received active extracorporeal shock wave therapy including stretching exercises. Recruitment period was from Mach 2019 to July 2020.

The main outcome was foot pain, measured by visual analogue scale and the secondary outcome measures were recorded by Roles and Maudsley scores respectively, at the beginning and at one week, one month and six months.

Eighty-eight patients were assessed for eligibility. Eighty-three patients were recruited and randomised. This study showed significant differences between both groups according to the visual analogue scale. In control group, the difference was at baseline (P 0.01) and, in the experimental group was at the one- and six-month follow-up (P 0.001). The mean (SD) visual analogue scale at baseline were Control group 6.31 (1.69) and Experimental group 5.27 (1.64); and at six months were 7.52 (3.40) and 3.29 (4.26), respectively. The custom-made foot orthosis was perceived as ‘good’ (85%) and ‘excellent’ (97.5%) at medium-long term.

Wearing a custom-made foot orthosis leads to a improvement in patients with plantar fasciitis; it reduced foot pain and improved foot functionality.

To identify where and how trauma survivors’ rehabilitation needs are met after trauma, to map rehabilitation across five UK major trauma networks, and to compare with recommended pathways.

Qualitative study (interviews, focus groups, workshops) using soft-systems methodology to map usual care across trauma networks and explore service gaps. Publicly available documents were consulted. CATWOE (Customers, Actors, Transformation, Worldview, Owners, Environment) was used as an analytic framework to explore the relationship between stakeholders in the pathway.

Five major trauma networks across the UK.

106 key rehabilitation stakeholders (service providers, trauma survivors) were recruited to interviews (n = 46), focus groups (n = 4 groups, 17 participants) and workshops (n = 5 workshops, 43 participants).

None.

Mapping of rehabilitation pathways identified several issues: (1) lack of vocational/psychological support particularly for musculoskeletal injuries; (2) inconsistent service provision in areas located further from major trauma centres; (3) lack of communication between acute and community care; (4) long waiting lists (up to 12 months) for community rehabilitation; (5) most well-established pathways were neurologically focused.

The trauma rehabilitation pathway is complex and varies across the UK with few, if any patients following the recommended pathway. Services have developed piecemeal to address specific issues, but rarely meet the needs of individuals with multiple impairments post-trauma, with a lack of vocational rehabilitation and psychological support for this population.

To identify risk factors for falling for people with Multiple Sclerosis.

Prospective cohort study.

Neurology service in a tertiary hospital.

Participants were 101 people with Multiple Sclerosis and Expanded Disability Status Score of 3-6.5. One participant withdrew after the baseline assessment; data were analysed for 100 participants.

No intervention.

Outcome was rate of falls, and predictors were Timed Up and Go, Symbol Digit Modalities test, demographics and 15 self-report questions about various symptoms including fatigue, concentration, dual tasking, bladder and bowel control. Three-month prospective diaries recorded falls.

There were 791 falls reported over the 3-month period from a total of 56 fallers. Falls rate per person-year was 32.08 falls. Following multivariable regression analysis, the model with the greatest levels of clinical utility and discriminative ability (sensitivity 88% and area under the receiving operating curve statistic = 0.72, 95% CI 0.62–0.82), included the variables of history of a fall, not having visual problems, problems with bladder control and a slower speed on the Timed Up and Go.

This study confirms the high incidence of falls for people with Multiple Sclerosis and provides a risk prediction model including fall history, problems with bladder control, not having visual problems and a slower Timed Up and Go speed that may be used to identify those at greater risk and in need of tailored falls prevention intervention.

This study evaluated the capacity of cardiac risk stratification protocols on simple complications that occur during activities of a cardiovascular rehabilitation program.

Observational longitudinal cohort study.

Outpatient clinic of cardiovascular rehabilitation.

Patients diagnosed with cardiovascular disease and/or risk factors.

Not applicable.

The relationship between the cardiac risk classes of seven risk stratification protocols and the occurrence of simple complications (such angina, abnormal changes in blood pressure, arrhythmias, fatigue, muscle pain, pallor) was assessed using the chi-square test, and when statistical significance was observed, sensitivity, specificity and accuracy were determined.

About 76 patients were analyzed. The American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) protocol showed a statistically significant relationship between simple complications and cardiac risk classes (P-value = 0.046), however the results of sensitivity (0.53), specificity (0.52), and accuracy (0.53) were not significant. The other protocols analyzed were not significant: American College of Sports Medicine (P-value = 0.801), Brazilian Society of Cardiology (P-value = 0.734), American Heart Association (P-value = 0.957), Pashkow (P-value = 0.790), Society French Cardiology (P-value = 0.314), and Spanish Society of Cardiology (P-value = 0.078).

The AACVPR protocol showed a significant relationship between the risk classes and the occurrence of simple complications, however, the low values obtained for sensitivity, specificity and accuracy show that it is not useful for this purpose.

NCT03446742.