Upper limb practice with a dynamic hand orthosis to improve arm and hand function in people after stroke: a feasibility study.

BACKGROUND: Dynamic hand orthosis may help upper limb recovery by keeping the wrist and hand in an optimal position while executing a grasp. Our aim was to investigate the feasibility of combining a dynamic hand orthosis with task-oriented upper limb practice after stroke. METHOD: Fifteen adult stroke survivors were recruited in a single-group, pre-post intervention study. They received 12 weeks of task-oriented upper limb training with a dynamic hand orthosis with 3 weeks supervised at a community rehabilitation unit followed by 9 weeks unsupervised at home. Feasibility was determined by recruitment (proportion of eligible/enrolled and enrolled/retained participants), intervention (adherence, acceptability, and safety) and measurement (time taken to collect outcomes and proportion of participants where all measures were collected). Clinical outcomes were measured at baseline (Week 0), end of Week 3 and Week 12. RESULTS: Fifteen (46%) of eligible volunteers were enrolled in the study. Eight (53%) of those enrolled completed the 12-week intervention. Eighty eight percent were satisfied or very satisfied with the dynamic hand orthosis. Clinical measures were collected for all participants at baseline and in all those who completed the intervention but often took over one hour to complete. At 12 weeks, participants had improved by 7 points out of 57 (95% CI 2 to 13) on the ARAT and by 8 points out of 66 (95% CI 0 to 15) on the FMA-UE. CONCLUSION: The intervention appears to be feasible in terms of acceptability and safety, while recruitment and measurement need further consideration. The magnitude of the clinical outcomes suggests that the intervention has a potential to improve both upper limb activity and impairment, and this study provides useful information for the design of a pilot randomized trial. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03396939.

Fat infiltration in the thigh muscles is associated with symptomatic spinal stenosis and reduced physical functioning in adults with achondroplasia.

BACKGROUND: Symptomatic spinal stenosis is a prevalent complication in adults with achondroplasia. Increased muscle fat infiltration (MFI) and reduced thigh muscle volumes have also been reported, but the pathophysiology is poorly understood. We explored whether the increased MFI and reduced thigh muscle volumes were associated with the presence of symptomatic spinal stenosis and physical functioning. METHODS: MFI and thigh muscle volumes were assessed by MRI in 40 adults with achondroplasia, and compared to 80 average-statured controls, matched for BMI, gender, and age. In achondroplasia participants, the six-minute walk-test (6MWT), the 30-s sit-to-stand test (30sSTS), and a questionnaire (the IPAQ) assessed physical functioning. RESULTS: Symptomatic spinal stenosis was present in 25 of the participants (the stenosis group), while 15 did not have stenosis (the non-stenosis group). In the stenosis group, 84% (21/25) had undergone at least one spinal decompression surgery. The stenosis group had significantly higher MFI than the non-stenosis group, with an age-, gender and BMI-adjusted difference in total MFI of 3.3 percentage points (pp) (95% confidence interval [CI] 0.04 to 6.3 pp; p = 0.03). Compared to matched controls, the mean age-adjusted difference was 3.3 pp (95% CI 1.7 to 4.9 pp; p < 0.01). The non-stenosis group had MFI similar to controls (age-adjusted difference - 0.9 pp, 95% CI - 3.4 to 1.8 pp; p = 0.51). MFI was strongly correlated with the 6MWT (r = - 0.81, - 0.83, and - 0.86; all p-values < 0.01), and moderately correlated with the 30sSTS (r = - 0.56, - 0.57, and - 0.59; all p-values < 0.01). There were no significant differences in muscle volumes or physical activity level between the stenosis group and the non-stenosis group. CONCLUSION: Increased MFI in the thigh muscles was associated with the presence of symptomatic spinal stenosis, reduced functional walking capacity, and reduced lower limb muscle strength. The causality between spinal stenosis, accumulation of thigh MFI, and surgical outcomes need further study. We have demonstrated that MRI might serve as an objective muscle biomarker in future achondroplasia studies, in addition to functional outcome measures. The method could potentially aid in optimizing the timing of spinal decompression surgery and in planning of post-surgery rehabilitation.

Physical Health Conditions in Persons with Spinal Cord Injury Across 21 Countries Worldwide.

OBJECTIVES: To describe the 3-month prevalence and correlates of self-reported physical health conditions in persons with spinal cord injury (SCI) worldwide. STUDY DESIGN: Multinational cross-sectional survey. SUBJECTS: Community-living persons with traumatic or non-traumatic SCI aged >18 years from 21 countries representing all the 6 World Health Organization regions. METHODS: The study used data from 11,058 participants in the International SCI Community Survey (InSCI). The survey, based on the International Classification of Functioning, Disability and Health (ICF) Core Sets for SCI, was conducted in 2017-19 simultaneously in the participating countries. The health conditions were reported on a modified version of the SCI Secondary Conditions Scale. RESULTS: Overall, 95.8% of the participants reported having experienced 1 or more health problems secondary to SCI. Having pain was the most prevalent problem (77.3%), followed by spasticity/muscle spasms (73.5%) and sexual dysfunction (71.3%), and the least prevalent was respiratory problems (28.8%). The participants reported a mean of 7.4 concurrent health conditions. Unmet healthcare needs, being a smoker, being a female, having a complete lesion, and a traumatic injury exhibited significant associations with comorbidity. CONCLUSION: Physical health problems secondary to SCI are extremely common worldwide and demand investment in appropriate management, medical care and preventative measures.

Upper Limb Training with a Dynamic Hand Orthosis in Early Subacute Stroke: A Pilot Randomized Trial.

OBJECTIVES: To investigate the effect of the addition of a dynamic hand orthosis to unilateral task-oriented training in early subacute stroke. DESIGN: Pilot randomized trial with concealed allocation, measurer blinding, and intention-to-treat analysis. SETTING: Rehabilitation hospital. PARTICIPANTS: Thirty subacute stroke patients with moderate-to-severe upper limb disability. INTERVENTION: All participants received 4 weeks (60 min per day, 5 days a week) of unilateral task-oriented training. The experimental group (n = 15) wore a dynamic hand orthosis during half of the training time (i.e. 30 min per day). OUTCOME MEASURES: Primary outcome was the upper limb activity measured using the Action Research Arm Test (ARAT) measured at baseline and 4 weeks. Secondary outcomes were the Nine-hole Peg Test, Fugl-Meyer Assessment for upper extremity, grip strength, modified Ashworth Scale, Barthel Index and EuroQol-5D. RESULTS: No difference between groups was found for the primary outcome ARAT (mean difference 4/57, 95% confidence interval (95% CI) -5 to 13) nor for any secondary outcome. CONCLUSION: No additional benefit was found of wearing a dynamic hand orthosis during unilateral taskoriented training in the early subacute period.

Obstructive sleep apnea in Norwegian adults with achondroplasia: a population-based study.

BACKGROUND: Previous studies have found a high prevalence of obstructive sleep apnea (OSA) in children with achondroplasia, but clinical studies on this complication in adults with achondroplasia are lacking. OBJECTIVES: This population-based, cross-sectional study investigated the prevalence, severity, and predictive factors of OSA in Norwegian adults with achondroplasia. METHODS: We collected clinical data on 49 participants. Participants without a preexisting diagnosis of OSA had an overnight sleep registration. OSA was defined as an apnea-hypopnea index (AHI) ≥ 5 plus characteristic clinical symptoms, or AHI ≥ 15. We used the Berlin Questionnaire to assess clinical symptoms of OSA. RESULTS: OSA was found in 59% (29/49) of the participants (95% confidence interval 44 to 73%), of whom 59% (17/29) had moderate to severe OSA (AHI ≥ 15), and 48% (14/29) were previously undiagnosed. Variables predictive of OSA were: excessive daytime sleepiness; unrested sleep; loud snoring; observed nocturnal breathing stops; hypertension; age > 40 years; and BMI > 30 kg/m2. CONCLUSION: OSA was highly prevalent in Norwegian adults with achondroplasia, which we believe is representative of this population worldwide. Follow-up of adults with achondroplasia should include assessment of symptoms and signs of OSA, with a low threshold for conducting an overnight sleep registration if findings suggestive of OSA are present.

Cardiovascular risk factors and body composition in adults with achondroplasia.

PURPOSE: An increased cardiovascular mortality has been reported in achondroplasia. This population-based, case-control study investigated cardiovascular risk factors and body composition in Norwegian adults with achondroplasia. METHODS: We conducted anthropometric, clinical, and laboratory assessments in 49 participants with achondroplasia, of whom 40 completed magnetic resonance imaging (MRI) for body composition analysis. Controls consisted of 98 UK Biobank participants, matched for body mass index (BMI), sex, and age. RESULTS: Participants were well matched for BMI (33.3 versus 32.5 kg/m2) and sex, but achondroplasia participants were younger than controls (mean age 41.1 versus 54.3 years). Individuals with achondroplasia had lower age-adjusted mean blood pressure, total and low-density lipoprotein (LDL) cholesterol, and triglycerides compared with controls, but similar fasting glucose and HbA1c values. Age-adjusted mean visceral fat store was 1.9 versus 5.3 L (difference -2.7, 95% confidence interval [CI] -3.6 to -1.9; P < 0.001), abdominal subcutaneous fat was 6.0 versus 11.2 L (-4.7, 95% CI -5.9 to -3.4; P < 0.001), and liver fat was 2.2 versus 6.9% (-2.8, 95% CI -5.2 to -0.4; P = 0.02). CONCLUSION: Despite a high BMI, the cardiovascular risks appeared similar or lower in achondroplasia compared with controls, indicating that other factors might contribute to the increased mortality observed in this condition.

Pain in adults with cerebral palsy: A systematic review and meta-analysis of individual participant data.

BACKGROUND: There is little focus on adults with cerebral palsy (CP) in research and health care and insufficient knowledge on how to identify and manage pain in this population. OBJECTIVES: This systematic review and meta-analysis aimed to determine whether pain prevalence in adults with CP is high and to explore variations in pain prevalence of subgroups, pain locations, pain severity and pain interference. METHODS: Potential datasets were identified by experts in the field and literature searches in Embase, MEDLINE, and Cochrane, from January 2000 to October 2016. Included studies had a representative sample of ≥25 adults with CP and ≥1 pain outcomes. Methodological quality assessment, pain prevalence estimates and logistic regression models for subgroup effects on pain prevalence were conducted. RESULTS: In total, 17 eligible studies were identified from 4584 publications. A meta-analysis was performed with individual participant data from 15 studies totalling 1243 participants (mean [SD] age 34.3 [12.6] years). Overall mean pain prevalence was 70% (95% CI 62-78). Women were more likely to have pain than men (P<0.001). The odds of pain was increased in adults with gross motor function level II (odds ratio [OR] 1.92, 95% CI 1.22-3.12) and IV (OR 1.77, 95% CI 1.03-4.29). Participants with pain reported pain predominantly in the legs (76%, 95% CI 66-84), and mean pain severity was 3.7/10 (95% CI 2.7-4.7) and pain interference 3.5/10 (95% CI 2.5-4.5). CONCLUSIONS: This meta-analysis provides the first reliable pain prevalence estimate in a large international sample of adults with CP. The high prevalence of pain, 70%, suggests that adults with CP should be routinely screened for pain and treated accordingly. The range of measurement instruments used by the included studies emphasizes using common outcome measures specific to pain internationally.

Correction to: High prevalence of symptomatic spinal stenosis in Norwegian adults with achondroplasia: a population-based study.

An amendment to this paper has been published and can be accessed via the original article.

Self-administered, home-based, upper limb practice in stroke patients: A systematic review.

OBJECTIVE: To investigate the effectiveness of self-administered, home-based, upper limb practice in improving upper limb activity after stroke. To compare structured home-based practice vs non-structured home-based practice. METHODS: Databases were searched for randomized or quasi-randomized controlled trials using a pre-defined search strategy. Data were extracted from 15 studies involving 788 participants. The quality of included studies was assessed using the PEDro scale. The studies included an experimental group that received self-administered, home-based practice for upper limb activity limitations of any level of severity and any time after stroke, and a control group that received no intervention, or received non-structured home-based practice. Only measures of upper limb activity were investigated. RESULTS: Self-administered, home-based practice did not improve activity compared with no intervention (standardized mean difference 0.00, 95% confidence interval; -0.47 to 0.48). There was no difference between structured and non-structured home-based practice in terms of upper limb activity (SMD -0.05, 95% CI -0.22 to 0.13). CONCLUSION: Existing self-administered, home-based practice is not more effective than no intervention in improving upper limb activity in chronic, severely disabled stroke survivors. Structured home-based practice is no more effective than non-structured home-based practice.

High prevalence of symptomatic spinal stenosis in Norwegian adults with achondroplasia: a population-based study.

BACKGROUND: Symptomatic spinal stenosis (SSS) is a well-known medical complication in achondroplasia. The reported prevalence of SSS is 10 to 30%, an estimate based on small studies or selected populations. No population-based studies exist currently. Furthermore, the relationship between SSS and physical functioning has not been investigated in detail. The aims of this study were to describe the prevalence of SSS in Norwegian adults with achondroplasia, and to explore the impact of SSS on physical functioning. METHODS: This was a population-based study on Norwegian community-dwelling adults with genetically confirmed achondroplasia. Prevalence of SSS was defined by clinical symptoms, and confirmed by imaging or surgical reports. Physical functioning was assessed by walking capacity (6-min walk test), hand strength (Grippit), and activities of daily living (the Health Assessment Questionnaire, HAQ). Pain was assessed by pain site locations and intensity (Numeric Rating Scale, NRS). RESULTS: In total, 50 participants were included (27 males, 23 females). Median age was 41 years (range 16 to 87 years), 34 (68%) had SSS. The estimated median age at first symptom onset was 33 years (95% confidence interval (CI) 29 to 43 years), range 10 to 67 years. The majority had multiple spinal levels affected. The walking distance was 110 m shorter in the SSS group (95% CI - 172 to - 40 m) as compared with the non-SSS group (p < 0.01). There was no considerable difference in hand strength between the two groups. Mean HAQ scores (0-3) for walking and hygiene were significantly higher in the SSS group, reflecting more activity limitations. Mean differences were 0.9 (95% CI 0.3 to 1.4, p < 0.01) and 0.6 (95% CI 0.2 to 1.0, p < 0.01). Pain intensity (NRS 0-10) was also significantly higher in the SSS group with a mean difference of 3.2 (95% CI 0.6 to 5.6, p = 0.02). CONCLUSIONS: SSS was highly prevalent in Norwegian adults with achondroplasia, with symptom onset at young age, and multiple spinal levels affected. The presence of SSS was associated with reduced walking distance, activity limitations, and more pain. The findings underline the importance of thorough assessment and monitoring of SSS in achondroplasia, including a formal assessment of physical functioning.

A Mindfulness-Based Stress Reduction Program via Group Video Conferencing for Adults With Cerebral Palsy - A Pilot Study.

Purpose: Adults with cerebral palsy experience challenges related to lifelong disability, such as stress, fatigue, pain and emotional issues. E-health services can be delivered regardless of residence and level of functioning. The aim of this pilot study was to explore the potential benefits and feasibility of a mindfulness-based program delivered to adults with cerebral palsy via group video conferencing. Methods: Six adults with cerebral palsy received an 8 week mindfulness group-based program via video conferencing. A multiple single-case study design was applied, including quantitative and qualitative elements. Pain was assessed 16 times through the study period. Questionnaires were administered to gather data on pain catastrophizing, stress, fatigue, emotional distress, positive and negative affect, and quality of life. A focus group interview addressed experiences with the intervention and the mode of delivery. Results: The participants' pain levels showed varied trajectories. Pain catastrophizing and negative affect were statistically significant decreased. Qualitative data indicated benefits from mindfulness in coping and stress management. The video conferencing delivery was evaluated as feasible, with no major adverse effects. Conclusion: Since the pilot study had a small sample size, potential treatment benefits should be interpreted with caution. However, this pilot study provides important information in the planning of future larger and controlled studies on mindfulness-based interventions programs via video conferencing for adults with cerebral palsy and other persons living with long-term disability.

Persons injured in the 2011 terror attacks in Norway - Relationship between post-traumatic stress symptoms, emotional distress, fatigue, sleep, and pain outcomes, and medical and psychosocial factors.

Purpose: The main aim was to assess long-term post-traumatic stress symptoms, emotional distress, fatigue, sleep disturbances and pain in individuals hospitalized with physical injuries after two terror attacks in Oslo in 2011, approximately three years after the events. A secondary aim was to explore the relationship between these outcomes and medical and psychosocial factors.Materials and methods: Thirty of 43 potential persons participated. Injury characteristics were collected from medical charts. Level of post-traumatic stress, emotional distress, fatigue, sleep disturbances and pain was assessed and the association with injury severity, resilience, optimism, neuroticism and extroversion, and perceived access to social support was explored.Results: Nine of 30 met criteria for full or partial PTSD, and 14 of 30 displayed clinical levels of emotional distress. Fifteen reported moderate to severe fatigue, and 16 said sleep disturbances affected their daily life. Twelve indicated that pain affected daily activities and work ability, and 15 that pain affected their quality of life. I Resilience, optimism, neuroticism, and perceived social support, were associated with outcomes, but injury severity was not. When controlling for pain, many of the psychosocial variables failed to reach significance.Conclusions: Injury severity was not associated with outcomes. On the other hand, psychosocial factors were, but seemed to be influenced by pain.Implications for rehabilitationPersons who have obtained physical injuries under extreme psychological conditions such as terror, are at high risk of poor long-term outcomes, and will often be in need of comprehensive interdisciplinary rehabilitation services.Psychological outcomes are not associated with severity of physical injury, but premorbid and current psychological variables such as resilience, optimism, personality, and access to social support are highly associated with long-term outcome.Longstanding pain seems to diminish or weaken the role of protective psychological factors and should be addressed in the rehabilitation context.

A single-subject study of robotic upper limb training in the subacute phase for four persons with cervical spinal cord injury.

Study design: Single-subject design, standard training ("B") compared with Robotic training ("C"). Objectives: To explore the impact of robotic training on upper limb function, activities of daily living (ADL) and training experience in subacute tetraplegic inpatients. Setting: Inpatient subacute Norwegian spinal cord injury (SCI) unit. Methods: Four participants (C4-7, AIS A-C) completed 11 sessions of robotic training using a passive robotic exoskeleton (Armeo Spring®). Descriptive statistics and visual analyses were used for comparing standard occupational therapy and robotic training. Outcome measures included the Spinal Cord Independence Measure (SCIM-III), the Graded Redefined Assessment of Strength Sensibility and Prehension (GRASSP), and a questionnaire. Results: All of the participants exhibited an increase in assessments of upper limb function (GRASSP-total) right side (0.4%-61.2%), and all except for one participant (-8%) showed an increase on their left side (20.9%-106.2%). Three out of four participants had improvements in ADL function SCIM-III (ranging from 5.6% to 46.7%). Results demonstrated improvements during the robotic intervention period in five out of 28 measurements. The participants enjoyed the exercise, and found it motivating and relevant to their injury (median ranged from 3.5 to 6.5 on a 0-7 scale). Conclusions: Three out of four participants improved upper limb function and ADL independence, but the study could not confirm that improvements were due to the robotic intervention. The participants enjoyed the robotic training and found it relevant to their injury.

Chronic pain among the hospitalized patients after the 22 July 2011 terror attacks in Oslo and at Utøya Island.

BACKGROUND: On 22 July 2011, 48 people were hospitalized due to physical injuries from gun shots or explosion, following 2 terror attacks in the Oslo area, Norway. In this study, we have investigated the occurrence of chronic pain, the severity and consequences of chronic pain in these patients, 3 to 4 years after the incidents. METHODS: Totally 43 eligible terror trauma patients were invited to participate in the study, 30 patients were included. They underwent a consultation with a psychologist and a physician; containing psychological assessment, neuropsychological screening, a standardized clinical interview, medical examination, and a pain protocol. RESULTS: In 18 (60%) the injury was severe, as defined by New Injury Severity Score > 15. Twenty-four patients (80%) reported injury-related chronic pain after the trauma, in 22 with consequences on daily life. Analgesics were used by 20 patients, including 5 in need of opioids. Ten patients had unmet needs of further specialist pain care. In 12 patients, the average pain score last week was above three on a 0-10 Numeric Rating Scale. In these patients, clinical signs of neuropathic pain were evident in 10, as tested by the Douleur Neuropathique score. There were significant correlations (P < 0.05) between severity of chronic pain and presence of post-traumatic stress symptoms, reduced quality of life, reduced psychosocial and physical function; but no correlation with pre-injury patient characteristics or the degree of physical injury. CONCLUSION: Chronic pain was frequent and significant, irrespective of injury severity, in these patients who obtained their physical injuries under extreme psychological conditions.

Clinical characteristics and physical functioning in persons hospitalized following the Norwegian terror attacks in July 2011: A follow up study.

OBJECTIVE: To describe the clinical characteristics and physical functioning in persons hospitalized after 2 terror attacks in Norway in 2011. DESIGN: Cross-sectional study with retrospective acute medical data. SUBJECTS: Surviving persons hospitalized with physical injuries. METHODS: Medical and psychological assessments 3-4 years after injury, with data on injury type and severity collected from medical records. RESULTS: A total of 30 out of 43 potential subjects participated (19 women, 11 men; age range 17-71 years (median 23 years)). Eighteen participants had suffered a severe injury, with New Injury Severity Scale (NISS) scores > 15. All body parts were affected. The number of surgical procedures ranged from 0 to 22 (median 3), and days in intensive care ranged from 0 to 59 (median 2.5), of which 16 had more than 24 h intensive care. Three to 4 years later, a majority of the participants had a broad spectrum of somatic and psychological problems and reduced physical functioning. Two-thirds of the participants reported their physical health to be unsatisfactory, and continuous need for healthcare and unmet needs were identified for all except 4 of the participants. CONCLUSION: Persons hospitalized following a terror attack experience a broad spectrum of somatic and psychological problems and need long-term physical and psychological follow-up. This study indicates specific needs for rehabilitation after injuries acquired under psychological traumatic circumstances.