Barriers and facilitators for increased accessibility to quality rehabilitation services in low- and middle- income countries: a systematic review.

INTRODUCTION: With an increasing number of people experiencing limitations in functioning during their life course, the need for comprehensive rehabilitation services is high. In 2017, the WHO Rehabilitation 2030 initiative noted that the need for the establishment and expansion of rehabilitation services is paramount in order to obtain well-being for the population and to ensure equal access to quality healthcare for all. The organization of rehabilitation services is however facing challenges especially in low-and middle-income countries with a very small proportion of people who require rehabilitation actually getting them. Various surveys conducted in low-and -middle income countries have revealed existing gaps between the need for rehabilitation services and the actual receipt of these services. This systematic review aimed to determine the barriers and facilitators for increasing accessibility to rehabilitation services in low- and middle-income countries. Recommendations for strengthening rehabilitation service organization are presented based on the available retrieved data. EVIDENCE ACQUISITION: In this systematic review, an electronic search through three primary databases, including Medline (PubMed), Scopus and Web of Science (WOS) was conducted to identify original studies reporting on barriers and facilitators for rehabilitation service organization in low-and middle-income countries. Date of search: 25th April 2021 (PubMed), 3rd May 2021 (Scopus and Web of Science). All studies including barriers or/and facilitators for rehabilitation services in low- and middle income countries which were written in English were included in the review. The articles written in other languages and grey literature, were excluded from this review. EVIDENCE SYNTHESIS: Total of 42 articles were included from year 1989 to 2021. Numerous barriers were identified that related to education, resources, leadership, policy, technology and advanced treatment, community-based rehabilitation (CBR), social support, cultural influences, political issues, registries and standards of care. National health insurance including rehabilitation and funding from government and NGOs are some of the facilitators to strengthen rehabilitation service organization. Availability of CBR programs, academic rehabilitation training programs for allied health professionals, collaboration between Ministry of Heath (MOH) and Non-governmental Organizations (NGOs) on telerehabilitation services are amongst other facilitators. CONCLUSIONS: Recommendations for improving and expanding rehabilitation service organization include funding, training, education, and sharing of resources.

Comparison between the effect of immersive virtual reality training versus conventional rehabilitation on limb loading and functional outcomes in patients after anterior cruciate ligament reconstruction: A prospective randomized controlled trial.

Purpose: Anterior cruciate ligament injury (ACL) commonly occurs during sporting events. It causes pain, instability and reduction in range of movement of the knee which results in altered balance, reduced strength as well as loading to the involved knee. The challenge to get the patient back to competitive sports level much depends on the rehabilitation process. Post ACLR rehabilitation is challenging due to the long rehabilitation time as well as boring repetitive exercises. The aim of this study is to compare between the effectiveness of using immersive virtual reality (PlayStation VR) in addition to the conventional rehabilitation as an aid in rehabilitation of patients after ACLR in terms of objective functional assessment and pain and subjective knee function scoring. Methods: This randomised controlled trial was undertaken in a tertiary hospital in Malaysia from July 2019 until July 2020. Thirty patients were randomised into a group undergoing purely conventional rehabilitation (Group 1) and a group undergoing both conventional rehabilitation and immersive virtual reality assisted rehabilitation (Group 2). The immersive virtual reality assisted rehabilitation was started at 3 months post operatively for 3 months duration. Limb loading, balance, range of motion, functional hop tests of the knee, pain and subjective scoring of the knee with the International Knee Documentation Committee (IKDC) Scores were measured preoperatively and at 6 months. Results: There were significant differences in terms of improvement of pain scores (p = 0.012) as well as IKDC Scores (p = 0.024) in Group 2 as compared to Group 1. However, there were no significant differences with regards to limb loading, balance, range of motion and functional hop tests of the knee (p > 0.05). No adverse events were observed during the study period. Conclusion: Immersive virtual reality can be used as an adjunct in rehabilitation of patients after ACL reconstruction in terms of improving their pain as well as their subjective knee evaluation. Large randomised control trial is recommended to further investigate the efficacy.

A Prospective Study Comparing the Infection Rate Between Buried vs Exposed Kirschner Wires in Hand and Wrist Fixations.

INTRODUCTION: Kirschner wires (K-wires) are used in fracture fixations but are often associated with pin tract infections. This prospective study compared the infection rate between buried and exposed K-wires in closed injuries of the wrist and hands in individuals with no comorbidities. METHODS: Fifteen patients were recruited with a total of 41 K-wires (21 buried K-wires; 20 exposed K-wires). Clinical and radiographic evidence of infection was assessed at three months based on the Modified Oppenheim classification. RESULTS: Two out of 21 wires in the buried group developed grade 4 infection, while 20 wires in the exposed group did not have any significant infection. No significant difference in infection rate based on K-wire size or number in both groups. CONCLUSION: There is no significant difference in infection rate between buried and exposed K-wires in healthy individuals with closed injuries of the wrist and hand.

Safety of Lidocaine During Wide-Awake Local Anesthesia No Tourniquet for Distal Radius Plating.

Purpose: This study evaluated the clinical and biochemical safety profile of infiltration of lidocaine with adrenaline in wide-awake local anesthesia no tourniquet for distal radius plating. Methods: Twenty-four participants were randomly assigned to the therapeutic group (n = 19) (1% lidocaine in 1:100,000 adrenaline) and control group (n = 5) (2% lidocaine alone). Clinical parameters, including skin necrosis, duration of recovery of sensation, and lidocaine toxicity, were monitored. The serum lidocaine level was measured at different time intervals using a high-performance liquid chromatography reagent. Results: No lidocaine toxicity was recorded in any participant. The therapeutic group had a longer time for recovery of sensation. There was a significant difference in the serum lidocaine levels between both the groups at all time intervals up to 6 hours, with all participants exhibiting serum lidocaine levels below the mild toxicity level of 6.0 µg/mL. Conclusions: Lidocaine used within a safe recommended dose in wide-awake local anesthesia no tourniquet for distal radius plating is clinically and biochemically safe. Clinical relevance: Determining the clinical and biochemical safety profile of lidocaine with adrenaline in wide-awake local anesthesia no tourniquet can promote wider use of this technique.

The Outcome of Neurotization of Brachial Plexus Injury in a Tertiary Centre: A Nine-Year Review.

INTRODUCTION: In neurotization or nerve transfer, a healthy but less valuable nerve is transferred to re-innervate a more important motor territory that has lost its innervation through irreparable damage to its nerve. METHODOLOGY: In this study, the outcomes of surgery were analyzed in relation to the muscle strength, range of motion of the upper limb, and functional outcome. The results were analyzed in 19 patients who were operated on between 2008 and 2016 with adequate follow-up.  Result: Of the 19 patients (15 complete brachial plexus injuries and four incomplete brachial plexus injuries), 13 patients (68%) recovered partial function after the neurotization surgery. Shoulder abduction and elbow flexion were achieved in 11 patients (58%). Six of the 10 patients (32%) in complete pre-ganglionic brachial plexus injury had recovered partial function. Whereas five of the six patients (83%) in complete post-ganglionic had recovered partial function. In incomplete upper trunk brachial plexus injury, three of the four patients (75%) recovered some function after the neurotization surgery. CONCLUSION: Nerve transfer is an effective treatment option to restore the function of the affected upper limb. Neurotization without intervening nerve graft shows better recovery. Earlier surgical intervention at a younger age can yield better outcomes.

Valorization of spent brewery yeast biosorbent with sonication-assisted adsorption for dye removal in wastewater treatment.

The effluent of textile industries containing synthetic dyes contributed to substantial pollution to water bodies. The biosorption process of Congo Red dye was successfully performed by integrating ultrasonication in the adsorption step with spent brewery yeast as a novel and renewable biosorbent. The adsorption process was hindered when ultrasonication was employed together with the biosorbent, indicating that desorption process had occurred. The adsorption process showed that 4 g/L of biosorbent was the optimum dosage for adsorption of 50 mg/L of Congo Red dye, and that the adsorption equilibrium fitted to the Langmuir model, with kinetics best fitted with pseudo-second order model. The maximum capacity of the adsorption was 52.6 mg/g, showing the potential of spent brewery yeast to aid in removing wastewater pollutants. Maximal Congo Red dye recovery (100%) was achieved in the sonication-assisted desorption studies using 0.01M NaOH as the eluting agent. The ultrasonication effects contributed to the efficient recovery of dye and good conversion of spent brewery yeast to biosorbent can be beneficial for treating pollution from textile wastewater.

Necrotizing Soft Tissue Infection of Left Shoulder and Upper Limb Following Intravenous Injection of Non-steroidal Anti-inflammatory Drug.

Necrotizing soft tissue infection (NSTI) is a rapidly spreading and fulminant infection that may occur within any layer of skin and soft tissue and may result in sepsis and multiorgan failure. Cases of intravenous injection of drugs causing NSTIs have been reported, especially involving injection of illicit drugs or insulin. NSTI can be due to polymicrobial or monomicrobial infection and infection involving Klebsiella species has been rising, especially in patients with diabetes mellitus. This is a case of an extensive upper limb and shoulder Klebsiella pneumoniae NSTI following an injection of a non-steroidal anti-inflammatory drug in a diabetic patient. NSTI diagnosis is based on history and clinical examination, supplemented with imaging and laboratory investigations. Early recognition, extensive and serial debridement, antibiotics, and wound management are crucial for the better outcome of the disease. This patient underwent emergent debridement with antibiotics coverage, followed by serial debridement and wound care. The wound healed within the stipulated time, with good function of the affected limb following the rehabilitation program.

Non-Traumatic Snapping Tendon on the Dorsal Aspect of the Thumb: A Diagnostic Challenge.

A snapping tendon on the dorsal aspect of the thumb is a rare condition as opposed to the common triggering on the volar aspect of the thumb. This condition is known as triggering of the extensor pollicis longus (EPL). A 21-year-old female presented with a clicking or snapping sensation that was felt on the dorsum of her thumb when it is extended. There was no history of trauma. She worked in an ice-cream parlor with repetitive scooping ice-cream motions. Her triggering immediately resolved on releasing the EPL fascia ulnar to Lister's tubercle. Upon wake-up surgery, we could immediately confirm this. We recommend dynamic ultrasound as an investigation and do not recommend MRI. The surgical method of choice is either wake-up surgery or wide-awake local anesthesia no tourniquet (WALANT) surgery.

A Randomized Controlled Trial Comparing Wide-Awake Local Anesthesia With No Tourniquet (WALANT) to General Anesthesia in Plating of Distal Radius Fractures With Pain and Anxiety Level Perception.

INTRODUCTION: Distal end radius fractures are common fractures commonly treated with an option of open reduction and plating. Traditionally, plating is performed under general anesthesia (GA) or regional block. Recently, a new technique of plating under wide-awake local anesthesia with no tourniquet (WALANT) has been introduced. We aim to compare the preoperative anxiety level, intraoperative pain scores, post-operative pain scores, operating time, blood loss and clinical outcome of distal end radius plating with WALANT versus GA with tourniquet. METHODS: We conducted a randomized controlled study on patients with closed fracture of the distal end of the radius requiring open reduction and plating from January 2019 till April 2020. We recruited 65 patients (33 patients in the WALANT group and 32 patients in the GA group). Randomization was done via block randomization. Data were collected to evaluate preoperative anxiety using the Amsterdam Preoperative Anxiety and Information Scale (APAIS) score, intraoperative pain score during injection (baseline) (V1), 10 minutes after injection (V2), during incision (V3), during gentle manipulation (V4), during aggressive manipulation (V5) and during first drilling of screw (V6), blood loss, duration of surgery and post-operative pain score. Additionally, intraoperative visual analog scale (VAS) score was obtained in the WALANT group. At three weeks, six weeks, three months and six months after operation, the Quick Disabilities of Arm, Shoulder and Hand (QuickDASH) scores and range of motion (ROM) of the wrists were obtained. RESULTS: The average age in the WALANT group was 47.19 (range, 36-64) years and GA group was 49.48 (range, 38-60) years. The mean APAIS score obtained was 7.78 (WALANT group) and 7.36 (GA group) with no statistical difference. For intraoperative VAS, only during V4 and V5 were the scores 1/10; otherwise at all other phases, the VAS score was 0. The average time for surgery was statistically longer in the WALANT group (61.22 minutes) compared to the GA group (55.33 minutes) (p = 0.003). There was no statistical difference in mean blood loss in both groups. The average post-operative VAS showed statistical significance only at 1 hour and 12 hours post-operation with no statistical difference at 2 and 24 hours post-operation. There was no difference in the post-operative ROM including wrist flexion, extension, supination and pronation for both groups up to six months' follow-up. CONCLUSION: There was no statistically significant difference in terms of preoperative anxiety level, intraoperative and post-operative VAS score, amount of blood loss and clinical outcome in both groups for plating of the distal end radius. However, the operating time was slightly longer in the WALANT group. We conclude that distal radius plating under WALANT has similar outcomes to GA. In centres with limited resources, WALANT offers a safe, reliable and cheaper option, reserving GA time for head, abdominal and thoracic surgery.

Pain Perception During the Phases of Manual Reduction of Distal End Radius Fracture With a Periosteal Block.

Introduction Closed reduction is an effective method of treatment for distal end radius fractures. We present a case series of patients with distal end radius fractures who underwent closed manipulative reduction using the periosteal block. We describe the technique in detail and examine its efficacy in pain lowering effect during closed reduction. Methods Nineteen patients with distal end radial and ulnar fractures were included and grouped based on the Frykman classification. The reduction was performed using a periosteal block of 10 ml of 2% lignocaine injection. The severity of pain was recorded by utilizing the visual analog scale (VAS) in five phases: 1) before injection, 2) after 15 minutes of analgesia in a resting position, 3) during minimal motion, 4) during full manipulation and reduction, and 5) post-procedure. The VAS scoring was classified as painless (VAS score of 0), mild pain (VAS score between 1-3), and painful (VAS score of 4 and above). Results The study included 19 patients [median age of 53 years (range: 18-88 years)]; there were 11 (58%) males and eight (42%) females. The mechanism of injury was a fall (n=12, 63%) or a motor vehicle accident (n=7, 37%). There was a statistically significant reduction of pain between phase one and all the other phases. Between the different fracture configurations, there was no significant difference in pain reduction. The most painful phase was expected to be phase four, ie, during full manipulation, in which four (21%) patients had a VAS score of 0, 12 (63%) patients had a VAS score between 1-3, and three (16%) patients had a VAS score of 4. Thus, 16 out of 19 patients (84%) had no or minimal pain during the most painful phase. There were no complications from the periosteal blocks. Conclusions The periosteal nerve block is an effective procedure providing satisfactory analgesia during the reduction of distal radial and ulnar fractures. It has no side effects and is free from complications associated with conventional sedation.

Stepease™ diabetic socks: An answer to efficacious indoor foot pressure relief- A prospective study.

BACKGROUND: Diabetic foot ulcer is commonly seen in people with diabetes mellitus. Inadequate plantar pressure offloading has been identified as a contributing factor to development of diabetic foot ulcers. Various pressure off-loading footwear are widely available in the market but poor compliance has been reported especially for indoor usage. StepEase™ diabetic socks have been designed using Ethylene Vinyl Acetate (EVA) microspheres for better redistribution of plantar pressure. The objective of this study was to determine the efficacy of StepEase™ in redistributing the foot plantar pressure and to assess patients' satisfaction on the usage of the socks. METHODS: This was a prospective non randomized clinical trial conducted on 31 patients with diabetes mellitus with high risk foot (King's classification stage II) over a 12 weeks period. Dynamic foot plantar pressure reading was recorded at day 0, 6 weeks and 12 weeks intervals, both barefoot and with StepEase™, using Novel Pedar-X system (Novel GmbH, Munich, Germany). Patients' satisfaction and usage practice were assessed by a questionnaire. RESULTS: The mean age of subjects was 57.9 years with mean body mass index (BMI) of 26 kg/m2. The mean duration of diagnosis with diabetes mellitus was 10.2 years. The mean peak plantar pressure was found to be highest at the right forefoot and left heel region, 267.6 kPa (SD113.5 kPa) and 266.3 kPa (SD 94.6 kPa) respectively. There was a statistically significant reduction of mean peak pressure (P < 0.0001 to P = 0.024) in all masked regions except the left toe region ranging from 22.3 to 47.5% (53.2-117.4 kPa). The highest reduction was seen in the right toe region (47.5%). The reduction of peak pressure was still significant (P < 0.0001 to P = 0.034) at 6 weeks ranging from 24.7% to 46.8% (46.1-100.6 kPa) and at 12 weeks, which was 22.2-49.2% (40.6-91.9 kPa). Mean usage of the socks was 4.39 days per week (SD 1.82), with the mode of 4-6 h per day. Most of the subjects were satisfied or very satisfied with the StepEase™ socks (77.4%) while 87.1% agreed to continue using the socks. None had any new ulcer development or fall during the study period. CONCLUSION: StepEase™ was significantly effective as an indoor foot pressure relieving footwear. It resulted in significant peak plantar pressure reduction by up to 49.2% and the effect was maintained for at least 12 weeks duration.