Effects of an ankle-foot orthosis on balance and walking after stroke: a systematic review and pooled meta-analysis.

OBJECTIVE: To determine the effectiveness of an ankle-foot orthosis (AFO) on mobility, walking, and balance in people with stroke. DATA SOURCES: The following databases were searched from inception to November 2011: Cochrane Stroke, Movement Disorders and Injuries Groups, MEDLINE, Embase, CINAHL, AMED, PsycINFO, and the Physiotherapy Evidence Database. Previous reviews, reference lists, and citation tracking of the selected articles were screened, and the authors of selected trials were contacted for any further unpublished data. STUDY SELECTION: Randomized controlled trials of AFOs in people with stroke, which measured balance, walking impairments, or mobility and were reported in English, were selected. Then we independently identified trials, extracted data, and assessed trial quality. DATA EXTRACTION: Trials with a low risk of selection, performance, and attrition bias were selected for analysis. Information on the trial design, population recruited, intervention delivered, outcomes measured, and the mean ± SD values for the treatment and control groups were extracted. DATA SYNTHESIS: Continuous outcomes were combined using weighted or standardized mean differences with 95% confidence intervals and a fixed-effect model. Thirteen trials with 334 participants were selected. The effect of an AFO on walking activity (P=.000-.001), walking impairment (P=.02), and balance (weight distribution) (P=.003) was significant and beneficial. The effect on postural sway (P=.10) and timed mobility tests (P=.07-.09) was nonsignificant, and the effect on functional balance was mixed. The selected trials were all crossover trials of the immediate effects; long-term effects are unexplored. CONCLUSIONS: An AFO can improve walking and balance after stroke, but only the immediate effects have been examined. The effects and acceptability of long-term usage need to be evaluated.

Development of a self-report scale of spasticity.

BACKGROUND: Although the Modified Ashworth Scale is the most common instrument used to grade spasticity, it is unsuitable for busy follow-up clinics, longer term follow-up, or community surveys. OBJECTIVES: To establish a simple questionnaire that would indicate the presence and extent of spasticity and would be suitable for use in everyday outpatient clinical practice and/or community follow-up. METHODS: Qualitative exploration of the experience and impact of spasticity among stroke patients led to the development of a short questionnaire. Rasch analysis was performed on the data and the scale items were externally validated by correlation with comparator measures. RESULTS: Forty-eight subjects were recruited for the qualitative interviews, half of whom were more than 2 years post stroke. Interviews generated items relating to spasticity that were categorized into pain, spasm, fatigue, restricted movement, loss of balance, and altered appearance. Eight items were chosen for the draft questionnaire. Five hundred questionnaires were sent, and 188 (38%) were returned. The mean age of the 188 responders was 72.6 years. In regard to health, 18.5% reported that they were in good or excellent health, and 49.7% reported only fair or poor health. Data from the 8-item scale were fitted to the Rasch measurement model. Initial fit of the 8 items was good, and all the assumptions of the model were satisfied. A strong and significant gradient was found between the summed 8-item scale and self-reported health. CONCLUSIONS: A short self-perceived scale for spasticity has been developed from grounded theory, which satisfies the most rigorous standards for measurement with fit to the Rasch model.

Real-World Dosing of OnabotulinumtoxinA and IncobotulinumtoxinA for Cervical Dystonia and Blepharospasm: Results from TRUDOSE and TRUDOSE II.

The real-world use of onabotulinumtoxinA and incobotulinumtoxinA for cervical dystonia and blepharospasm treatment was assessed in two separate retrospective studies using identical protocols (TRUDOSE and TRUDOSE II). The studies were conducted in Mexico, Norway, and United Kingdom and designed to evaluate dose utilization of the two botulinum toxins in clinical practice. Eighty-three patients treated with both onabotulinumtoxinA and incobotulinumtoxinA for ≥2 years for each botulinum toxin were included, (52, cervical dystonia; 31, blepharospasm). All patients switched from onabotulinumtoxinA to incobotulinumtoxinA for administrative/financial reasons. A range of dose ratios (incobotulinumtoxinA to onabotulinumtoxinA) was reported; with the majority of dose ratios being >1. The mean dose ratio was >1 regardless of the study site or underlying clinical condition. The inter-injection interval was significantly longer for onabotulinumtoxinA versus incobotulinumtoxinA when assessed for all patients (15.5 vs. 14.3 weeks; p = 0.006), resulting in fewer onabotulinumtoxinA treatments over the study time period. Consistent with product labeling, no single fixed-dose ratio exists between incobotulinumtoxinA and onabotulinumtoxinA. The dosage of each should be individualized based on patient needs and used as per product labeling. These real-world utilization data may have pharmacoeconomic implications.

Pharmacotherapy for treatment of attention deficits after non-progressive acquired brain injury. A systematic review.

OBJECTIVE: To systematically review the effectiveness of medications used to improve attention in people with non-progressive acquired brain injury. DESIGN: A systematic review. METHODS: MEDLINE, EMBASE, CINALH, PUBMED and PsychINFO databases were used to identify studies published between 1987 and 2008 meeting the following criteria: studies with subjects older than 18 years; diagnosis of new onset or previous acquired brain injury; medication given to improve attention and use of outcome to measure attention. Studies involving subjects in low arousal states or with neurogenerative conditions were excluded. The studies were categorized into three evidence levels: I - Randomized controlled trials; II - Prospective studies, controlled trials with methodological limitations; and III - Retrospective studies, clinical case series. RESULTS: Forty-seven articles were identified on initial search. Twenty-six met the pre-specified criteria. Five articles were assessed as meeting the level I evidence criteria, 12 were level II studies and 9 were level III studies. Methylphenidate can improve information processing speed but not all attention aspects in some people after traumatic brain injury. There is weak evidence for use of dopamine agonists to improve neglect/inattention after stroke. There is little evidence on the frequency of adverse effects and long-term functional benefits. CONCLUSION: Although there is lack of robust evidence to recommend the routine use of medication to improve attention after traumatic brain injury and stroke, the existing evidence indicates potential for benefit in some patents and therefore further research is warranted.

Adult outcomes and lifespan issues for people with childhood-onset physical disability.

This paper aimed to discuss functioning, quality of life, (QoL) and lifespan care issues of adolescents and young adults with childhood-onset physical disability from a clinical, scientific, and personal perspective. We present a résumé of results of recently performed studies in rehabilitation-based samples of (young) adults with childhood-onset conditions such as cerebral palsy (CP) and spina bifida (SB), and different models of transition and lifespan care. The studies showed that many young adults with a childhood-onset disability experience health-related problems such as functional deterioration, pain or fatigue, and an inactive lifestyle. A significant number are restricted in participation in work, housing, and intimate relationships. They perceive a lower health-related and global QoL compared with a reference group. In some centres in the UK and the Netherlands specialized outpatient services are available or being developed. In conclusion, transition to adulthood is a critical phase for reaching autonomous participation in adult life. There is an international challenge to incorporate a lifespan perspective in paediatric, transition, and adult health care services for persons with a childhood-onset disability.

Orthotic devices after stroke and other non-progressive brain lesions.

BACKGROUND: Post-stroke motor impairments cause difficulty controlling the joints of the affected limbs to produce useful movements. One way to manage this to use an orthosis to control the movement of the affected joints but evidence for their benefit is lacking. OBJECTIVES: To determine the effectiveness of upper or lower limb orthoses on activity and impairment in people with stroke and other non-progressive brain lesions. SEARCH STRATEGY: In February 2007 we searched the trials registers of the Cochrane Stroke, Movement Disorders and Injuries Groups, the Cochrane Database of Systematic Reviews and the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 1, 2007), MEDLINE (from 1966), EMBASE (from 1980), CINAHL (from 1983), AMED (from 1985), PsycINFO (from 1967) and RECAL (from 1990), and other databases and trials registers. We screened reference lists, contacted lead authors and other researchers in the field. SELECTION CRITERIA: We included randomised controlled trials of orthoses applied to the upper or lower limb in people with stroke and other non-progressive brain lesions. DATA COLLECTION AND ANALYSIS: Two review authors independently identified trials, extracted data, and assessed trial quality. Results for continuous outcomes were combined and analysed using mean difference or standardised mean difference, both with 95% confidence intervals and fixed-effect model. MAIN RESULTS: We analysed 14 trials with 429 participants. The overall effect of lower limb orthoses on walking disability (speed), walking impairment (step/stride length) and balance impairment (weight distribution in standing) was significant and beneficial. There was no significant effect on postural sway (balance impairment) or mobility disability but the numbers of studies and participants were low. However, these were all cross-over trials that looked at the immediate effect while wearing the orthosis; they did not assess the effects of wearing an orthosis over the long term. Upper limb orthoses showed no effect on upper limb function, range of movement at the wrist, fingers or thumb, nor pain. However, this was based on only three trials. AUTHORS' CONCLUSIONS: A lower limb orthosis can improve walking and balance but the included studies have only examined the immediate effects while wearing the orthosis; the effects of long-term use have not been investigated. An upper limb orthosis does not effect on upper limb function, range of movement at the wrist, fingers or thumb, nor pain, but this conclusion is based on only three trials.

WITHDRAWN: Orthotic devices after stroke and other non-progressive brain lesions.

BACKGROUND: Post-stroke motor impairments cause difficulty controlling the joints of the affected limbs to produce useful movements. One way to manage this to use an orthosis to control the movement of the affected joints but evidence for their benefit is lacking. OBJECTIVES: To determine the effectiveness of upper or lower limb orthoses on activity and impairment in people with stroke and other non-progressive brain lesions. SEARCH STRATEGY: In February 2007 we searched the trials registers of the Cochrane Stroke, Movement Disorders and Injuries Groups, the Cochrane Database of Systematic Reviews and the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 1, 2007), MEDLINE (from 1966), EMBASE (from 1980), CINAHL (from 1983), AMED (from 1985), PsycINFO (from 1967) and RECAL (from 1990), and other databases and trials registers. We screened reference lists, contacted lead authors and other researchers in the field. SELECTION CRITERIA: We included randomised controlled trials of orthoses applied to the upper or lower limb in people with stroke and other non-progressive brain lesions. DATA COLLECTION AND ANALYSIS: Two review authors independently identified trials, extracted data, and assessed trial quality. Results for continuous outcomes were combined and analysed using mean difference or standardised mean difference, both with 95% confidence intervals and fixed-effect model. MAIN RESULTS: We analysed 14 trials with 429 participants. The overall effect of lower limb orthoses on walking disability (speed), walking impairment (step/stride length) and balance impairment (weight distribution in standing) was significant and beneficial. There was no significant effect on postural sway (balance impairment) or mobility disability but the numbers of studies and participants were low. However, these were all cross-over trials that looked at the immediate effect while wearing the orthosis; they did not assess the effects of wearing an orthosis over the long term. Upper limb orthoses showed no effect on upper limb function, range of movement at the wrist, fingers or thumb, nor pain. However, this was based on only three trials. AUTHORS' CONCLUSIONS: A lower limb orthosis can improve walking and balance but the included studies have only examined the immediate effects while wearing the orthosis; the effects of long-term use have not been investigated. An upper limb orthosis does not effect on upper limb function, range of movement at the wrist, fingers or thumb, nor pain, but this conclusion is based on only three trials.

Audit of head injury management in Accident and Emergency at two hospitals: implications for NICE CT guidelines.

BACKGROUND: The National Institute for Clinical Excellence (NICE) has produced guidelines on the early management of head injury. This study audits the process of the management of patients with head injury presenting at Accident and Emergency (A&E) departments and examines the impact upon resources of introducing NICE guidelines for eligibility of a CT scan. METHODS: A retrospective audit of consecutive patients of any age, presenting at A&E with a complaint of head injury during one month in two northern District General Hospitals forming part of a single NHS Trust. RESULTS: 419 patients presented with a median age of 15.5 years, and 61% were male. 58% had a Glasgow Coma Score (GCS) recorded and 33 (8%) were admitted. Only four of the ten indicators for a CT scan were routinely assessed, but data were complete for only one (age), and largely absent for another (vomiting). Using just three (incomplete) indicators showed a likely 4 fold increase in the need for a CT scan. CONCLUSIONS: The majority of patients who present with a head injury to Accident and Emergency departments are discharged home. Current assessment processes and associated data collection routines do not provide the information necessary to implement NICE guidelines for CT brain scans. The development of such clinical audit systems in a busy A&E department is likely to require considerable investment in technology and/or staff. The resource implications for radiology are likely to be substantial.

Cerebral palsy.

Cerebral palsy affects movement and posture causing activity limitation; it is a lifelong condition, with foreseeable complications. There are evidence-based interventions that will prevent participation restriction. Childhood interventions are generally delivered within multidisciplinary rehabilitation programs. Sadly young adults are often not transferred to an appropriate multidisciplinary adult neurodisability service. An unexplained neurological deterioration should warrant further investigation. Pain is an important underreported symptom and musculoskeletal complaints are prevalent. Disabled adults have less participation socially, in employment, marriage, and independent living related to health problems, discrimination, or lack of access to information, support, and equipment. Evidence-based interventions include a variety of modalities at all International Classification of Functioning, Disability, and Health levels to include support and adaptations. Rehabilitation interventions that have been shown to be effective include surgery in childhood, ankle-foot orthoses, strength training, and electrical stimulation. Management of spasticity is beneficial and has an evidence base. Orthotics and casting are also used. Systematic reviews of upper limb therapies also show the benefit of physical therapy exercise, strengthening, fitness training, and constraint therapy. Occupational therapy has a weaker evidence base than in other disabling conditions but many modalities are transferable. Speech therapy is effective although no specific intervention is better. Psychological wellbeing interventions, including improving self-efficacy, health knowledge, and coping skills, are beneficial. Management of continence, nutrition, and fatigue promote wellbeing.

The effect of upper limb orthotics after stroke: a systematic review.

UNLABELLED: Upper limb orthotics, or splints, are widely advocated for people with stroke however opinion about whether, and how, they should be used is varied. We therefore systematically reviewed the literature on upper limb orthotics for people with stroke and other non-progressive brain lesions to establish whether an orthosis can improve function or/and impairments. SEARCH STRATEGY: The Cochrane library, MEDLINE, EMBASE, CINAHL, AMED, PsycINFO and RECAL were searched. We screened reference lists and contacted lead authors and other researchers in the field. SELECTION CRITERIA: Randomised controlled trials of upper limb orthoses in stroke survivors and other non-progressive brain lesions. DATA COLLECTION AND ANALYSIS: Two reviewers independently identified trials, extracted data and assessed trial quality. Results for continuous outcomes were combined and analysed using mean difference or standardised mean difference, both with 95% confidence intervals and fixed-effect model. MAIN RESULTS: We analysed 4 trials with 126 participants. Upper limb orthoses showed no effect on upper limb function, range of movement at the wrist, fingers or thumb, nor pain. CONCLUSIONS: Current evidence suggests that an upper limb orthosis does not effect upper limb function, range of movement at the wrist, fingers or thumb, nor pain.