Transcutaneous auricular vagus nerve stimulation modifies cortical excitability in middle-aged and older adults.

There is a growing interest in the clinical application of transcutaneous auricular vagus nerve stimulation (taVNS). However, its effect on cortical excitability, and whether this is modulated by stimulation duration, remains unclear. We evaluated whether taVNS can modify excitability in the primary motor cortex (M1) in middle-aged and older adults and whether the stimulation duration moderates this effect. In addition, we evaluated the blinding efficacy of a commonly reported sham method. In a double-blinded randomized cross-over sham-controlled study, 23 healthy adults (mean age 59.91 ± 6.87 years) received three conditions: active taVNS for 30 and 60 min and sham for 30 min. Single and paired-pulse transcranial magnetic stimulation was delivered over the right M1 to evaluate motor-evoked potentials. Adverse events, heart rate and blood pressure measures were evaluated. Participant blinding effectiveness was assessed via guesses about group allocation. There was an increase in short-interval intracortical inhibition (F = 7.006, p = .002) and a decrease in short-interval intracortical facilitation (F = 4.602, p = .014) after 60 min of taVNS, but not 30 min, compared to sham. taVNS was tolerable and safe. Heart rate and blood pressure were not modified by taVNS (p > .05). Overall, 96% of participants detected active stimulation and 22% detected sham stimulation. taVNS modifies cortical excitability in M1 and its effect depends on stimulation duration in middle-aged and older adults. taVNS increased GABAAergic inhibition and decreased glutamatergic activity. Sham taVNS protocol is credible but there is an imbalance in beliefs about group allocation.

Identifying spatial neglect - an updated systematic review of the psychometric properties of assessment tools in adults post-stroke.

Spatial neglect commonly occurs after a stroke, resulting in diverse impacts depending on the type and severity. There are almost 300 tools for assessing neglect, yet there is a lack of knowledge on the psychometric properties of these tools. The objective of this systematic review, registered on Prospero (CRD42021271779), was to determine the quality of the evidence for assessing spatial neglect, categorized by neglect subtype. The following databases were searched on 3rd May 2022 from database inception: Ovid Emcare, Embase, Ovid MEDLINE, APA PsycINFO, Web of Science (SCI-EXPANDED; SSCI; A&HCI; ESCI) and Scopus. All primary peer-reviewed studies (>5 participants) of adults post stroke, reporting any psychometric property of 33 commonly used neglect assessment tools were included. The COSMIN (COnsensus-based Standards for the selection of health Measurement INstruments) risk of bias tool was used to assess the methodological quality of the studies and summarize the psychometric properties of each tool. 164 articles were included, with a total of 12,463 people with stroke. The general quality of the evidence was poor and no one tool had high-quality evidence of both validity and reliability. Eleven tools show some promise as they meet the minimum criteria for good measurement properties for both validity and reliability.

Implementation of the South Australian Regional Telestroke service is associated with improved care quality and lower stroke mortality: A retrospective cohort study.

INTRODUCTION: Stroke in Regional Australia may have worse outcomes due to difficulties accessing optimal care. The South Australian Regional Telestroke service aimed to improve telestroke neurologist access, supported by improved ambulance triage. OBJECTIVE: To assess stroke care quality and patient mortality pre- and postimplementation of a vascular neurologist-led Telestroke service. DESIGN: Historically controlled mixed methods cohort study comparing key quality indicators and patient mortality (6 months pre- vs. 18 months postimplementation date [4 June 2018]) at the three major South Australian regional stroke centres. The primary outcome was 13 care quality indicators as a combined composite risk-adjusted score, and the secondary outcome was risk-adjusted mortality at 12-month postadmission. FINDINGS: On an annualised basis, of 189 patients with stroke, more were admitted postintervention to the regional stroke centres than in the control period (158 [annualised rate 105.3, 95% CI 86.2-127.4] vs. 31 [annualised rate 62.0, 95% CI 47.5-79.5]) Baseline patient characteristics were similar in both periods. Post-implementation, median last-known-well time to presentation (3.5 h [IQR 1.6-17] vs. 2.0 [IQR 1-14]; p = 0.46) and door to needle times (121 min [IQR 97-144] vs. 90 [IQR 75-138]; p = 0.65) were not significantly lower but an improvement in the combined composite quality score was observed (0.069 [95% CI 0.004-0.134; p = 0.04]), reflecting individual improvements in some quality indicators. Mortality at 12-month postimplementation was substantially lower postimplementation (prechange 23% vs. postchange 13% [hazard ratio 0.58 (95% CI 0.44-0.76; p < 0.001)]). CONCLUSION: Implementation of a South Australian Regional Telestroke service was associated with improved care metrics and lower mortality.

Perspectives of choice and control in daily life for people following brain injury: A qualitative systematic review and meta-synthesis.

BACKGROUND AND OBJECTIVE: Acquired brain injury (ABI) can result in considerable life changes. Having choice and control over daily life is valued by people following ABI. This meta-synthesis will analyse and integrate international research exploring perspectives of choice and control in daily life following ABI. METHODS: Databases were searched from 1980 to 13 January 2022 for eligible qualitative studies. After duplicates were removed, 22,768 studies were screened by title and abstract, and 241 studies received full-text assessment with 56 studies included after pearling. Study characteristics and findings were extracted that related to personal perspectives on choice and control by people with an ABI (including author interpretation and quotes). Data from each study were coded and then segments of coded data across the studies were compared to create multiple broad categories. FINDINGS: Findings were then reduced from categories into 3 overarching themes with 12 subthemes. These themes were: (1) feeling like a second-class citizen; (2) reordering life and (3) choosing a path. Participants with an ABI tussled between their feelings of loss following brain injury and their thinking about how they start to regain control and become agents of their own choices. The themes describe their sense of self, their changed self and their empowered self in relation to 'choice and control'. CONCLUSIONS: Re-engaging with choice and control after ABI is dynamic and can be challenging. Health professionals and supporters need to facilitate a gradual and negotiated return to agency for people following ABI. A sensitive and person-centred approach is needed that considers the readiness of the person with ABI to reclaim choice and control at each stage of their recovery. Clear service or process indicators that are built on lived experience research are needed to facilitate changes in service delivery that are collaborative and inclusive. PATIENT OR PUBLIC CONTRIBUTION: This review included the voices of 765 people living with ABI and was conducted by a diverse team of allied health professionals with practice knowledge and research experience with people following ABI. Twenty-nine of the 56 included studies had participants contributing to their design or analysis.

Can body awareness training improve recovery following stroke: A study to assess feasibility and preliminary efficacy.

BACKGROUND: Impairments in body awareness are common after stroke and are associated with decreased participation and performance in everyday activities. OBJECTIVES: To explore the feasibility and safety of a body awareness program after stroke, and identify the preliminary efficacy of class-based lessons compared to home-based lessons on sensation, body awareness, motor impairment and quality of life. METHODS: A two-armed pilot randomized controlled trial with a nested qualitative descriptive study was conducted. Individuals with a diagnosis of stroke (at least three months post injury) were randomized to either class-based face-to-face body awareness lessons or home-based individually performed body awareness lessons. Outcome measures were safety, feasibility, sensation, body awareness, motor impairment, self-efficacy and quality of life. Semi-structured interviews were used to allow greater exploration and understanding of participants' experience of the program. RESULTS: Twenty participants were randomized, 16 participants completed the program. Feasibility was greater in the class-based group. No adverse events were detected. The class-based group led to improvement in body awareness (p = 0.002), quality of life (p = 0.002), and the arm (p = 0.025) and leg (p = 0.005) motor impairment scores. Qualitative data similarly indicated that the class-based group experienced a stronger sense of awareness, achievement and connection than the home-based group. CONCLUSIONS: Body awareness training was safe, feasible and acceptable in people with stroke. Individuals in the class-based group showed greater benefit compared to those receiving home-based therapy.

Cognitive Reserve Modifies the Relationship Between Neural Function, Neural Injury and Upper-Limb Recovery After Stroke.

OBJECTIVE: To investigate whether cognitive reserve modifies the relationship between functional connectivity, lesion volume, stroke severity and upper-limb motor impairment and recovery in stroke survivors. METHODS: Ten patients with first-ever ischemic middle cerebral artery stroke completed the Cognitive Reserve Index Questionnaire at baseline. Upper-limb motor impairment and functional connectivity were assessed using the Fugl-Meyer Assessment and electroencephalography respectively at baseline and 3-months post-stroke. A debiased weighted phase lag index was computed to estimate functional connectivity between electrodes. Partial least squares (PLS) regression identified a connectivity model that maximally predicted variance in the degree of upper-limb impairment. Regression models were generated to determine whether cognitive reserve modified the relationship between neural function (functional connectivity), neural injury (lesion volume), stroke severity (National Institutes of Health Stroke Scale) and upper-limb motor impairment at baseline and recovery at 3-months (Fugl-Meyer Assessment). RESULTS: The addition of cognitive reserve to a regression model with a dependent variable of upper-limb motor recovery and independent variables of functional connectivity between the ipsilesional motor cortex and parietal cortex, stroke severity and lesion volume improved model efficiency (∆BIC=-7.07) despite not reaching statistical significance (R2=0.90, p=0.07). Cognitive reserve did not appear to improve regression models examining motor impairment at baseline. CONCLUSIONS: Preliminary observations suggest cognitive reserve might modify the relationship between neural function, neural injury, stroke severity and upper-limb motor recovery. Further investigation of cognitive reserve in motor recovery post-stroke appears warranted.

Increased Relative Functional Gain and Improved Stroke Outcomes: A Linked Registry Study of the Impact of Rehabilitation.

OBJECTIVES: It is unclear how acute care influences patient outcomes in those who receive rehabilitation. We aimed to determine the associations between acute stroke therapies, outcomes during inpatient rehabilitation and self-reported outcomes at 90-180 days after stroke. MATERIALS AND METHODS: Patient-level data from adults with acute stroke registered in the Australian Stroke Clinical Registry (AuSCR, 2014-2017) were linked with data from the Australasian Rehabilitation Outcomes Centre (AROC). The main outcome was relative function gain (RFG), which is a measure of the FIM change achieved between admission to discharge as a proportion of the total gain possible based on admission FIM, relative to the maximum achievable score. Multilevel logistic/median regression analyses were used to investigate the association between RFG achieved in rehabilitation and (1) acute stroke therapies; (2) 90-180 day outcomes (health-related quality of life using EuroQoL-5D-3L; independence according to modified Rankin Scale (score 0-2) and self-reported hospital readmission). RESULTS: Overall, 8397/8507 eligible patients from the AuSCR were linked with corresponding AROC data (95% linkage rate; median age 75 years, 43% female); 4239 had 90-180 days survey data. Receiving thrombolysis (16% of the cohort) had a minimal association with RFG in rehabilitation (coefficient: 0.03; 95% Confidence Interval [CI]: 0.01, 0.05). Greater RFG achieved whilst in in-patient rehabilitation was associated with better longer-term HR-QoL (coefficient 21.77, 95% CI 17.8, 25.8) including fewer problems with mobility, self-care, pain, usual activities and anxiety/depression; greater likelihood of independence (adjusted Odds Ratio: 10.66; 95% CI 7.86, 14.45); and decreased odds of self-reported hospital readmission (adjusted Odds Ratio: 0.53; 95% CI 0.41, 0.70) within 90-180 days post-stroke. CONCLUSIONS: Stroke survivors who achieved greater RFG during inpatient rehabilitation had better HR-QoL and were more likely to be independent at follow-up. Acute care processes did not appear to impact RFG or long-term outcomes for those who accessed inpatient rehabilitation.

Good Heart: Telling Stories of Cardiovascular Protective and Risk Factors for Aboriginal Women.

BACKGROUND: Aboriginal and Torres Strait Islander peoples' perspectives of health and cultural wellbeing encapsulate the spiritual, social and environmental health of individuals, their communities and country. Strategies designed to reduce the cardiovascular burden of Aboriginal and Torres Strait Islander people often fail to consider their unique knowledge and worldview. METHODS: This adapted, grounded theory study sought to explore Aboriginal women's views of cardiovascular protective and risk factors. RESULTS: Twenty-eight (28) women from five women's groups across Central and South Australia participated. Women distinguished the heart as core to their spiritual and physical wellbeing. Women identified six attributes that keep a woman's heart strong, four that can make the heart sick, and eight socio-ecological factors which affect a woman's capacity to care for their heart. Women described having a healthy heart when able to identify as Aboriginal women, being connected to family and community, having a healthy life and body, and being engaged in their health and health care. CONCLUSIONS: There are gaps in the provision of cardiovascular risk assessment and management, gaps in the cultural safety of primary health care services, and gaps in the communication of the sex-specific warning signs of a heart attack, all of which must be addressed.

The Physiotherapy in Preschools Program: Describing a Student-Led Assessment Service for Children With Possible Motor Skill Difficulties.

The aim of this study was to describe and undertake an initial evaluation of a student-led assessment service for children with possible motor-skill difficulties. A secondary analysis of cross-sectional descriptive clinical data collected from 2015 to 2016 was undertaken. Children (N = 102) were assessed in preschools by physiotherapy students (supervised by qualified physiotherapists). Key outcomes included the following: Children's Activities Scale, Movement Assessment Battery for Children-2, and demographic/service-usage/onward referral statistics. The results highlighted that for every five children referred/assessed, two were at risk of motor-skill difficulties (∼43%). About 66% of children were subsequently referred on or monitored (40% requiring multidisciplinary follow-up). Conversely 34% of children did not require further services. In conclusion, a student-led assessment service may be a sustainable and feasible option to assist children at risk of motor-skill difficulties, enabling onward referral. Additional evaluation is required to garner stakeholder feedback.

Economic Evaluation of Stem Cell Therapies in Neurological Diseases: A Systematic Review.

OBJECTIVES: To examine economic evaluation studies of stem cell therapies (SCTs) in neurological disorders and to provide an overview of the quality of the economic evidence available on this topic. METHODS: The review examined studies that performed an economic evaluation of the use of stem cells in adult patients with neurological diseases and that were published in English during the period 2007 to 2017. Data analyzed and reported included study population, disease indication, main analytical approaches for the economic analysis and perspective, key assumptions made or tested in sensitivity analyses, cost outcomes, estimates of incremental cost effectiveness, and approaches to quantifying decision uncertainty. RESULTS: A total of three studies reporting on the findings of the economic evaluation of the use of SCT in stroke, Parkinson disease, and secondary progressive multiple sclerosis, respectively, were identified. All three studies conducted a cost-utility analysis using decision-analytic models and reported an incremental cost per quality-adjusted life-years gained (incremental cost-effectiveness ratio) versus standard care. These studies reported meaningful cost savings in stroke, Parkinson disease, and secondary progressive multiple sclerosis in the base-case scenarios. CONCLUSIONS: Despite significant progress in clinical research in the use of SCT in neurological diseases, economic evaluation of these therapies is still at a nascent stage. Given the early stage of research inputs (clinical and cost outcomes data) into the models per se, further research is urgently needed to enable meaningful assessment of the cost effectiveness of these advanced therapies and to ensure sustainable access for population groups most likely to benefit in clinical practice.

Access to rehabilitation for patients with stroke in Australia.

OBJECTIVE: To identify factors associated with receiving acute goal-directed treatment, being assessed for ongoing rehabilitation, and receiving post-acute rehabilitation after having a stroke. DESIGN: Retrospective analysis of National Stroke Audit data for patients with acute stroke treated at Australian hospitals during 1 September 2014 - 28 February 2015. SETTING, PARTICIPANTS: 112 Australian hospitals that admit adults with acute stroke. MAIN OUTCOMES: Associations between patient-related and organisational factors and the provision of rehabilitation interventions. RESULTS: Data for 3462 patients were eligible for analysis; their median age was 74 years, 1962 (57%) were men, and 2470 (71%) had received care in a stroke unit. 2505 patients (72%) received goal-directed treatment during their acute admission; it was not provided to 364 patients (10.5%) who were responsive, had not fully recovered, and did not refuse treatment. Factors associated with higher odds of receiving goal-directed treatment included goal-setting with the patient and their family (odds ratio [OR], 6.75; 95% CI, 5.07-8.90) and receiving care in a stroke unit (OR, 2.08; 95% CI, 1.61-2.70). 1358 patients (39%) underwent further rehabilitation after discharge from acute care; factors associated with receiving post-acute rehabilitation included care in a stroke unit (OR, 1.73; 95% CI, 1.34-2.22) and having an arm or speech deficit. Dementia was associated with lower odds of receiving acute goal-directed treatment (OR, 0.49; 95%, 0.33-0.73) and post-acute rehabilitation (OR, 0.43; 95%, 0.30-0.61). CONCLUSIONS: Access to stroke units and to early and ongoing rehabilitation for patients after stroke can be improved in Australia, both to optimise outcomes and to reduce the burden of care on underresourced community and primary care providers.

Exercising Choice and Control: A Qualitative Meta-synthesis of Perspectives of People With a Spinal Cord Injury.

OBJECTIVE: To systematically search the literature and construct a meta-synthesis of how choice and control are perceived by people with spinal cord injury (SCI). DATA SOURCES: Medline, Academic Search Premier, CINAHL, Cochrane, EMBASE, HealthSource, ProQuest, PsychInfo, SAGE, and SCOPUS were searched from 1980 until September 2018 including all languages. Reference lists of selected studies were also reviewed. STUDY SELECTION: Eligible qualitative studies included perspectives about choice of control as reported by people with an SCI. Studies were excluded if they included perspectives from other stakeholder groups. A total of 6706 studies were screened for title and abstract and full text of 127 studies were reviewed resulting in a final selection of 29. DATA EXTRACTION: Characteristics of the studies were extracted along with any data (author interpretations and quotes) relating to perspectives on choice and control. DATA SYNTHESIS: First-order analysis involved coding the data in each study and second-order analysis involved translating each segment of coded data into broader categories with third-order analysis condensing categories to 2 broad overarching themes. These themes were experiencing vulnerability or security and adapting to bounded abilities. CONCLUSIONS: Perspectives of choice and control are influenced by interrelated environmental, interpersonal, and personal contexts. From a personal perspective, participants reported a readiness for adaptation that included turning points where emotional and cognitive capacity to make choices and take control changed. Health professionals need to be responsive to this readiness, promote empowerment and foster, rather than remove, hope.

PERSPECTIVES: Stroke survivors' views on the design of an early-phase cell therapy trial for patients with chronic ischaemic stroke.

BACKGROUND: Stem cell research holds the potential for a paradigm shift in the management of diseases such as stroke. Patient and public involvement in research (PPIR) can bring a focus to issues of clinical relevance and accelerate translation to real-world clinical practice. OBJECTIVE: A qualitative thematic analysis of the perspectives of stroke survivors regarding the conduct and design aspects of a proposed phase I clinical cell therapy study in stroke. DESIGN: Twelve stroke survivors were purposively recruited in July 2016-August 2017 and participated in semi-structured, face-to-face interviews for input into the design of a proposed phase I clinical study of autologous dental pulp stem cells. Concurrent thematic analysis was conducted until data saturation was achieved. DISCUSSION AND CONCLUSIONS: Participants conveyed that the most relevant outcomes to them were regaining participation, decreased dependence on caregivers and improvement in cognition, memory, mood, pain and fatigue. The perception of risk vs. benefit was likely influenced by the time elapsed since stroke, with participants being more willing to accept a higher level of risk early in the post-stroke disease course. They believed that all stroke survivors should be given an opportunity to participate in research, irrespective of their cognitive capacity. A relatively small sample population of 12 stroke survivors was studied as thematic saturation was achieved. PERSPECTIVES study applied principles of PPIR to early-phase cell research. Incorporation of outcomes relevant to patients' need within the study design is critical to generate data that will enable personalized application of regenerative medicine in stroke.

The evidence for services to avoid or delay residential aged care admission: a systematic review.

BACKGROUND: Interventions that enable people to remain in their own home as they age are of interest to stakeholders, yet detailed information on effective interventions is scarce. Our objective was to systematically search and synthesise evidence for the effectiveness of community-based, aged care interventions in delaying or avoiding admission to residential aged care. METHOD: Nine databases were searched from January 2000 to February 2018 for English publications. Reference lists of relevant publications were searched. The databases yielded 55,221 citations and 50 citations were gleaned from other sources. Where there was sufficient homogeneity of study design, population, intervention and measures, meta-analyses were performed. Studies were grouped by the type of intervention: complex multifactorial interventions, minimal/single focus interventions, restorative programs, or by the target population (e.g. participants with dementia). RESULTS: Data from 31 randomised controlled trials (32 articles) that met our inclusion criteria were extracted and analysed. Compared to controls, complex multifactorial interventions in community aged care significantly improved older adults' ability to remain living at home (risk difference - 0.02; 95% CI -0.03, - 0.00; p = 0.04). Commonalities in the 13 studies with complex interventions were the use of comprehensive assessment, regular reviews, case management, care planning, referrals to additional services, individualised interventions, frequent client contact if required, and liaison with General Practitioners. Complex interventions did not have a significantly different effect on mortality. Single focus interventions did not show a significant effect in reducing residential aged care admissions (risk difference 0, 95% CI -0.01, 0.01; p = 0.71), nor for mortality or quality of life. Subgroup analysis of complex interventions for people with dementia showed significant risk reduction for residential aged care admissions (RD -0.05; 95% CI -0.09, -0.01; p = 0.02). Compared to controls, only interventions targeting participants with dementia had a significant effect on improving quality of life (SMD 3.38, 95% CI 3.02, 3.74; p < 0.000001). CONCLUSIONS: Where the goal is to avoid residential aged care admission for people with or without dementia, there is evidence for multifactorial, individualised community programs. The evidence suggests these interventions do not result in greater mortality and hence are safe. Minimal, single focus interventions will not achieve the targeted outcomes. TRIAL REGISTRATION: PROSPERO Registration CRD42016050086 .

Strategies to implement and monitor in-home transcranial electrical stimulation in neurological and psychiatric patient populations: a systematic review.

BACKGROUND: Transcranial electrical stimulation is a promising technique to facilitate behavioural improvements in neurological and psychiatric populations. Recently there has been interest in remote delivery of stimulation within a participant's home. OBJECTIVE: The purpose of this review is to identify strategies employed to implement and monitor in-home stimulation and identify whether these approaches are associated with protocol adherence, adverse events and patient perspectives. METHODS: MEDLINE, Embase Classic + Embase, Emcare and PsycINFO databases and clinical trial registries were searched to identify studies which reported primary data for any type of transcranial electrical stimulation applied as a home-based treatment. RESULTS: Nineteen published studies from unique trials and ten on-going trials were included. For published data, internal validity was assessed with the Cochrane risk of bias assessment tool with most studies exhibiting a high level of bias possibly reflecting the preliminary nature of current work. Several different strategies were employed to prepare the participant, deliver and monitor the in-home transcranial electrical stimulation. The use of real time videoconferencing to monitor in-home transcranial electrical stimulation appeared to be associated with higher levels of compliance with the stimulation protocol and greater participant satisfaction. There were no severe adverse events associated with in-home stimulation. CONCLUSIONS: Delivery of transcranial electrical stimulation within a person's home offers many potential benefits and appears acceptable and safe provided appropriate preparation and monitoring is provided. Future in-home transcranial electrical stimulation studies should use real-time videoconferencing as one of the approaches to facilitate delivery of this potentially beneficial treatment.

Upper limb function in children with attention-deficit/hyperactivity disorder (ADHD).

Upper limb function was investigated in children with ADHD using objective methods. We hypothesised that children with ADHD exhibit abnormal dexterity, force application during manipulation of a novel object, and movement rhythmicity. Two groups of age- and gender-matched children were investigated: 35 typically developing children (controls, 10.5 ± 0.4 years, 32M-3F) and 29 children (11.5 ± 0.5 years, 27M-2F) with formally diagnosed ADHD according to DSM-IV-TR criteria. Participants underwent a series of screening tests and tests of upper limb function while "off" medication. Objective quantification of upper limb function involved measurement of force during a grip and lift task, maximal finger tapping task, and maximal pinch grip. Acceleration at the index finger was also measured during rest, flexion and extension, and a postural task to quantify tremor. The Movement Assessment Battery for Children-2 (MABC-2) was also administered. Significant between-group differences were observed in movement rhythmicity, manipulation of a novel object, and performance of the MABC-2 dexterity and aiming and catching components. Children with ADHD lifted a novel object using a lower grip force (P = 0.036), and held the object with a more variable grip force (P = 0.003), than controls. Rhythmicity of finger tapping (P = 0.008) and performance on the dexterity (P = 0.007) and aiming and catching (P = 0.042) components of the MABC-2 were also significantly poorer in the ADHD group than controls. Movement speed, maximum pinch grip strength, and tremor were unaffected. The results of the study show for the first time that ADHD is associated with deficits in multiple, but not all domains of upper limb function.

Rehabilitation Interventions for Upper Limb Function in the First Four Weeks Following Stroke: A Systematic Review and Meta-Analysis of the Evidence.

OBJECTIVE: To investigate the therapeutic interventions reported in the research literature and synthesize their effectiveness in improving upper limb (UL) function in the first 4 weeks poststroke. DATA SOURCES: Electronic databases and trial registries were searched from inception until June 2016, in addition to searching systematic reviews by hand. STUDY SELECTION: Randomized controlled trials (RCTs), controlled trials, and interventional studies with pre/posttest design were included for adults within 4 weeks of any type of stroke with UL impairment. Participants all received an intervention of any physiotherapeutic or occupational therapeutic technique designed to address impairment or activity of the affected UL, which could be compared with usual care, sham, or another technique. DATA EXTRACTION: Two reviewers independently assessed eligibility of full texts, and methodological quality of included studies was assessed using the Cochrane Risk of Bias Tool. DATA SYNTHESIS: A total of 104 trials (83 RCTs, 21 nonrandomized studies) were included (N=5225 participants). Meta-analyses of RCTs only (20 comparisons) and narrative syntheses were completed. Key findings included significant positive effects for modified constraint-induced movement therapy (mCIMT) (standardized mean difference [SMD]=1.09; 95% confidence interval [CI], .21-1.97) and task-specific training (SMD=.37; 95% CI, .05-.68). Evidence was found to support supplementary use of biofeedback and electrical stimulation. Use of Bobath therapy was not supported. CONCLUSIONS: Use of mCIMT and task-specific training was supported, as was supplementary use of biofeedback and electrical simulation, within the acute phase poststroke. Further high-quality studies into the initial 4 weeks poststroke are needed to determine therapies for targeted functional UL outcomes.

The reassuring potential of spinal imaging results: development and testing of a brief, psycho-education intervention for patients attending secondary care.

PURPOSE: To develop and test a standardised method of interpreting spinal imaging findings in a manner designed to reassure patients with low back pain and promote engagement in an active recovery. METHODS: A five-phase development and testing process involved collaborative working party contributions, informal and formal appraisal of the intervention content by clinicians and consumers, a two-stage online evaluation of the take-home patient resource, and onsite testing. RESULTS: A total of 12 health professionals and 77 consumers were included in formal evaluative processes at various stages of the development and testing process. Consumers assessed the revised iteration of the take-home resource to be clearer and easier to understand than the original version. We integrated all feedback and evaluation outcomes to develop the final intervention content, which was approved by experienced clinicians and considered safe. We devised a framework to guide delivery of the low-cost clinical intervention and a 10-15-min timeframe was demonstrated to be realistic. CONCLUSIONS: We have developed, modified, and tested a pragmatic framework for a brief, psychoeducational intervention. We have established face validity and acceptability from key stakeholders and engaged clinicians and are ready to proceed with a pilot feasibility trial.

Custom foot orthoses improve first-step pain in individuals with unilateral plantar fasciopathy: a pragmatic randomised controlled trial.

BACKGROUND: Foot orthoses are routinely used to treat plantar fasciopathy in clinical practice. However, minimal evidence exists as to the effect of both truly custom designed foot orthoses, as well as that of the shoe the foot orthoses are placed into. This study investigated the effect of wearing custom foot orthoses and new athletic footwear on first-step pain, average 24-h pain and plantar fascia thickness in people with unilateral plantar fasciopathy over 12 weeks. METHODS: A parallel, three-arm randomised controlled trial with blinding of participants and assessors. 60 participants diagnosed with unilateral plantar fasciopathy were randomised to either custom foot orthoses and new shoes (orthoses group), a sham insole with a new shoes (shoe group) or a sham insole placed in the participant's regular shoes (control group). Primary outcome was first-step pain. Secondary outcomes were average 24-h pain and plantar fascia thickness measured on ultrasound. Outcomes were assessed at baseline, 4 week and 12 week trial time-points. RESULTS: At 4 weeks, the orthoses group reported less first-step pain (p = 0.002) compared to the control group. At 12 weeks, the orthoses group reported less first-step pain compared to both the shoe (p = < 0.001) and sham (p = 0.01) groups. Both the orthoses (p = < 0.001) and shoe (p = 0.006) groups reported less average 24-h pain compared to the control group at 4 and 12 weeks. The orthoses group demonstrated reduced plantar fascia thickness on ultrasound compared to both the shoe (p = 0.032) and control groups (p = 0.011). CONCLUSIONS: Custom foot orthoses in new shoes improve first-step pain and reduce plantar fascia thickness over a period of 12 weeks compared to new shoes alone or a sham intervention. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ( ACTRN 12613000446763 ). Submitted on the 10th of April 2013 and registered on the 18th of April 2013.

Measuring dexterity in the podiatrist population: a cross-sectional comparison of novice students and experienced podiatrists.

BACKGROUND: There is no 'gold-standard' for the evaluation of dexterity for the health professional or podiatrist populations. This has resulted in a broad array of generalised tests to evaluate dexterity. Thus, the aim was to determine which objective generalised dexterity tests are best suited to evaluating dexterity in a podiatry student population. METHODS: A cohort of Novice podiatry students and Experienced podiatrists were recruited and evaluated on a battery of dexterity tests selected to evaluate a variety of different elements. Group differences were evaluated statistically and regression undertaken on significant test outcomes. RESULTS: A total of 108 participants were recruited with 54 participants in each of the Novice and Experienced groups. Five of the eight tests were able to discriminate dexterous ability of participants in the Novice and Experienced groups. These included the Grip-lift task, GPT, P-MVC, G-MVC and the AsTex® sensory discrimination test. These tests comprised a total of 11 significant dependent variables (p <  0.05). From the test battery, outcomes were able to predict 79% of the group membership. Age and experience did not explain within-group variability for the Experienced group. CONCLUSION: Whilst the Experienced group displayed superior performance in strength and speed, the Novice group showed superior coordination and sensory ability. From these findings, we would recommend that outcomes from the Grooved Pegboard Test, Grip-lift task, Grip Strength test and Pinch Grip strength test be used to evaluate elements of dexterity in this population.