Emerging technologies for the prevention and management of diabetic foot ulcers.

Diabetic foot ulcers (DFUs) are one of the most serious complications of diabetes mellitus (DM). Although research has improved understanding of DFU etiology, an effective clinical prevention and management of DFUs remains undetermined. Knowledge of recent technologies may enable clinicians and researchers to provide appropriate interventions to prevent and treat DFUs. This paper discusses how diabetes causes peripheral neuropathy and peripheral arterial diseases, which contribute to increased risk of DFUs. Then, emerging technologies that could be used to quantify risks of DFUs are discussed, including laser Doppler flowmetry for assessing plantar tissue viability, infrared thermography for early detection of plantar tissue inflammation, plantar pressure and pressure gradient system for identification of specific site at risk for DFUs, and ultrasound indentation tests (elastography) to quantify plantar tissue mechanical property. This paper also reviews how physical activity reduces risks of DFUs and how technology promotes adherence of physical activity. The clinician should encourage people with DM to exercise (brisk walking) at least 150 min per week and assess their exercise log along with the blood glucose log for providing individualized exercise prescription. Last, rehabilitation interventions such as off-loading devices, thermotherapy and electrotherapy are discussed. Although the exact etiology of DFUs is unclear, the emerging technologies discussed in this paper would enable clinicians to closely monitor the change of risk of DFUs and provide timely intervention. An integrated approach using all these emerging technologies should be promoted and may lead to a better outcome of preventing and managing DFUs.

Exploring head and neck cancer patients' experiences with radiation therapy immobilisation masks: A qualitative study.

OBJECTIVE: Head and neck cancer (HNC) patients commonly undergo radiation therapy requiring immobilisation by a mask. Some find the mask distressing, and this can disrupt treatment sessions. This study aimed to explore the patient experience of immobilisation masks in the Australian and New Zealand (ANZ) context, to guide possible intervention. METHODS: Semi-structured interviews were conducted with HNC patients who had completed radiation therapy, recruited via hospitals and social media. Interviews continued until data saturation; then, three further interviews were conducted for member-checking purposes. Qualitative methodology with thematic analysis was used to identify themes in the data. RESULTS: Twenty HNC survivors participated in interviews, and seven themes were identified: information received by participants, potential predictors of mask anxiety, participant reactions to the mask, trajectories of mask anxiety, supportive behaviour and communication of health professionals, coping with the mask, and thoughts and feelings about the mask. CONCLUSIONS: Participant experiences of the immobilisation mask were diverse. The findings fit with Lazarus and Folkman's (Stress, appraisal, and coping. New York, NY: Springer Pub. Co) transactional model of stress and coping, as participants appeared to make cognitive appraisals of the mask and their coping abilities throughout treatment, resulting in varied levels of mask-related distress. Complex intervention is recommended to reduce mask anxiety in HNC patients across ANZ.

Repeated Restraint Stress Decreases Na,K-ATPase Activity via Oxidative and Nitrosative Damage in the Frontal Cortex of Rats.

Chronic psychogenic stress can increase neuronal calcium influx and generate the intracellular accumulation of oxidative (ROS) and nitrosative (RNS) reactive species, disrupting synaptic transmission in the brain. These molecules impair the Na,K-ATPase (NKA) activity, whose malfunction has been related to neuropsychiatric disorders, including anxiety, depression, schizophrenia, and neurodegenerative diseases. In this study, we assessed how 14 days of restraint stress in rats affect NKA activity via oxidative/nitrosative damage in the frontal cortex (FCx), a crucial region for emotional and cognitive control. One day after the last stress session (S14 + 1d), but not immediately after the last stress session (S14), α2,3-NKA activity was significantly reduced in the FCx, without changes in the protein levels. The S14 + 1d animals also showed increased lipid peroxidation, iNOS, and AP-1 activities, as well as TNF-α protein levels, evidencing oxidative stress and neuroinflammation. No cellular death or neurodegeneration was observed in the FCx of S14 + 1d animals. Pharmacological inhibition of iNOS or COX-2 before each stress session prevented lipid peroxidation and the α2,3-NKA activity loss. Our results show that repeated restraint exposure for 14 days decreases the activity of α2,3-NKA in FCx 24 h after the last stress, an effect associated with augmented inflammatory response and oxidative and nitrosative damage and suggest new pathophysiological roles to neuroinflammation in neuropsychiatric diseases.

Unimanual versus bimanual therapy in children with unilateral cerebral palsy: Same, same, but different.

BACKGROUND: There is high-level evidence supporting constraint-induced movement therapy (CIMT) and bimanual therapy for children with unilateral cerebral palsy. Evidence-based intervention includes time-limited, goal-directed, skills-based, intensive blocks of practice based on motor learning theory. AIM AND METHODS: Using supporting literature and clinical insight, we provide a theoretical rationale to highlight previously unreported differences between CIMT and bimanual therapy. DISCUSSION: The current emphasis on total dosage of practice for achieving positive outcomes fails to recognise the influence of other critical concepts within motor learning. Limitations exist in the application of motor learning principles using CIMT due to its unimanual nature. CIMT is effective for development of unimanual actions brought about by implicit learning, however it is difficult to target explicit learning that is required for learning how to use two hands together. Using bimanual therapy, object properties can be adapted to trigger goal-related perceptual and cognitive processes required for children to learn to recognise when two hands are required for task completion. CONCLUSION: CIMT and bimanual should be viewed as complementary. CIMT could be used to target unimanual actions. Once these actions are established, bimanual therapy could be used for children to learn how to use these actions for bimanual skill development.

Effects of Unilateral Upper Limb Training in Two Distinct Prognostic Groups Early After Stroke: The EXPLICIT-Stroke Randomized Clinical Trial.

Background and Objective Favorable prognosis of the upper limb depends on preservation or return of voluntary finger extension (FE) early after stroke. The present study aimed to determine the effects of modified constraint-induced movement therapy (mCIMT) and electromyography-triggered neuromuscular stimulation (EMG-NMS) on upper limb capacity early poststroke. Methods A total of 159 ischemic stroke patients were included: 58 patients with a favorable prognosis (>10° of FE) were randomly allocated to 3 weeks of mCIMT or usual care only; 101 patients with an unfavorable prognosis were allocated to 3-week EMG-NMS or usual care only. Both interventions started within 14 days poststroke, lasted up until 5 weeks, focused at preservation or return of FE. Results Upper limb capacity was measured with the Action Research Arm Test (ARAT), assessed weekly within the first 5 weeks poststroke and at postassessments at 8, 12, and 26 weeks. Clinically relevant differences in ARAT in favor of mCIMT were found after 5, 8, and 12 weeks poststroke (respectively, 6, 7, and 7 points; P < .05), but not after 26 weeks. We did not find statistically significant differences between mCIMT and usual care on impairment measures, such as the Fugl-Meyer assessment of the arm (FMA-UE). EMG-NMS did not result in significant differences. Conclusions Three weeks of early mCIMT is superior to usual care in terms of regaining upper limb capacity in patients with a favorable prognosis; 3 weeks of EMG-NMS in patients with an unfavorable prognosis is not beneficial. Despite meaningful improvements in upper limb capacity, no evidence was found that the time-dependent neurological improvements early poststroke are significantly influenced by either mCIMT or EMG-NMS.

A combination of constraint-induced therapy and motor control retraining in the treatment of focal hand dystonia in musicians: a long-term follow-up study.

UNLABELLED: Focal hand dystonia (FHD) in musicians is a painless, task-specific motor disorder characterized by involuntary loss of control of individual finger movements. The aim of this study was to investigate the long-term effects of a combined behavioral therapy intervention aimed at normalizing finger movement patterns. METHODS: Eight musicians with FHD had taken part in the 1-year study involving intensive constraint-induced therapy and motor control retraining at slow speed as the interventions. Four of these subjects volunteered to take part in this 4-year follow-up. A quasi-experimental, repeated measures design was used, with 9 testing sessions over 4 years. Video recordings of the subjects playing two pieces were used for data analysis. The Frequency of Abnormal Movements scale (FAM) was the main outcome measure. It was hypothesized that there would be significant differences in FAM scores achieved over the 4-year period. RESULTS: The results from the ANOVA revealed a significant decrease, by approximately 80%, in the number of abnormal movements for both pieces over the 4-year period (F=7.85, df=8, p<0.001). Tukey's post-hoc test revealed that significant improvements occurred after 6 months of therapy (p-values between p<0.001 and p=0.044). Although the results were not significant between month 12 and follow-up at year 4, the trend revealed that the progress achieved during the first year of intensive retraining was maintained at year 4. CONCLUSIONS: A 1-year period of intensive task-specific retraining may be a successful strategy with long-term, lasting effects for the treatment of musician's FHD. Results suggest that retraining strategies may need to be carried out for at least 6 months before statistically significant changes are noted.

Efficacy of constraint-induced therapy on functional performance and health-related quality of life for children with cerebral palsy: a randomized controlled trial.

To better generalize training effects to the context of daily living, home-based constraint-induced therapy has been proposed. Therapeutic success of constraint-induced therapy is limited as to whether the improvements in functional performance can be transferred to quality of life. This randomized controlled trial aimed to investigate the efficacy of home-based constraint-induced therapy on functional performance and health-related quality of life. Twenty-two children with spastic unilateral cerebral palsy (6-8 years, 10 boys) were randomly assigned to receive constraint-induced therapy or traditional rehabilitation. Home-based constraint-induced therapy had immediate and maintaining effects on motor efficacy and functional performance and induced greater gains in health-related quality of life in the long run than in the short term. The home-based constraint-induced therapy protocol (relatively moderate intensity and shortened constraint time), which might balance the effectiveness and compliance of participants and caregivers, may be an effective alternative to conventional constraint-induced therapy.

Bedrails and vulnerable older adults: how should nurses make 'safe and sound' decisions surrounding their use?

AIM AND OBJECTIVES: This paper examines the available evidence and uses ethical principles to answer how nurses should make safe and sound decisions surrounding the use of bedrails. BACKGROUND: Bedrails are frequently observed in practice. They are designed as safety devices but there is evidence of indiscriminate and misuse with vulnerable adults. METHODS: The OVID MEDLINE, BNI and CINAHL databases were searched using key words dignity or autonomy and old[er] or elder[s/ly]), people, adult[s], patient[s], client[s] or user[s], and bed rails, bed guards, cot sides or side rails (and associated variations). Additionally United Kingdom legislation, professional codes of practice and national patient safety agency resources were also searched. RESULTS: Bedrail use needs careful consideration. The published evidence can be confusing and contradictory. Nurses have a duty to provide care which promotes respect for patient's autonomy, integrity and dignity for which individualised assessment is essential. Additionally overt consideration of beneficence, non-maleficence and justice supports decision making. CONCLUSIONS: Protection and promotion of respect for autonomy, integrity and dignity especially with older adults must be evidenced in practice. The use of an ethical framework can enable nurses to make transparent and defensible decisions about the appropriate use of bedrails, thereby fulfilling professional, moral, and legal requirements. IMPLICATIONS FOR PRACTICE: Bedrail use has implications beyond falls prevention. Protection and promotion of respect for autonomy, integrity and dignity with older adults must be considered in decision-making. Physical safety must be assessed as part of a holistic assessment. Nurses may need support and training to ensure 'safe and sound' surrogate decision-making in practice.

Bimanual training and constraint-induced movement therapy in children with hemiplegic cerebral palsy: a randomized trial.

BACKGROUND: Constraint-induced movement therapy (CIMT) promotes hand function using intensive unimanual practice along with restraint of the less-affected hand. CIMT has not been compared with a treatment with equivalent dosing frequency and intensity in children with cerebral palsy (CP). OBJECTIVES: The authors report a randomized trial comparing CIMT and a bimanual intervention (hand-arm intensive bimanual therapy; HABIT) that maintains the intensity of practice associated with CIMT but where children are engaged in functional bimanual tasks. METHODS: A total of 42 participants with hemiplegic CP between the ages of 3.5 and 10 years (matched for age and hand function) were randomized to receive 90 hours of CIMT or an equivalent dosage of functional bimanual training (HABIT) conducted in day-camp environments. A physical therapist blinded to treatment allocation tested hand function before and after treatment. The primary outcomes were changes in Jebsen-Taylor Test of Hand Function (JTTHF) and Assisting Hand Assessment (AHA) scores. Secondary measures included the Goal Attainment Scale (GAS). RESULTS: Both the CIMT and HABIT groups demonstrated comparable improvement from the pretest to immediate posttest in the JTTHF and AHA (P < .0001), which were maintained at 6 months. GAS, however, revealed greater progress toward goals for the HABIT group (P < .0001), with continued improvement across test sessions for both groups (P < .0001). CONCLUSIONS: Both CIMT and bimanual training lead to similar improvements in hand function. A potential benefit of bimanual training is that participants may improve more on self-determined goals.

Randomized trial of constraint-induced movement therapy and bimanual training on activity outcomes for children with congenital hemiplegia.

AIM: To determine if constraint-induced movement therapy (CIMT) is more effective than bimanual training (BIM) in improving upper limb activity outcomes for children with congenital hemiplegia in a matched-pairs randomized trial. METHOD: Sixty-three children (mean age 10.2, SD 2.7, range 5-16 y; 33 males, 30 females), 16 in Manual Ability Classification System level I, 46 level II, and 1 level III and 16 in Gross Motor Function Classification level I, 47 level II) were randomly allocated to either CIMT or BIM group day camps (60 hours over 10 days). The Melbourne Assessment of Unilateral Upper Limb Function assessed unimanual capacity of the impaired limb and Assisting Hand Assessment evaluated bimanual coordination at baseline, 3 and 26 weeks, scored by blinded raters. RESULTS: After concealed random allocation, there was no baseline difference between groups. CIMT had superior outcomes compared with BIM for unimanual capacity at 26 weeks (estimated mean difference [EMD] 4.4, 95% confidence interval [CI] 2.2-6.7; p < 0.001). There was no other significant difference between groups post-intervention. Both groups demonstrated significant improvements in bimanual performance at 3 weeks, with gains maintained by BIM at 26 weeks (EMD 2.3; 95% CI 0.6-4.0; p = 0.008). Interpretation Overall, there were only small differences between the two training approaches. CIMT yielded greater changes in unimanual capacity of the impaired upper limb compared with BIM. Results generally reflect specificity of practice, with CIMT improving unimanual capacity and BIM improving bimanual performance. Considerable inter-individual variation in response to either intervention was evident. Future research should consider serial sequencing unimanual then BIM approaches to optimize upper limb outcomes for children with congenital hemiplegia.

Alternatives for hand over mouth exercise after its elimination from the clinical guidelines of the american academy of pediatric dentistry.

PURPOSE: The purpose of this study was to survey the alternative behavior management techniques that might be utilized by pediatric dentists in place of hand over mouth exercise (HOME) after its elimination from the clinical guidelines of the American Academy of Pediatric Dentistry (AAPD). METHODS: A questionnaire was electronically mailed to 2,600 AAPD members. The survey included items related to HOME alternatives after the elimination, concerns with its use, and if the elimination had affected access to care for children. RESULTS: Seven hundred four respondents (30%) completed the survey. Voice control was the first alternative, and minimum/moderate sedation was the second most common. Three hundred fifty respondents (50%) believed that HOME is an acceptable behavior management technique, and 290 (41%) believed it should be continued to be recognized by the AAPD. Only 7% believed that HOME elimination affected access to care for some children. CONCLUSION: Advanced behavior management techniques will be utilized more by pediatric dentists after the elimination of the hand over mouth exercise from the American Academy of Pediatric Dentistry's clinical guidelines.

Environmental enrichment and chronic restraint stress in ICR mice: effects on prepulse inhibition of startle and Y-maze spatial recognition memory.

In most studies regarding the improving or therapeutical effects induced by enriched environment (EE), EE was performed after the stress treatment or in patients with certain diseases. In the current study, the effects of chronic restraint stress (6h/day) in mice living in an enriched environment or standard environment (SE) were tested. Mice were randomly divided into 4 groups: non-stressed or stressed mice housed in SE or EE conditions (SE, stress+SE, EE, stress+EE). Prepulse inhibition (PPI) of startle was tested after the 2 weeks or 4 weeks stress and/or EE treatment and 1 or 2 weeks withdrawal from the 4 weeks treatment. After the 4 weeks treatment, spatial recognition memory in Y-maze was also tested. The results showed that EE increased PPI in stressed and non-stressed mice after 2 weeks treatment. No effect of EE on PPI was found after the 4 weeks treatment. 4 weeks chronic restraint stress increased PPI in mice housed in standard but not EE conditions. Stressed mice showed deficits on the 1h delay version of the Y-maze which could be prevented by living in an enriched environment. Our results indicated that living in an enriched environment reversed the impairing effects of chronic restraint stress on spatial recognition memory. However, EE did not change the effects of stress on PPI.

Ascorbic acid protects against restraint stress-induced memory deficits in Wistar rats.

OBJECTIVE: Chronic stress has been shown to cause oxidative damage in the central nervous system. Although stress-induced impairments in learning and memory have been studied extensively, very few studies have investigated possible ways to prevent their ill effects. The present work was designed to study the protective effects of ascorbic acid in memory loss induced by chronic restraint stress. METHODS: Adult male Wistar rats were designated into the following groups: (i) Normal control, (ii) Ascorbic acid treatment, (iii) Vehicle control, (iv) Restraint stress, (v) Restraint stress + vehicle, and (vi) Restraint stress + ascorbic acid treatment. At the end of 21 days, animals of all groups were subjected to memory tests using Morris water maze and passive avoidance apparatus. Then, the results obtained were compared between the experimental groups. RESULTS: Rats exposed to restraint stress alone and those pretreated with vehicle solution before restrained stress showed deficits in learning and impaired memory retention in the memory tests when compared to animals in other experimental groups. Animals pretreated with ascorbic acid before restraining showed significant improvement in memory retention in the same memory tests. CONCLUSIONS: Results of this study suggest the possibility of using ascorbic acid as a dietary supplement to prevent stress-induced memory impairments.

Pediatric constraint-induced movement therapy is associated with increased contralateral cortical activity on functional magnetic resonance imaging.

The mechanism behind constraint-induced movement therapy (constraint therapy) success is unknown. Study objectives were to evaluate cortical change after modified constraint therapy and explore a novel approach to quantify developmental disregard. Five participants underwent modified constraint therapy. Functional magnetic resonance imaging (MRI) and clinical measures were done pretreatment and posttreatment. Developmental disregard indices were calculated. Four participants showed clinical improvement posttreatment. Functional MRI laterality indices were variable pretreatment and exclusively contralateral among participants posttreatment. The disregard index range was -12.9 to 62.6 among participants. Disregard indices were correlated with change scores after treatment on the Pediatric Motor Activity Log amount of use domain (r = .93, P = .02), Assisting Hand Assessment (r = .93, P = .02), and grip strength (r = .92, P = .03). Study results suggest that a shift to or persistence of contralateral cortical activity for affected hand movement is important for constraint therapy mechanism of action; and developmental disregard may be a predictor of positive response to treatment.

Sex differences in stress-induced hyperthermia in rats: restraint versus confinement.

Studies using restraint to induce psychological stress consistently report the expected hyperthermic response in core body temperature (CBT), but many also report a hypothermic response that precedes the hyperthermia. To understand the conditions that produce hypothermia, and to study sex differences in stress-induced hyperthermia, we measured CBT in male and female rats at 70 and 180 days of age in response to two types of stressors: immobilization through restraint (Plexiglas restrainer) and confinement in a small area (circular wire mesh cylinders that allowed free airflow). Restraint early in the light period induced hypothermia only in 180-day-old males, with no hyperthermia observed during the 30-minute restraint period. Increases in humidity and temperature of the microenvironment due to the larger body weight at this age may contribute to the hypothermia. Hyperthermia during restraint in 70-day-old males was significantly attenuated and delayed in onset compared to the rise in females. All females exhibited a CBT rise of approximately 1.3 degrees C occurring 10-15 min after the onset of restraint. Restraint early in the dark period induced no significant change in CBT in males of either age during immobilization, while females exhibited a small rise of approximately 0.5 degrees C. Confinement early in the light period induced a significant rise of approximately 1.5 degrees C in all groups, with no preceding hypothermia. However, the male response was significantly delayed compared to females. Overall, these results indicate that CBT changes during restraint likely involve both anxiogenic and physiological components, while the marked hyperthermia during confinement is primarily psychological in both sexes.

Oral supplementation with melon superoxide dismutase extract promotes antioxidant defences in the brain and prevents stress-induced impairment of spatial memory.

The purpose of this study was to investigate the effect of antioxidant ingestion on stress-induced impairment of cognitive memory. Male C57BL/6 mice were divided into four groups as follows: (1) control mice (C mice) fed in a normal cage without immobilization; (2) restraint-stressed (RS mice) fed in a small cage; (3) vitamin E mice (VE mice), mice were fed in a small cage with a diet supplemented with vitamin E; (4) GliSODin mice (GS mice) fed in a small cage with a diet supplemented with GliSODin. RS, VE and GS mice were exposed to 12 h of immobilization daily. Five weeks later, spatial learning was measured using the Morris Water Maze (MWM) test. After water maze testing, we performed immunohistochemical analysis using 4-hydroxy-2-noneral (4-HNE) and an anti-Ki67 antibody. 4-HNE is a marker of lipid peroxidation. RS mice showed impaired spatial learning performance and an increased number of 4-HNE-positive cells in the granule cell layer (GCL) of the hippocampal dentate gyrus when compared to C mice. Moreover, RS mice showed a decreased number of Ki67-positive cells in the subgranular zone (SGZ). GS mice showed better spatial learning memory than RS mice. The number of 4-HNE-positive cells in the GCL of GS mice was significantly less than that of RS mice. The number of Ki67-positive cells in the SGZ of GS mice was significantly greater than that of RS mice. These finding suggests that GliSODin prevents stress-induced impairment of cognitive function and maintains neurogenesis in the hippocampus through antioxidant activity.

Involvement of thyroid hormones in the alterations of T-cell immunity and tumor progression induced by chronic stress.

BACKGROUND: Stress alters the neuroendocrine system, immunity, and cancer. Although the classic stress hormones are glucocorticoids and catecholamines, thyroid hormones have also been related to stress. We recently reported that chronic restraint stress impairs T-cell mediated immunity and enhances tumor growth in mice. METHODS: To study the participation of these hormones on the stress-induced alterations of the immune function and lymphoma growth, mice were subjected to acute or chronic stress, with or without thyroxin supplementation. Hormone levels, immune status, and cancer progression were evaluated. RESULTS: Differential endocrine alterations were observed in response to acute and chronic stress. Although corticosterone and noradrenaline levels were increased by acute stress, they were restored after prolonged exposure to the stressor. Instead, thyroid hormone levels were only reduced in chronically stressed animals in comparison with control subjects. Correlating, chronic but not acute stress impaired T-cell reactivity. Thyroxin replacement treatment of chronic restraint stress-exposed mice, which restored the euthyroid status, reversed the observed reduction of T-cell lymphoproliferative responses. Moreover, therapeutic thyroid replacement also reversed the alterations of lymphoma growth induced by chronic stress in syngeneic mice bearing tumors as well as Interleukin-2 production and specific cytotoxic response against tumor cells. Finally, we found that the isoforms theta and alpha of the protein kinase C are involved in these events. CONCLUSIONS: These results show for the first time that thyroid hormones are important neuroendocrine regulators of tumor evolution, most probably acting through the modulation of T-cell mediated immunity affected by chronic stress.

Possible therapeutic effect of a Traditional Chinese Medicine, Sinisan, on chronic restraint stress related disorders.

According to Traditional Chinese Medicine (TCM), the liver is the origin or most associated with stress related disorders such as depression. Sinisan, a TCM prescription, has been used as a hepatic protectant. We examined whether Sinisan exerts therapeutic effects in an experimental animal model: the chronic restraint stress (CRS) model. Sinisan was administered in the animal's drinking water at a concentration of 100mg/kg for 21 days (7 days pre-CRS and 14 days during the CRS). Spatial learning and memory were measured 24h after the CRS procedures using the Morris Water Maze (MWM). Aggressive behavior and body weight were determined as well. The Sinisan treatment decreased aggressive behaviors and reversed CRS-induced impairment of spatial learning and memory as well as decreased rate of growth. In conclusion, our results suggest that Sinisan does exert measurable therapeutic effects in an experimental chronic stress model.