The value of physical tests for subacromial impingement syndrome: a study of diagnostic accuracy.

OBJECTIVE: To determine the diagnostic accuracy of commonly used physical tests for subacromial impingement syndrome, using ultrasound as the reference standard. DESIGN: A cross-sectional study of 59 participants with chronic shoulder pain of more than four months duration with a referral for diagnostic ultrasound scanning were invited to participate in the study. MAIN MEASURES: Thirty-four participants met the inclusion criteria and had an ultrasound scan followed immediately by application of the following tests: Neer's sign, Hawkins and Kennedy test, painful arc of abduction, empty and full can tests, resisted isometric shoulder abduction and resisted isometric shoulder external rotation. Using the two-way contingency table method sensitivity, specificity, likelihood ratios and overall accuracy were calculated for each physical test. RESULTS: Diagnostic values for each test varied considerably. The Hawkins and Kennedy test was the most accurate test for diagnosing any degree of subacromial impingement syndrome (71.0%). The most accurate tests for diagnosing subcategories of impingement were pain on resisted external rotation and weakness during the full can test (63.6%) for presence of subdeltoid fluid, pain on resisted external rotation (58.8%) for partial thickness tears and the painful arc test (62.1%) for full thickness tears. CONCLUSIONS: As the predictive values of these tests are shown to be variable in this study it indicates that the clinical tests identified have limited use in informing diagnosis. Emphasis on the management of dysfunction may be more appropriate rather than reliance on clinical tests with inconclusive sensitivity and specificity if ultrasound scanning is not available.

Seated bilateral leg exercise effects on hemiparetic lower extremity function in chronic stroke.

BACKGROUND: Bilateral arm training with rhythmic auditory cueing (BATRAC) improves hemiparetic upper extremity (UE) function in stroke. It is unknown whether a similar exercise for the hemiparetic lower extremity (LE) is effective. OBJECTIVE: The authors sought to test whether the BATRAC strategy would transfer to the legs by improving LE motor function following ten 30-minute sessions of bilateral leg training with rhythmic auditory cueing (BLETRAC). METHODS: Twenty-four chronic stroke participants, recruited from the community, were randomized to either the BLETRAC or the BATRAC intervention. Assessments were performed before (week 0) and after (week 6) training as well as 3 months later (week 18). Change in the Fugl-Meyer LE and UE subscales served as primary outcomes. Timed 10-m walk, movement parameters during treadmill walking, and a repetitive aiming task for both feet and hands were the secondary outcomes. RESULTS: Following an intention-to-treat approach, data from 21 subjects were analyzed. After training, improvements in the Fugl-Meyer LE and UE subscales tended to be better for the corresponding intervention group. The BLETRAC group also showed increases in step length during treadmill walking and performance in the repetitive foot and hand aiming tasks. No differences between the intervention groups were found at follow-up. CONCLUSIONS: This exploratory trial demonstrates that transfer of the BATRAC approach to the legs is feasible. Transient improvements of limb motor function in chronic stroke participants were induced by targeted exercise (BATRAC for the UE and BLETRAC for the LE). It may be that further periods of training would increase and maintain effects.

Rehabilitation interventions for foot drop in neuromuscular disease.

BACKGROUND: "Foot drop" or "Floppy foot drop" is the term commonly used to describe weakness or contracture of the muscles around the ankle joint. It may arise from many neuromuscular diseases. OBJECTIVES: To conduct a systematic review of randomised trials for the treatment of foot drop resulting from neuromuscular disease. SEARCH STRATEGY: In this update, we searched the Cochrane Neuromuscular Disease Group Trials Register (April 2009), MEDLINE (January 1966 to April 24 2009), EMBASE January 1980 to April 24 2009), CINAHL (January 1982 to May 6 2009), AMED (January 1985 to April 24 2009), the British Nursing Index (January 1985 to January 2008) and Royal College of Nursing Journal of Databases (January 1985 to January 2008). SELECTION CRITERIA: Randomised and quasi-randomised trials of physical, orthotic and surgical treatments for foot drop resulting from lower motor neuron or muscle disease and related contractures were included. People with primary joint disease were excluded. Interventions included a 'wait and see' approach, physiotherapy, orthoses, surgery and pharmacological therapy. The primary outcome measure was quantified ability to walk whilst secondary outcome measures included range of movement, dorsiflexor torque and strength, measures of activity and participation, quality of life and adverse effects. DATA COLLECTION AND ANALYSIS: Methodological quality was evaluated by two authors using the van Tulder criteria. Four studies with a total of n = 152 participants were included in the update to the original review. Heterogeneity of the studies precluded pooling the data. MAIN RESULTS: Early surgery did not significantly affect walking speed in a trial including 20 children with Duchenne muscular dystrophy. Both groups deteriorated during the 12 months follow-up. After one year, the mean difference (MD) of the 28 feet walking time was 0.00 seconds (95% confidence interval (CI) -0.83 to 0.83) and the MD of the 150 feet walking time was -2.88 seconds, favouring the control group (95% CI -8.18 to 2.42). Night splinting of the ankle did not significantly affect muscle force or range of movement about the ankle in a trial of 26 participants with Charcot-Marie-Tooth disease. Improvements were observed in both the splinting and control groups. In a trial of 26 participants with Charcot-Marie-Tooth disease and 28 participants with myotonic dystrophy, 24 weeks of strength training significantly improved six-metre timed walk in the Charcot-Marie-Tooth group compared to the control group (MD 0.70 seconds, favouring strength training, 95% CI 0.23 to 1.17), but not in the myotonic dystrophy group (MD -0.20 seconds, favouring the control group, 95% CI -0.79 to 0.39). No significant differences were observed for the 50 metre timed walk in the Charcot-Marie-Tooth disease group (MD 1.90 seconds, favouring the training group, 95% CI -0.29 to 4.09) or the myotonic dystrophy group (MD -0.80 seconds, favouring the control group, 95% CI -5.29 to 3.69). In a trial of 65 participants with facioscapulohumeral muscular dystrophy, 26 weeks of strength training did not significantly affect ankle strength. After one year, the mean difference in maximum voluntary isometric contraction was -0.43 kg, favouring the control group (95%CI -2.49 to 1.63) and the mean difference in dynamic strength was 0.44 kg, favouring the training group (95%CI -0.89 to 1.77). AUTHORS' CONCLUSIONS: Only one study, involving people with Charcot-Marie-Tooth disease, demonstrated a statistically significant positive effect of strength training. No effect of strength training was found in people with either myotonic dystrophy or facioscapulohumeral muscular dystrophy. Surgery had no significant effect in children with Duchenne muscular dystrophy and night splinting of the ankle had no significant effect in people with Charcot-Marie-Tooth disease. More evidence generated by methodologically sound trials is required.

An exploratory cluster randomized controlled trial of group exercise on mobility and depression in care home residents.

OBJECTIVE: To investigate the feasibility, acceptability and potential efficacy of group exercise for residents in care homes. DESIGN: Exploratory cluster randomized controlled trial. SETTING: Five randomly selected care homes in South Birmingham, UK. PARTICIPANTS: Fifty-six care home residents (mean age 84.5, 71% female), 39 (70%) with cognitive impairments. INTERVENTION: Two homes (n = 28) were randomized to group exercise held twice weekly for five weeks. The remaining three homes (n = 28) formed the control group and received usual care, with no person specifically responsible for exercise training. OUTCOME MEASURES: Assessments were conducted at zero (pre-intervention), three (post-intervention) and six months (follow-up) using the Rivermead Mobility Index and Hospital Anxiety and Depression Scale or Stroke Aphasic Depression Questionnaire (depending on cognitive impairment). Adherence to group exercise and retention to the study were also documented. RESULTS: No statistically significant improvements in mobility or depression were found in favour of group exercise. Retention to the study was high with 46 (82%) participants completing all assessments. Adherence to group exercise was somewhat lower with participants attending a mean of 3.61 out of 8.5 prescribed sessions (42.5%). CONCLUSIONS: Group exercise can be delivered to care home residents with reduced mobility but it is not suitable for residents with severe cognitive impairment. An estimated sample size of 240 participants would be required to detect a clinically significant difference in the Rivermead Mobility Index with 90% power.

The prevalence of joint contractures, pressure sores, painful shoulder, other pain, falls, and depression in the year after a severely disabling stroke.

BACKGROUND AND PURPOSE: Complications after stroke have been shown to impede rehabilitation, lead to poor functional outcome, and increase cost of care. This inception cohort study sought to investigate the prevalence of immobility-related complications during the first year after severely disabling stroke in relation to functional independence and place of residence. METHODS: Over a 7-month period, 600 stroke survivors were identified in the hospital through the Nottingham Stroke Register. Those who had a Barthel Index score

Short-term effects on mobility, activities of daily living and health-related quality of life of a Conductive Education programme for adults with multiple sclerosis, Parkinson's disease and stroke.

OBJECTIVE: To evaluate the impact of 10 sessions of Conductive Education on mobility, functional independence and health-related quality of life in adults with multiple sclerosis, Parkinson's disease and stroke. DESIGN: Observational, pretest-posttest design. SETTING: The National Institute of Conductive Education, Birmingham, UK. PARTICIPANTS: One hundred and twenty-nine self-referred community-living individuals with moderate disability. INTERVENTION: Following an individual consultation, participants attended 10 diagnostic-specific group sessions of Conductive Education, scheduled daily or less commonly weekly. OUTCOME MEASURES: All participants were assessed using the Barthel Index and the Nottingham Extended Activities of Daily living Index. Stroke, multiple sclerosis and Parkinson's disease patients also completed the Short Form 36 (SF-36) Health Survey, the Multiple Sclerosis Quality of Life 54 questionnaire (MSQoL-54) and the Parkinson's Disease Questionnaire (PDQ-39) respectively. RESULTS: One hundred and five individuals completed the programme as well as all pre and post-assessments. Of these, 34 had suffered a stroke, 55 had Parkinson's disease and 16 had multiple sclerosis. Stroke patients demonstrated statistically significant improvements in the Nottingham Extended Activities of Daily living Index (mean change 3.4, P<0.001) and the SF-36 mental health subsection (mean change 7.8, P<0.001). Non-significant trends towards improved physical and mental function were demonstrated by other outcome measures across all three diagnoses. CONCLUSIONS: The results emphasize potential benefits of Conductive Education for individuals with stroke. The results will inform further randomized comparisons of the effects of Conductive Education in neurologically disabled people.