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1.
Br J Psychiatry ; : 1-8, 2019 Oct 24.
Artigo em Inglês | MEDLINE | ID: mdl-31647041

RESUMO

BACKGROUND: There is strong public belief that polyunsaturated fats protect against and ameliorate depression and anxiety. AIMS: To assess effects of increasing omega-3, omega-6 or total polyunsaturated fat on prevention and treatment of depression and anxiety symptoms. METHOD: We searched widely (Central, Medline and EMBASE to April 2017, trial registers to September 2016, ongoing trials updated to August 2019), including trials of adults with or without depression or anxiety, randomised to increased omega-3, omega-6 or total polyunsaturated fat for ≥24 weeks, excluding multifactorial interventions. Inclusion, data extraction and risk of bias were assessed independently in duplicate, and authors contacted for further data. We used random-effects meta-analysis, sensitivity analyses, subgrouping and Grading of Recommendations, Assessment, Development and Evaluations (GRADE) assessment. RESULTS: We included 31 trials assessing effects of long-chain omega-3 (n = 41 470), one of alpha-linolenic acid (n = 4837), one of total polyunsaturated fat (n = 4997) and none of omega-6. Meta-analysis suggested that increasing long-chain omega-3 probably has little or no effect on risk of depression symptoms (risk ratio 1.01, 95% CI 0.92-1.10, I2 = 0%, median dose 0.95 g/d, duration 12 months) or anxiety symptoms (standardised mean difference 0.15, 95% CI 0.05-0.26, I2 = 0%, median dose 1.1 g/d, duration 6 months; both moderate-quality evidence). Evidence of effects on depression severity and remission in existing depression were unclear (very-low-quality evidence). Results did not differ by risk of bias, omega-3 dose, duration or nutrients replaced. Increasing alpha-linolenic acid by 2 g/d may increase risk of depression symptoms very slightly over 40 months (number needed to harm, 1000). CONCLUSIONS: Long-chain omega-3 supplementation probably has little or no effect in preventing depression or anxiety symptoms. DECLARATION OF INTEREST: L.H. and A.A. were funded to attend the World Health Organization Nutrition Guidance Expert Advisory Group (NUGAG) Subgroup on Diet and Health meetings and present review results. The authors report no other conflicts of interest.

2.
BMJ Open ; 9(5): e029554, 2019 May 24.
Artigo em Inglês | MEDLINE | ID: mdl-31129605

RESUMO

OBJECTIVE: To create a database of long-term randomised controlled trials (RCTs) comparing higher with lower omega-3, omega-6 or total polyunsaturated fatty acid (PUFA), regardless of reported outcomes, and to develop methods to assess effects of increasing omega-6, alpha-linolenic acid (ALA), long-chain omega-3 (LCn3) and total PUFA on health outcomes. DESIGN: Systematic review search, methodology and meta-analyses. DATA SOURCES: Medline, Embase, CENTRAL, WHO International Clinical Trials Registry Platform, Clinicaltrials.gov and trials in relevant systematic reviews. ELIGIBILITY CRITERIA: RCTs of ≥24 weeks' duration assessing effects of increasing ALA, LCn3, omega-6 or total PUFAs, regardless of outcomes reported. DATA SYNTHESIS: Methods included random-effects meta-analyses and sensitivity analyses. Funnel plots were examined, and subgrouping assessed effects of intervention type, replacement, baseline diabetes risk and use of diabetic medications, trial duration and dose. Quality of evidence was assessed using Grading of Recommendations Assessment, Development and Evaluation (GRADE). RESULTS: Electronic searches generated 37 810 hits, de-duplicated to 19 772 titles and abstracts. We assessed 2155 full-text papers, conference abstracts and trials registry entries independently in duplicate. Included studies were grouped into 363 RCTs comparing higher with lower omega-3, omega-6 and/or total PUFA intake of at least 6 months' duration-the Database.Of these 363 included RCTs, 216 RCTs were included in at least one of our reviews of health outcomes, data extracted and risk of bias assessed in duplicate. Ninety five RCTs were included in the Database but not included in our current reviews. Of these 311 completed trials, 27 altered ALA intake, 221 altered LCn3 intake and 16 trials altered omega-3 intake without specifying whether ALA or LCn3. Forty one trials altered omega-6 and 59 total PUFA.The remaining 52 trials are ongoing though 13 (25%) appear to be outstanding, or constitute missing data. CONCLUSIONS: This extensive database of trials is available to allow assessment of further health outcomes.

3.
BMC Health Serv Res ; 18(1): 346, 2018 05 10.
Artigo em Inglês | MEDLINE | ID: mdl-29743064

RESUMO

BACKGROUND: Self-administration of medicines by patients whilst in hospital is being increasingly promoted despite little evidence to show the risks and benefits. Pain control after total knee replacement (TKR) is known to be poor. The aim of the study was to determine if patients operated on with a TKR who self-medicate their oral analgesics in the immediate post-operative period have better pain control than those who receive their pain control by nurse-led drug rounds (Treatment as Usual (TAU)). METHODS: A prospective, parallel design, open-label, randomised controlled trial comparing pain control in patient-directed self-management of pain (PaDSMaP) with nurse control of oral analgesia (TAU) after a TKR. Between July 2011 and March 2013, 144 self-medicating adults were recruited at a secondary care teaching hospital in the UK. TAU patients (n = 71) were given medications by a nurse after their TKR. PaDSMaP patients (n = 73) took oral medications for analgesia and co-morbidities after two 20 min training sessions reinforced with four booklets. Primary outcome was pain (100 mm visual analogue scale (VAS)) at 3 days following TKR surgery or at discharge (whichever came soonest). Seven patients did not undergo surgery for reasons unrelated to the study and were excluded from the intention-to-treat (ITT) analysis. RESULTS: ITT analysis did not detect any significant differences between the two groups' pain scores. A per protocol (but underpowered) analysis of the 60% of patients able to self-medicate found reduced pain compared to the TAU group at day 3/discharge, (VAS -9.9 mm, 95% CI -18.7, - 1.1). One patient in the self-medicating group over-medicated but suffered no harm. CONCLUSION: Self-medicating patients did not have better (lower) pain scores compared to the nurse-managed patients following TKR. This cohort of patients were elderly with multiple co-morbidities and may not be the ideal target group for self-medication. TRIAL REGISTRATION: ISRCTN10868989 . Registered 22 March 2012, retrospectively registered.


Assuntos
Artroplastia do Joelho/efeitos adversos , Dor Pós-Operatória/prevenção & controle , Administração Oral , Idoso , Analgesia Controlada pelo Paciente/métodos , Analgesia Controlada pelo Paciente/enfermagem , Analgésicos/administração & dosagem , Feminino , Hospitalização , Hospitais de Ensino , Humanos , Masculino , Manejo da Dor/métodos , Manejo da Dor/enfermagem , Medição da Dor/enfermagem , Dor Pós-Operatória/enfermagem , Estudos Prospectivos , Autoadministração , Autogestão/métodos , Resultado do Tratamento
4.
Arthritis Care Res (Hoboken) ; 70(7): 1064-1073, 2018 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-29409110

RESUMO

OBJECTIVE: Functional ability and participation in life situations are compromised in many primary Sjögren's syndrome (SS) patients. This study aimed to identify the key barriers and priorities to participation in daily living activities, in order to develop potential future interventions. METHODS: Group concept mapping, a semiquantitative, mixed-methods approach was used to identify and structure ideas from UK primary SS patients, adult household members living with a primary SS patient, and health care professionals. Brainstorming generated ideas, which were summarized into a final set of statements. Participants individually arranged these statements into themes and rated each statement for importance. Multidimensional scaling and hierarchical cluster analysis were applied to sorted and rated data to produce visual representations of the ideas (concept maps), enabling identification of agreed priority areas for interventions. RESULTS: A total of 121 patients, 43 adult household members, and 67 health care professionals took part. In sum, 463 ideas were distilled down to 94 statements. These statements were grouped into 7 clusters: Patient Empowerment, Symptoms, Wellbeing, Access and Coordination of Health Care, Knowledge and Support, Public Awareness and Support, and Friends and Family. Patient Empowerment and Symptoms were rated as priority conceptual themes. Important statements within priority clusters indicate patients should be taken seriously and supported to self-manage symptoms of oral and ocular dryness, fatigue, pain, and poor sleep. CONCLUSION: Our data highlighted the fact that in addition to managing primary SS symptoms, interventions aiming to improve patient empowerment, general wellbeing, access to health care, patient education, and social support are important to facilitate improved participation in daily living activities.

5.
BMJ Open ; 7(5): e014642, 2017 05 29.
Artigo em Inglês | MEDLINE | ID: mdl-28554918

RESUMO

OBJECTIVE: To assess associations between cognitive status, intelligibility, acoustics and functional communication in PD. DESIGN: Cross-sectional exploratory study of functional communication, including a within-participants experimental design for listener assessment. SETTING: A major academic medical centre in the East of England, UK. PARTICIPANTS: Questionnaire data were assessed for 45 people with Parkinson's disease (PD), who had self-reported speech or communication difficulties and did not have clinical dementia. Acoustic and listener analyses were conducted on read and conversational speech for 20 people with PD and 20 familiar conversation partner controls without speech, language or cognitive difficulties. MAIN OUTCOME MEASURES: Functional communication assessed by the Communicative Participation Item Bank (CPIB) and Communicative Effectiveness Survey (CES). RESULTS: People with PD had lower intelligibility than controls for both the read (mean difference 13.7%, p=0.009) and conversational (mean difference 16.2%, p=0.04) sentences. Intensity and pause were statistically significant predictors of intelligibility in read sentences. Listeners were less accurate identifying the intended emotion in the speech of people with PD (14.8% point difference across conditions, p=0.02) and this was associated with worse speaker cognitive status (16.7% point difference, p=0.04). Cognitive status was a significant predictor of functional communication using CPIB (F=8.99, p=0.005, η2 = 0.15) but not CES. Intelligibility in conversation sentences was a statistically significant predictor of CPIB (F=4.96, p=0.04, η2 = 0.19) and CES (F=13.65, p=0.002, η2 = 0.43). Read sentence intelligibility was not a significant predictor of either outcome. CONCLUSIONS: Cognitive status was an important predictor of functional communication-the role of intelligibility was modest and limited to conversational and not read speech. Our results highlight the importance of focusing on functional communication as well as physical speech impairment in speech and language therapy (SLT) for PD. Our results could inform future trials of SLT techniques for PD.


Assuntos
Doença de Parkinson/complicações , Doença de Parkinson/psicologia , Distúrbios da Fala/etiologia , Distúrbios da Fala/psicologia , Idoso , Cognição , Estudos Transversais , Inglaterra , Feminino , Humanos , Linguagem , Terapia da Linguagem , Modelos Lineares , Masculino , Pessoa de Meia-Idade , Escalas de Graduação Psiquiátrica , Inteligibilidade da Fala , Fonoterapia , Inquéritos e Questionários
6.
Rheumatology (Oxford) ; 56(4): 570-580, 2017 04 01.
Artigo em Inglês | MEDLINE | ID: mdl-28013207

RESUMO

Objectives: To identify whether sleep disturbances are more prevalent in primary SS (pSS) patients compared with the general population and to recognize which specific sleep symptoms are particularly problematic in this population. Methods: Electronic searches of the literature were conducted in PubMed, Medline (Ovid), Embase (Ovid), PsychINFO (Ovid) and Web of Science and the search strategy registered a priori . Titles and abstracts were reviewed by two authors independently against a set of prespecified inclusion/exclusion criteria, reference lists were examined and a narrative synthesis of the included articles was conducted. Results: Eight whole-text papers containing nine separate studies met the inclusion criteria and were included in the narrative analysis. Few of these studies met all of the quality assessment criteria. The studies used a range of self-reported measures and objective measures, including polysomnography. Mixed evidence was obtained for some of the individual sleep outcomes, but overall compared with controls, pSS patients reported greater subjective sleep disturbances and daytime somnolence and demonstrated more night awakenings and pre-existing obstructive sleep apnoea. Conclusions: A range of sleep disturbances are commonly reported in pSS patients. Further polysomnography studies are recommended to confirm the increased prevalence of night awakenings and obstructive sleep apnoea in this patient group. pSS patients with excessive daytime somnolence should be screened for co-morbid sleep disorders and treated appropriately. Interventions targeted at sleep difficulties in pSS, such as cognitive behavioural therapy for insomnia and nocturnal humidification devices, have the potential to improve quality of life in this patient group and warrant further investigation.


Assuntos
Síndrome de Sjogren/complicações , Transtornos do Sono-Vigília/etiologia , Terapia Cognitivo-Comportamental/métodos , Estudos Epidemiológicos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Polissonografia , Qualidade de Vida , Transtornos do Sono-Vigília/epidemiologia , Transtornos do Sono-Vigília/terapia
7.
J Parkinsons Dis ; 6(3): 453-62, 2016 03 16.
Artigo em Inglês | MEDLINE | ID: mdl-27003782

RESUMO

BACKGROUND: Communication is fundamental to human interaction and the development and maintenance of human relationships and is frequently affected in Parkinson's disease (PD). However, research and clinical practice have both tended to focus on impairment rather than participation aspects of communicative deficit in PD. In contrast, people with PD have reported that it is these participation aspects of communication that are of greatest concern to them rather than physical speech impairment. OBJECTIVE: To systematically review the existing body of evidence regarding the association between cognitive status and/or intelligibility and everyday communication in PD. METHODS: Five online databases were systematically searched in May 2015 (Medline Ovid, EMBASE, AMED, PsycINFO and CINAHL) and supplementary searches were also conducted. Two reviewers independently evaluated retrieved records for inclusion and then performed data extraction and quality assessment using standardised forms. Articles were eligible for inclusion if they were English-language original peer-reviewed research articles, book chapters or doctoral theses investigating the associations between at least one of cognitive status and level of intelligibility impairment and an everyday communication outcome in human participants with PD. RESULTS: 4816 unique records were identified through database searches with 16 additional records identified through supplementary searches. 41 articles were suitable for full-text screening and 15 articles (12 studies) met the eligibility criteria. 10 studies assessed the role of cognitive status and 9 found that participants with greater cognitive impairment had greater everyday communication difficulties. 4 studies assessed the role of intelligibility and all found that participants with greater intelligibility impairment had greater everyday communication difficulties, although effects were often weak and not consistent. CONCLUSIONS: Both cognitive status and intelligibility may be associated with everyday communicative outcomes in PD. The contribution of intelligibility to everyday communication appears to be of small magnitude, suggesting that other factors beyond predominantly motor-driven impairment-level changes in intelligibility may play an important role in everyday communication difficulties in PD.


Assuntos
Disfunção Cognitiva/etiologia , Transtornos da Comunicação/etiologia , Doença de Parkinson/complicações , Inteligibilidade da Fala , Humanos
8.
J Huntingtons Dis ; 4(3): 261-70, 2015.
Artigo em Inglês | MEDLINE | ID: mdl-26444023

RESUMO

BACKGROUND: The complex effects of Huntington's disease (HD) negatively impact on every area of independent living. The perspectives of people impacted by HD on how to best manage the disease are not clearly understood. OBJECTIVE: To identify what is most helpful for living with HD from the perspectives of people with HD, family caregivers and health professionals. METHODS: A cross-sectional, mixed methods concept mapping methodology was used. Participants generated statements during brainstorming in response to the question 'what helps people with HD live with their condition'. Participants then prioritised statements for importance and they grouped together statements that were related into clusters. Concept mapping software ('Ariadne' ®) used multi-dimensional scaling and hierarchical cluster analysis to produce a conceptual framework of participants views about what is helpful for people living with HD. RESULTS: Thirty nine people at various stages of HD disease progression, 48 family caregivers and 39 health professionals with experience of HD care (n = 126) participated. The most helpful factors for living with HD were identified as access to expert assessment and treatment for co-morbid mental health problems, integrated specialist multi-disciplinary HD expertise, and the provision of flexible care. CONCLUSIONS: HD requires specialist, expert, multidisciplinary care teams to manage it well. Specialists need to focus on the mental health aspects, and the provision must be flexible and responsive to current needs. Patients may have impaired insight into their abilities (e.g. driving) or the need for interventions, so carers' opinions should also be respected.


Assuntos
Adaptação Psicológica , Atitude do Pessoal de Saúde , Cuidadores/psicologia , Doença de Huntington/psicologia , Estudos Transversais , Humanos , Pesquisa Qualitativa , Inquéritos e Questionários
9.
Rheumatology (Oxford) ; 54(11): 2025-32, 2015 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-26135587

RESUMO

OBJECTIVE: To evaluate the effects of non-pharmacological interventions for primary SS (pSS) on outcomes falling within the World Health Organization International Classification of Functioning Disability and Health domains. METHODS: We searched the following databases from inception to September 2014: Cochrane Database of Systematic Reviews; Medline; Embase; PsychINFO; CINAHL; and clinical trials registers. We included randomized controlled trials of any non-pharmacological intervention. Two authors independently reviewed titles and abstracts against the inclusion/exclusion criteria and independently assessed trial quality and extracted data. RESULTS: A total of 1463 studies were identified, from which 17 full text articles were screened and 5 studies were included in the review; a total of 130 participants were randomized. The included studies investigated the effectiveness of an oral lubricating device for dry mouth, acupuncture for dry mouth, lacrimal punctum plugs for dry eyes and psychodynamic group therapy for coping with symptoms. Overall, the studies were of low quality and at high risk of bias. Although one study showed punctum plugs to improve dry eyes, the sample size was relatively small. CONCLUSION: Further high-quality studies to evaluate non-pharmacological interventions for PSS are needed.


Assuntos
Terapia por Acupuntura , Equipamentos e Provisões , Psicoterapia Psicodinâmica , Síndrome de Sjogren/terapia , Humanos , Qualidade de Vida , Ensaios Clínicos Controlados Aleatórios como Assunto , Resultado do Tratamento
10.
BMJ Open ; 4(12): e006434, 2014 Dec 14.
Artigo em Inglês | MEDLINE | ID: mdl-25500772

RESUMO

OBJECTIVES: This priority setting partnership was commissioned by Parkinson's UK to encourage people with direct and personal experience of the condition to work together to identify and prioritise the top 10 evidential uncertainties that impact on everyday clinical practice for the management of Parkinson's disease (PD). SETTING: The UK. PARTICIPANTS: Anyone with experience of PD including: people with Parkinson's (PwP), carers, family and friends, healthcare and social care professionals. Non-clinical researchers and employees of pharmaceutical or medical devices companies were excluded. 1000 participants (60% PwP) provided ideas on research uncertainties, 475 (72% PwP) initially prioritised them and 27 (37% PwP) stakeholders agreed a final top 10. METHODS: Using a modified nominal group technique, participants were surveyed to identify what issues for the management of PD needed research. Unique research questions unanswered by current evidence were identified and participants were asked to identify their top 10 research priorities from this list. The top 26 uncertainties were presented to a consensus meeting with key stakeholders to agree the top 10 research priorities. RESULTS: 1000 participants provided 4100 responses, which contained 94 unique unanswered research questions that were initially prioritised by 475 participants. A consensus meeting with 27 stakeholders agreed the top 10 research priorities. The overarching research aspiration was an effective cure for PD. The top 10 research priorities for PD management included the need to address motor symptoms (balance and falls, and fine motor control), non-motor symptoms (sleep and urinary dysfunction), mental health issues (stress and anxiety, dementia and mild cognitive impairments), side effects of medications (dyskinesia) and the need to develop interventions specific to the phenotypes of PD and better monitoring methods. CONCLUSIONS: These research priorities identify crucial gaps in the existing evidence to address everyday practicalities in the management of the complexities of PD.


Assuntos
Assistência à Saúde , Gerenciamento Clínico , Prioridades em Saúde , Doença de Parkinson/terapia , Pesquisa , Cuidadores , Consenso , Coleta de Dados , Família , Amigos , Pessoal de Saúde , Necessidades e Demandas de Serviços de Saúde , Humanos , Doença de Parkinson/complicações , Pacientes , Reino Unido
11.
BMJ Open ; 4(8): e006264, 2014 Aug 21.
Artigo em Inglês | MEDLINE | ID: mdl-25146718

RESUMO

INTRODUCTION: A significant proportion of patients with primary Sjögren's syndrome (PSS) is functionally impaired and experience difficulties participating in various aspects of everyday life. There is currently no evidence of efficacy for non-pharmacological interventions aimed specifically at supporting the patients with PSS to improve their participation and ability to perform daily activities. This paper describes a research protocol for a mixed-methods study to develop an intervention to improve these outcomes. The protocol follows the Medical Research Council framework for complex interventions. METHODS AND ANALYSIS: We will use group concept mapping with the patients, adults who live with them and healthcare professionals to identify factors which prevent people with PSS from participating in daily life and performing daily activities. The factors will be prioritised by participants for importance and feasibility and will inform an intervention to be delivered within a National Health Service (NHS) setting. Evidence-based intervention techniques will be identified for the prioritised factors and combined into a deliverable intervention package. Key stakeholders will comment on the intervention content and mode of delivery through focus groups, and the data will be used to refine the intervention. The acceptability and feasibility of the refined intervention will be evaluated in a future study. ETHICS AND DISSEMINATION: The study has been approved by an NHS Research Ethics Committee, REC Reference: 13/NI/0190. The findings of this study will be disseminated in peer-reviewed journals and through presentation at national and international conferences. TRIAL REGISTRATION NUMBER: UKCRN Study ID: 15939.


Assuntos
Atividades Cotidianas , Qualidade de Vida , Síndrome de Sjogren/terapia , Análise Custo-Benefício , Pessoal de Saúde , Humanos , Projetos de Pesquisa
12.
Cochrane Database Syst Rev ; (6): CD002815, 2014 Jun 17.
Artigo em Inglês | MEDLINE | ID: mdl-24936965

RESUMO

BACKGROUND: Despite medical therapies and surgical interventions for Parkinson's disease (PD), patients develop progressive disability. The role of physiotherapy is to maximise functional ability and minimise secondary complications through movement rehabilitation within a context of education and support for the whole person. The overall aim is to optimise independence, safety and wellbeing, thereby enhancing quality of life. Trials have shown that physiotherapy has short-term benefits in PD. However, which physiotherapy intervention is most effective remains unclear. OBJECTIVES: To assess the effectiveness of one physiotherapy intervention compared with a second approach in patients with PD. SEARCH METHODS: Relevant trials were identified by electronic searches of numerous literature databases (for example MEDLINE, EMBASE) and trial registers, plus handsearching of major journals, abstract books, conference proceedings and reference lists of retrieved publications. The literature search included trials published up to the end of January 2012. SELECTION CRITERIA: Randomised controlled trials of one physiotherapy intervention versus another physiotherapy intervention in patients with PD. DATA COLLECTION AND ANALYSIS: Data were abstracted independently from each paper by two authors. Trials were classified into the following intervention comparisons: general physiotherapy, exercise, treadmill training, cueing, dance and martial arts. MAIN RESULTS: A total of 43 trials were identified with 1673 participants. All trials used small patient numbers (average trial size of 39 participants); the methods of randomisation and concealment of allocation were poor or not stated in most trials. Blinded assessors were used in just over half of the trials and only 10 stated that they used intention-to-treat analysis.A wide variety of validated and customised outcome measures were used to assess the effectiveness of physiotherapy interventions. The most frequently reported physiotherapy outcomes were gait speed and timed up and go, in 19 and 15 trials respectively. Only five of the 43 trials reported data on falls (12%). The motor subscales of the Unified Parkinson's Disease Rating Scale and Parkinson's Disease Questionnaire-39 were the most commonly reported clinician-rated disability and patient-rated quality of life outcome measures, used in 22 and 13 trials respectively. The content and delivery of the physiotherapy interventions varied widely in the trials included within this review, so no quantitative meta-analysis could be performed. AUTHORS' CONCLUSIONS: Considering the small number of participants examined, the methodological flaws in many of the studies, the possibility of publication bias, and the variety of interventions, formal comparison of the different physiotherapy techniques could not be performed. There is insufficient evidence to support or refute the effectiveness of one physiotherapy intervention over another in PD.This review shows that a wide range of physiotherapy interventions to treat PD have been tested . There is a need for more specific trials with improved treatment strategies to underpin the most appropriate choice of physiotherapy intervention and the outcomes measured.


Assuntos
Doença de Parkinson/reabilitação , Modalidades de Fisioterapia , Marcha/fisiologia , Humanos , Ensaios Clínicos Controlados Aleatórios como Assunto
13.
Cochrane Database Syst Rev ; (9): CD002817, 2013 Sep 10.
Artigo em Inglês | MEDLINE | ID: mdl-24018704

RESUMO

BACKGROUND: Despite medical therapies and surgical interventions for Parkinson's disease (PD), patients develop progressive disability. Physiotherapy aims to maximise functional ability and minimise secondary complications through movement rehabilitation within a context of education and support for the whole person. The overall aim is to optimise independence, safety, and well-being, thereby enhancing quality of life. OBJECTIVES: To assess the effectiveness of physiotherapy intervention compared with no intervention in patients with PD. SEARCH METHODS: We identified relevant trials by conducting electronic searches of numerous literature databases (e.g. MEDLINE, EMBASE) and trial registers, and by handsearching major journals, abstract books, conference proceedings, and reference lists of retrieved publications. The literature search included trials published up to the end of January 2012. SELECTION CRITERIA: Randomised controlled trials of physiotherapy intervention versus no physiotherapy intervention in patients with PD. DATA COLLECTION AND ANALYSIS: Two review authors independently extracted data from each article. We used standard meta-analysis methods to assess the effectiveness of physiotherapy intervention compared with no physiotherapy intervention. Trials were classified into the following intervention comparisons: general physiotherapy, exercise, treadmill training, cueing, dance, and martial arts. We used tests for heterogeneity to assess for differences in treatment effect across these different physiotherapy interventions. MAIN RESULTS: We identified 39 trials with 1827 participants. We considered the trials to be at a mixed risk of bias as the result of unreported allocation concealment and probable detection bias. Compared with no intervention, physiotherapy significantly improved the gait outcomes of speed (mean difference 0.04 m/s, 95% confidence interval (CI) 0.02 to 0.06, P = 0.0002); two- or six-minute walk test (13.37 m, 95% CI 0.55 to 26.20, P = 0.04) and Freezing of Gait questionnaire (-1.41, 95% CI -2.63 to -0.19, P = 0.02); functional mobility and balance outcomes of Timed Up & Go test (-0.63 s, 95% CI -1.05 to -0.21, P = 0.003), Functional Reach Test (2.16 cm, 95% CI 0.89 to 3.43, P = 0.0008), and Berg Balance Scale (3.71 points, 95% CI 2.30 to 5.11, P < 0.00001); and clinician-rated disability using the Unified Parkinson's Disease Rating Scale (UPDRS) (total -6.15 points, 95% CI-8.57 to -3.73, P < 0.00001; activities of daily living: -1.36, 95% CI -2.41 to -0.30, P = 0.01; and motor: -5.01, 95% CI -6.30 to -3.72, P < 0.00001). No difference between arms was noted in falls (Falls Efficacy Scale: -1.91 points, 95% CI -4.76 to 0.94, P = 0.19) or patient-rated quality of life (PDQ-39 Summary Index: -0.38 points, 95% CI -2.58 to 1.81, P = 0.73). One study reported that adverse events were rare; no other studies reported data on this outcome. Indirect comparisons of the different physiotherapy interventions revealed no evidence that the treatment effect differed across physiotherapy interventions for any of the outcomes assessed. AUTHORS' CONCLUSIONS: Benefit for physiotherapy was found in most outcomes over the short term (i.e. < 3 months) but was significant only for speed, two- or six-minute walk test, Freezing of Gait questionnaire, Timed Up & Go, Functional Reach Test, Berg Balance Scale, and clinician-rated UPDRS. Most of the observed differences between treatments were small. However, for some outcomes (e.g. speed, Berg Balance Scale, UPDRS), the differences observed were at, or approaching, what are considered minimal clinically important changes. These benefits should be interpreted with caution because the quality of most of the included trials was not high. Variation in measurements of outcome between studies meant that our analyses include a small proportion of the participants recruited.This review illustrates that a wide range of approaches are employed by physiotherapists to treat patients with PD. However, no evidence of differences in treatment effect was noted between the different types of physiotherapy interventions being used, although this was based on indirect comparisons. A consensus menu of 'best practice' physiotherapy is needed, as are large, well-designed randomised controlled trials undertaken to demonstrate the longer-term efficacy and cost-effectiveness of 'best practice' physiotherapy in PD.


Assuntos
Doença de Parkinson/reabilitação , Modalidades de Fisioterapia , Atividades Cotidianas , Marcha , Humanos , Qualidade de Vida , Ensaios Clínicos Controlados Aleatórios como Assunto , Caminhada , Conduta Expectante
14.
J Clin Nurs ; 22(13-14): 2039-52, 2013 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-23441835

RESUMO

AIMS AND OBJECTIVES: To investigate the experience of non-compliant hypertensive patients who had received seven sessions of adherence therapy (AT) as part of a randomised controlled trial. BACKGROUND: AT is a patient-centred approach used to explore patient attitudes, beliefs and discrepancy toward medications that aimed to enhance patients' medication-taking behaviour. DESIGN: Qualitative analysis of semi-structured interviews with patients who had completed an AT intervention. METHODS: A convenience sample of 10 hypertensive patients who received AT as part of an exploratory randomised controlled trial (ISRCTN99494659) were included. Thematic analysis of semi-structured interviews exploring patient's views and experiences of AT was used. RESULTS: Five major themes of AT emerged; modifying attitudes and beliefs, positive impact on self efficacy, therapist motivation, positive impact on well-being and a well-designed intervention. CONCLUSIONS: patients' views about the benefit of AT were entirely consistent with our proposed mechanism of action for this intervention; that is by improving patient's beliefs and attitudes regarding taking drugs, and finding solutions to barriers that prevent adherence, patients become more complaint with their medication which in turn has a positive impact on clinical outcomes [i.e. blood pressure, hypertension complication (stroke, myocardial infarction, and recurrent hospitalisation)]. RELEVANCE TO CLINICAL PRACTICE: Exploring patients' experience with AT and recognising these five elements help in tailoring a new effective strategy according to individual needs for enhancing adherence to prescribed drugs.


Assuntos
Anti-Hipertensivos/uso terapêutico , Hipertensão/tratamento farmacológico , Cooperação do Paciente , Atitude Frente a Saúde , Humanos , Hipertensão/psicologia , Motivação , Pesquisa Qualitativa , Autoeficácia
15.
BMJ ; 345: e5004, 2012 Aug 06.
Artigo em Inglês | MEDLINE | ID: mdl-22867913

RESUMO

OBJECTIVE: To assess the effectiveness of physiotherapy compared with no intervention in patients with Parkinson's disease. DESIGN: Systematic review and meta-analysis of randomised controlled trials. DATA SOURCES: Literature databases, trial registries, journals, abstract books, and conference proceedings, and reference lists, searched up to the end of January 2012. REVIEW METHODS: Randomised controlled trials comparing physiotherapy with no intervention in patients with Parkinson's disease were eligible. Two authors independently abstracted data from each trial. Standard meta-analysis methods were used to assess the effectiveness of physiotherapy compared with no intervention. Tests for heterogeneity were used to assess for differences in treatment effect across different physiotherapy interventions used. Outcome measures were gait, functional mobility and balance, falls, clinician rated impairment and disability measures, patient rated quality of life, adverse events, compliance, and economic analysis outcomes. RESULTS: 39 trials of 1827 participants met the inclusion criteria, of which 29 trials provided data for the meta-analyses. Significant benefit from physiotherapy was reported for nine of 18 outcomes assessed. Outcomes which may be clinically significant were speed (0.04 m/s, 95% confidence interval 0.02 to 0.06, P<0.001), Berg balance scale (3.71 points, 2.30 to 5.11, P<0.001), and scores on the unified Parkinson's disease rating scale (total score -6.15 points, -8.57 to -3.73, P<0.001; activities of daily living subscore -1.36, -2.41 to -0.30, P=0.01; motor subscore -5.01, -6.30 to -3.72, P<0.001). Indirect comparisons of the different physiotherapy interventions found no evidence that the treatment effect differed across the interventions for any outcomes assessed, apart from motor subscores on the unified Parkinson's disease rating scale (in which one trial was found to be the cause of the heterogeneity). CONCLUSIONS: Physiotherapy has short term benefits in Parkinson's disease. A wide range of physiotherapy techniques are currently used to treat Parkinson's disease, with little difference in treatment effects. Large, well designed, randomised controlled trials with improved methodology and reporting are needed to assess the efficacy and cost effectiveness of physiotherapy for treating Parkinson's disease in the longer term.


Assuntos
Atividades Cotidianas , Avaliação de Resultados (Cuidados de Saúde)/estatística & dados numéricos , Doença de Parkinson/reabilitação , Modalidades de Fisioterapia , Qualidade de Vida , Avaliação da Deficiência , Feminino , Marcha/fisiologia , Humanos , Masculino , Artes Marciais , Doença de Parkinson/fisiopatologia , Ensaios Clínicos Controlados Aleatórios como Assunto
16.
Cochrane Database Syst Rev ; (8): CD002812, 2012 Aug 15.
Artigo em Inglês | MEDLINE | ID: mdl-22895930

RESUMO

BACKGROUND: Parkinson's disease patients commonly suffer from speech and vocal problems including dysarthric speech, reduced loudness and loss of articulation. These symptoms increase in frequency and intensity with progression of the disease). Speech and language therapy (SLT) aims to improve the intelligibility of speech with behavioural treatment techniques or instrumental aids. OBJECTIVES: To compare the efficacy of speech and language therapy versus placebo or no intervention for speech and voice problems in patients with Parkinson's disease. SEARCH METHODS: Relevant trials were identified by electronic searches of numerous literature databases including MEDLINE, EMBASE, and CINAHL, as well as handsearching of relevant conference abstracts and examination of reference lists in identified studies and other reviews. The literature search included trials published prior to 11(th) April 2011. SELECTION CRITERIA: Only randomised controlled trials (RCT) of speech and language therapy versus placebo or no intervention were included. DATA COLLECTION AND ANALYSIS: Data were abstracted independently by CH and CT and differences settled by discussion. MAIN RESULTS: Three randomised controlled trials with a total of 63 participants were found comparing SLT with placebo for speech disorders in Parkinson's disease. Data were available from 41 participants in two trials. Vocal loudness for reading a passage increased by 6.3 dB (P = 0.0007) in one trial, and 11.0 dB (P = 0.0002) in another trial. An increase was also seen in both of these trials for monologue speaking of 5.4 dB (P = 0.002) and 11.0 dB (P = 0.0002), respectively. It is likely that these are clinically significant improvements. After six months, patients from the first trial were still showing a statistically significant increase of 4.5 dB (P = 0.0007) for reading and 3.5 dB for monologue speaking. Some measures of speech monotoni city and articulation were investigated; however, all these results were non-significant. AUTHORS' CONCLUSIONS: Although improvements in speech impairments were noted in these studies, due to the small number of patients examined, methodological flaws, and the possibility of publication bias, there is insufficient evidence to conclusively support or refute the efficacy of SLT for speech problems in Parkinson's disease. A large well designed placebo-controlled RCT is needed to demonstrate SLT's effectiveness in Parkinson's disease. The trial should conform to CONSORT guidelines. Outcome measures with particular relevance to patients with Parkinson's disease should be chosen and patients followed for at least six months to determine the duration of any improvement.


Assuntos
Disartria/terapia , Terapia da Linguagem , Doença de Parkinson/complicações , Fonoterapia , Disartria/etiologia , Humanos , Ensaios Clínicos Controlados Aleatórios como Assunto , Inteligibilidade da Fala , Conduta Expectante
17.
Cochrane Database Syst Rev ; (8): CD002814, 2012 Aug 15.
Artigo em Inglês | MEDLINE | ID: mdl-22895931

RESUMO

BACKGROUND: Patients with Parkinson's disease commonly suffer from speech and voice difficulties such as impaired articulation and reduced loudness. Speech and language therapy (SLT) aims to improve the intelligibility of speech with behavioural treatment techniques or instrumental aids. OBJECTIVES: To compare the efficacy and effectiveness of novel SLT techniques versus a standard SLT approach to treat Parkinsonian speech problems. SEARCH METHODS: We identified relevant, published prior to 11(th) April 2011, by electronic searches of numerous literature databases including CENTRAL, MEDLINE and CINAHL, as well as handsearching relevant conference abstracts and examining reference lists in identified studies and other reviews. SELECTION CRITERIA: Only randomised controlled trials (RCT) of one type of speech and language therapy versus another were included. DATA COLLECTION AND ANALYSIS: Two review authors independently extracted data and resolved differences by discussion. MAIN RESULTS: Six trials involving 159 patients satisfied the inclusion criteria. Data could not be analysed from one trial due to changes in patient numbers and from a second because the data provided were not in a usable format. All trials reported intelligibility measures but a statistically significant result was only reported for the diagnostic rhyme test used in the study of Lee Silverman Voice Treatment -LOUD (LSVT-LOUD) versus a modified version of this therapy (LSVT-ARTIC). In this case a difference of 12.5 points (95% confidence interval (CI) -22.2 to -2.8; P = 0.01) between the mean changes in favour of the LSVT-LOUD group was reported for a speech sample overlaid with Babble noise; this difference was not reproduced for the two additional noise conditions under which the speech samples were assessed. LSVT-LOUD also outperformed LSVT-ARTIC and Respiration therapy (RT) in improving loudness, with a difference in reading a sample text of 5.0 dB (95%CI -8.3 to -1.7; P = 0.003) and 5.5 dB (95% CI 3.4 to 7.7; P < 0.00001) respectively, and a difference in monologue speech of 2.9 dB (95% CI 0.6 to 5.2; P = 0.01) versus RT. AUTHORS' CONCLUSIONS: Considering the small patient numbers in these trials, there is insufficient evidence to support or refute the efficacy of any form of SLT over another to treat speech problems in patients with Parkinson's disease.


Assuntos
Disartria/terapia , Terapia da Linguagem/métodos , Doença de Parkinson/complicações , Fonoterapia/métodos , Viés , Disartria/etiologia , Humanos , Ensaios Clínicos Controlados Aleatórios como Assunto , Inteligibilidade da Fala
18.
Cochrane Database Syst Rev ; (8): CD002817, 2012 Aug 15.
Artigo em Inglês | MEDLINE | ID: mdl-22895932

RESUMO

BACKGROUND: Despite medical therapies and surgical interventions for Parkinson's disease (PD), patients develop progressive disability. The role of physiotherapy aims to maximise functional ability and minimise secondary complications through movement rehabilitation within a context of education and support for the whole person. The overall aim is to optimise independence, safety and well-being, thereby enhancing quality of life. OBJECTIVES: To assess the effectiveness of physiotherapy intervention compared with no intervention in patients with PD. SEARCH METHODS: We identified relevant trials by electronic searches of numerous literature databases (e.g. MEDLINE, EMBASE) and trial registers, plus handsearching of major journals, abstract books, conference proceedings and reference lists of retrieved publications. The literature search included trials published up to end of December 2010. SELECTION CRITERIA: Randomised controlled trials of physiotherapy intervention versus no physiotherapy intervention in patients with PD. DATA COLLECTION AND ANALYSIS: Two review authors independently extracted data from each article. We used standard meta-analysis methods to assess the effectiveness of physiotherapy intervention compared with no physiotherapy intervention. Trials were classified into the following intervention comparisons: general physiotherapy, exercise, treadmill training, cueing, dance and martial arts. We used tests for heterogeneity to assess for differences in treatment effect across these different physiotherapy interventions. MAIN RESULTS: We identified 33 trials with 1518 participants. Compared with no-intervention, physiotherapy significantly improved the gait outcomes of velocity (mean difference 0.05 m/s, 95% confidence interval (CI): 0.02 to 0.07, P = 0.0002), two- or six-minute walk test (16.40 m, CI: 1.90 to 30.90, P = 0.03) and step length (0.03 m, CI: 0 to 0.06, P = 0.04); functional mobility and balance outcomes of Timed Up & Go test (-0.61 s, CI: -1.06 to -0.17, P = 0.006), Functional Reach Test (2.16 cm, CI: 0.89 to 3.43, P = 0.0008) and Berg Balance Scale (3.36 points, CI: 1.91 to 4.81, P < 0.00001); and clinician-rated disability using the Unified Parkinson's Disease Rating Scale (UPDRS) (total: -4.46 points, CI -7.16 to -1.75, P = 0.001; activities of daily living: -1.36, CI -2.41 to -0.30, P = 0.01; and motor: -4.09, CI: -5.59 to -2.59, P < 0.00001). There was no difference between arms in falls or patient-rated quality of life. Indirect comparisons of the different physiotherapy interventions found no evidence that the treatment effect differed across the physiotherapy interventions for any of the outcomes assessed. AUTHORS' CONCLUSIONS: Benefit for physiotherapy was found in most outcomes over the short-term (i.e. < three months), but was only significant for velocity, two- or six-minute walk test, step length, Timed Up & Go, Functional Reach Test, Berg Balance Scale and clinician-rated UPDRS. Most of the observed differences between the treatments were small. However, for some outcomes (e.g. velocity, Berg Balance Scale and UPDRS), the differences observed were at, or approaching, what are considered minimally clinical important changes.The review illustrates that a wide range of approaches are employed by physiotherapists to treat PD. However, there was no evidence of differences in treatment effect between the different types of physiotherapy interventions being used, though this was based on indirect comparisons. There is a need to develop a consensus menu of 'best-practice' physiotherapy, and to perform large well-designed randomised controlled trials to demonstrate the longer-term efficacy and cost-effectiveness of 'best practice' physiotherapy in PD.


Assuntos
Doença de Parkinson/reabilitação , Modalidades de Fisioterapia , Atividades Cotidianas , Marcha , Humanos , Ensaios Clínicos Controlados Aleatórios como Assunto , Caminhada , Conduta Expectante
19.
Cochrane Database Syst Rev ; (7): CD002817, 2012 Jul 11.
Artigo em Inglês | MEDLINE | ID: mdl-22786482

RESUMO

BACKGROUND: Despite medical therapies and surgical interventions for Parkinson's disease (PD), patients develop progressive disability. The role of physiotherapy aims to maximise functional ability and minimise secondary complications through movement rehabilitation within a context of education and support for the whole person. The overall aim is to optimise independence, safety and well-being, thereby enhancing quality of life. OBJECTIVES: To assess the effectiveness of physiotherapy intervention compared with no intervention in patients with PD. SEARCH METHODS: We identified relevant trials by electronic searches of numerous literature databases (e.g. MEDLINE, EMBASE) and trial registers, plus handsearching of major journals, abstract books, conference proceedings and reference lists of retrieved publications. The literature search included trials published up to end of December 2010. SELECTION CRITERIA: Randomised controlled trials of physiotherapy intervention versus no physiotherapy intervention in patients with PD. DATA COLLECTION AND ANALYSIS: Two review authors independently extracted data from each article. We used standard meta-analysis methods to assess the effectiveness of physiotherapy intervention compared with no physiotherapy intervention. Trials were classified into the following intervention comparisons: general physiotherapy, exercise, treadmill training, cueing, dance and martial arts. We used tests for heterogeneity to assess for differences in treatment effect across these different physiotherapy interventions. MAIN RESULTS: We identified 33 trials with 1518 participants. Compared with no-intervention, physiotherapy significantly improved the gait outcomes of velocity (mean difference 0.05 m/s, 95% confidence interval (CI): 0.02 to 0.07, P = 0.0002), two- or six-minute walk test (16.40 m, CI: 1.90 to 30.90, P = 0.03) and step length (0.03 m, CI: 0 to 0.06, P = 0.04); functional mobility and balance outcomes of Timed Up & Go test (-0.61 s, CI: -1.06 to -0.17, P = 0.006), Functional Reach Test (2.16 cm, CI: 0.89 to 3.43, P = 0.0008) and Berg Balance Scale (3.36 points, CI: 1.91 to 4.81, P < 0.00001); and clinician-rated disability using the Unified Parkinson's Disease Rating Scale (UPDRS) (total: -4.46 points, CI -7.16 to -1.75, P = 0.001; activities of daily living: -1.36, CI -2.41 to -0.30, P = 0.01; and motor: -4.09, CI: -5.59 to -2.59, P < 0.00001). There was no difference between arms in falls or patient-rated quality of life. Indirect comparisons of the different physiotherapy interventions found no evidence that the treatment effect differed across the physiotherapy interventions for any of the outcomes assessed. AUTHORS' CONCLUSIONS: Benefit for physiotherapy was found in most outcomes over the short-term (i.e. < three months), but was only significant for velocity, two- or six-minute walk test, step length, Timed Up & Go, Functional Reach Test, Berg Balance Scale and clinician-rated UPDRS. Most of the observed differences between the treatments were small. However, for some outcomes (e.g. velocity, Berg Balance Scale and UPDRS), the differences observed were at, or approaching, what are considered minimally clinical important changes.The review illustrates that a wide range of approaches are employed by physiotherapists to treat PD. However, there was no evidence of differences in treatment effect between the different types of physiotherapy interventions being used, though this was based on indirect comparisons. There is a need to develop a consensus menu of 'best-practice' physiotherapy, and to perform large well-designed randomised controlled trials to demonstrate the longer-term efficacy and cost-effectiveness of 'best practice' physiotherapy in PD.


Assuntos
Doença de Parkinson/reabilitação , Modalidades de Fisioterapia , Idoso , Sinais (Psicologia) , Terapia através da Dança/métodos , Terapia por Exercício/métodos , Feminino , Marcha , Humanos , Masculino , Artes Marciais , Ensaios Clínicos Controlados Aleatórios como Assunto
20.
Cochrane Database Syst Rev ; (11): CD004538, 2011 Nov 09.
Artigo em Inglês | MEDLINE | ID: mdl-22071813

RESUMO

BACKGROUND: It is becoming increasingly common to release information about the performance of hospitals, health professionals or providers, and healthcare organisations into the public domain. However, we do not know how this information is used and to what extent such reporting leads to quality improvement by changing the behaviour of healthcare consumers, providers and purchasers, or to what extent the performance of professionals and providers can be affected. OBJECTIVES: To determine the effectiveness of the public release of performance data in changing the behaviour of healthcare consumers, professionals and organisations. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL), Cochrane Effective Practice and Organisation of Care (EPOC) Trials Register, MEDLINE Ovid (from 1966), EMBASE Ovid (from 1979), CINAHL, PsycINFO Ovid (from 1806) and DARE up to 2011. SELECTION CRITERIA: We searched for randomised or quasi-randomised trials, interrupted time series and controlled before-after studies of the effects of publicly releasing data regarding any aspect of the performance of healthcare organisations or individuals. The papers had to report at least one main outcome related to selecting or changing care. Other outcome measures were awareness, attitude, views and knowledge of performance data and costs. DATA COLLECTION AND ANALYSIS: Two review authors independently screened studies for eligibility and extracted data. For each study, we extracted data about the target groups (healthcare consumers, healthcare providers and healthcare purchasers), performance data, main outcomes (choice of healthcare provider and improvement by means of changes in care) and other outcomes (awareness, attitude, views, knowledge of performance data and costs). MAIN RESULTS: We included four studies containing more than 35,000 consumers, and 1560 hospitals. Three studies were conducted in the USA and examined consumer behaviour after the public release of performance data. Two studies found no effect of Consumer Assessment of Healthcare Providers and Systems information on health plan choice in a Medicaid population. One interrupted time series study found a small positive effect of the publishing of data on patient volumes for coronary bypass surgery and low-complication outliers for lumbar discectomy, but these effects did not persist longer than two months after each public release. No effects on patient volumes for acute myocardial infarction were found.One cluster-randomised controlled trial, conducted in Canada, studied improvement changes in care after the public release of performance data for patients with acute myocardial infarction and congestive heart failure. No effects for the composite process-of-care indicators for either condition were found, but there were some improvements in the individual process-of-care indicators. There was an effect on the mortality rates for acute myocardial infarction. More quality improvement activities were initiated in response to the publicly-released report cards. No secondary outcomes were reported. AUTHORS' CONCLUSIONS: The small body of evidence available provides no consistent evidence that the public release of performance data changes consumer behaviour or improves care. Evidence that the public release of performance data may have an impact on the behaviour of healthcare professionals or organisations is lacking.


Assuntos
Informação de Saúde ao Consumidor/métodos , Hospitais/normas , Disseminação de Informação , Garantia da Qualidade dos Cuidados de Saúde/métodos , Melhoria de Qualidade , Canadá , Estudos de Avaliação como Assunto , Sistemas Pré-Pagos de Saúde/normas , Humanos , Medicaid , Inovação Organizacional , Ensaios Clínicos Controlados Aleatórios como Assunto , Reprodutibilidade dos Testes , Estados Unidos
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