Sample Entropy Improves Assessment of Postural Control in Early-Stage Multiple Sclerosis.

Postural impairment in people with multiple sclerosis (pwMS) is an early indicator of disease progression. Common measures of disease assessment are not sensitive to early-stage MS. Sample entropy (SE) may better identify early impairments. We compared the sensitivity and specificity of SE with linear measurements, differentiating pwMS (EDSS 0-4) from healthy controls (HC). 58 pwMS (EDSS ≤ 4) and 23 HC performed quiet standing tasks, combining a hard or foam surface with eyes open or eyes closed as a condition. Sway was recorded at the sternum and lumbar spine. Linear measures, mediolateral acceleration range with eyes open, mediolateral jerk with eyes closed, and SE in the anteroposterior and mediolateral directions were calculated. A multivariate ANOVA and AUC-ROC were used to determine between-groups differences and discriminative ability, respectively. Mild MS (EDSS ≤ 2.0) discriminability was secondarily assessed. Significantly lower SE was observed under most conditions in pwMS compared to HC, except for lumbar and sternum SE when on a hard surface with eyes closed and in the anteroposterior direction, which also offered the strongest discriminability (AUC = 0.747), even for mild MS. Overall, between-groups differences were task-dependent, and SE (anteroposterior, hard surface, eyes closed) was the best pwMS classifier. SE may prove a useful tool to detect subtle MS progression and intervention effectiveness.

Gait stability reflects motor tracts damage at early stages of multiple sclerosis.

BACKGROUND: Gait in people with multiple sclerosis (PwMS) is affected even when no changes can be observed on clinical examination. A sensitive measure of gait deterioration is stability; however, its correlation with motor tract damage has not yet been established. OBJECTIVE: To compare stability between PwMS and healthy controls (HCs) and determine associations between stability and diffusion magnetic resonance image (MRI) measures of axonal damage in selected sensorimotor tracts. METHODS: Twenty-five PwMS (Expanded Disability Status Scale (EDSS) < 2.5) and 15 HCs walked on a treadmill. Stability from sacrum (LDESAC), shoulder (LDESHO) and cervical (LDECER) was calculated using the local divergence exponent (LDE). Participants underwent a 7T-MRI brain scan to obtain fibre-specific measures of axonal loss within the corticospinal tract (CST), interhemispheric sensorimotor tract (IHST) and cerebellothalamic tract (CTT). Correlation analyses between LDE and fibre density (FD) within tracts, fibre cross-section (FC) and FD modulated by FC (FDC) were conducted. Between-groups LDE differences were analysed using analysis of variance (ANOVA). RESULTS: Correlations between all stability measures with CSTFD, between CSTFDC with LDESAC and LDECER, and LDECER with IHSTFD and IHSTFDC were significant yet moderate (R < -0.4). Stability was significantly different between groups. CONCLUSIONS: Poorer gait stability is associated with corticospinal tract (CST) axonal loss in PwMS with no-to-low disability and is a sensitive indicator of neurodegeneration.

Functional correlates of motor control impairments in multiple sclerosis: A 7 Tesla task functional MRI study.

Upper and lower limb impairments are common in people with multiple sclerosis (pwMS), yet difficult to clinically identify in early stages of disease progression. Tasks involving complex motor control can potentially reveal more subtle deficits in early stages, and can be performed during functional MRI (fMRI) acquisition, to investigate underlying neural mechanisms, providing markers for early motor progression. We investigated brain activation during visually guided force matching of hand or foot in 28 minimally disabled pwMS (Expanded Disability Status Scale (EDSS) < 4 and pyramidal and cerebellar Kurtzke Functional Systems Scores ≤ 2) and 17 healthy controls (HC) using ultra-high field 7-Tesla fMRI, allowing us to visualise sensorimotor network activity in high detail. Task activations and performance (tracking lag and error) were compared between groups, and correlations were performed. PwMS showed delayed (+124 s, p = .002) and more erroneous (+0.15 N, p = .001) lower limb tracking, together with lower cerebellar, occipital and superior parietal cortical activation compared to HC. Lower activity within these regions correlated with worse EDSS (p = .034), lower force error (p = .006) and higher lesion load (p < .05). Despite no differences in upper limb task performance, pwMS displayed lower inferior occipital cortical activation. These results demonstrate that ultra-high field fMRI during complex hand and foot tracking can identify subtle impairments in lower limb movements and upper and lower limb brain activity, and differentiates upper and lower limb impairments in minimally disabled pwMS.

Comparison of segmental lean tissue mass in individuals with spinal cord injury measured by dual energy X-ray absorptiometry and predicted by bioimpedance spectroscopy.

STUDY DESIGN: Observational. OBJECTIVES: To compare two methods for predicting segmental (arms, legs, trunk) lean tissue mass (LTM: non-bone fat-free mass) from bioimpedance spectroscopy (BIS) against LTM measured from dual energy X-ray absorptiometry (DXA) in individuals with acute spinal cord injury (SCI). SETTING: Austin Health Victorian Spinal Cord Service, Victoria, Australia. METHODS: Fourteen participants (two female), within 8 weeks of traumatic SCI had BIS measured following an overnight fast and within 24 h of DXA scanning. Total body fat-free mass (FFM, body weight minus fat mass) and segmental LTM were predicted from BIS using manufacturer's proprietary software and a previously established SCI-specific prediction method. Appendicular LTM (ALM) was calculated from the sum of the LTM of the arms and legs. Agreement and strength of relationships with DXA for predicted LTM measures using both approaches were assessed using Lin's concordance coefficient and limits of agreement analysis (LOA). RESULTS: The BIS proprietary method performed better than the SCI-specific prediction method in predicting DXA LTM, demonstrating substantial concordance for total body FFM (rc = 0.80), ALM (rc = 0.78), arm (rc = 0.76) and leg LTM (rc = 0.65) and a smaller bias and LOA for ALM (+0.8 vs. -3.4 kg; LOA -4.9-6.4 vs. -11.9-5.1 kg), arm (+0.02 vs. -0.3 kg; LOA -1.1-1.1 kg vs. -2.2-1.6 kg) and leg (+0.4 vs. -1.4 kg; LOA -2.0-2.8 vs. -5.6-2.8) LTM. CONCLUSIONS: BIS can be used to accurately predict total body FFM, segmental LTM and ALM in individuals with acute SCI.

Expanding traditional tendon-based techniques with nerve transfers for the restoration of upper limb function in tetraplegia: a prospective case series.

BACKGROUND: Loss of upper extremity function after cervical spinal cord injury greatly affects independence, including social, vocational, and community engagement. Nerve transfer surgery offers an exciting new option for the reanimation of upper limb function in tetraplegia. The aim of this study was to evaluate the outcomes of nerve transfer surgery used for the reanimation of upper limb function in tetraplegia. METHODS: In this prospective case series, we consecutively recruited people of any age with early (<18 months post-injury) cervical spinal cord injury of motor level C5 and below, who had been referred to a single centre for upper extremity reanimation and were deemed suitable for nerve transfer. All participants underwent single or multiple nerve transfers in one or both upper limbs, sometimes combined with tendon transfers, for restoration of elbow extension, grasp, pinch, and hand opening. Participants were assessed at 12 months and 24 months post-surgery. Primary outcome measures were the action research arm test (ARAT), grasp release test (GRT), and spinal cord independence measure (SCIM). FINDINGS: Between April 14, 2014, and Nov 22, 2018, we recruited 16 participants (27 limbs) with traumatic spinal cord injury, among whom 59 nerve transfers were done. In ten participants (12 limbs), nerve transfers were combined with tendon transfers. 24-month follow-up data were unavailable for three patients (five limbs). At 24 months, significant improvements from baseline in median ARAT total score (34·0 [IQR 24·0-38·3] at 24 months vs 16·5 [12·0-22·0] at baseline, p<0·0001) and GRT total score (125·2 [65·1-154·4] vs 35·0 [21·0-52·3], p<0·0001) were observed. Mean total SCIM score and mobility in the room and toilet SCIM score improved by more than the minimal detectable change and the minimal clinically important difference, and the mean self-care SCIM score improved by more than the minimal detectable change between baseline and 24 months. Median Medical Research Council strength grades were 3 (IQR 2-3) for triceps and 4 (IQR 4-4) for digital extensor muscles after 24 months. Mean grasp strength at 24 months was 3·2 kg (SD 1·5) in participants who underwent distal nerve transfers (n=5), 2·8 kg (3·2) in those who had proximal nerve transfers (n=9), and 3·9 kg (2·4) in those who had tendon transfers (n=8). There were six adverse events related to the surgery, none of which had any ongoing functional consequences. INTERPRETATION: Early nerve transfer surgery is a safe and effective addition to surgical techniques for upper limb reanimation in tetraplegia. Nerve transfers can lead to significant functional improvement and can be successfully combined with tendon transfers to maximise functional benefits. FUNDING: Institute for Safety, Compensation, and Recovery Research (Australia).

The Effect of Transcranial Direct Current Stimulation on Chronic Neuropathic Pain in Patients with Multiple Sclerosis: Randomized Controlled Trial.

OBJECTIVE: Chronic neuropathic pain is a common symptom in multiple sclerosis (MS). This randomized controlled single-blinded study investigated whether a new protocol involving five days of transcranial direct current stimulation (tDCS) with an interval period would be effective to reduce pain using the visual analog scale (VAS). Other secondary outcomes included the Neuropathic Pain Scale (NPS), Depression Anxiety Stress Score (DASS), Short Form McGill Pain Questionnaire (SFMPQ), and Multiple Sclerosis Quality of Life 54 (MSQOL54). DESIGN: A total of 30 participants were recruited for the study, with 15 participants randomized to a sham group or and 15 randomized to an active group. After a five-day course of a-tDCS, VAS and NPS scores were measured daily and then weekly after treatment up to four weeks after treatment. Secondary outcomes were measured pretreatment and then weekly up to four weeks. RESULTS: After a five-day course of a-tDCS, VAS scores were significantly reduced compared with sham tDCS and remained significantly low up to week 2 post-treatment. There were no statistically significant mean changes in MSQOL54, SFMPQ, NPS, or DASS for the sham or treatment group before treatment or at four-week follow-up. CONCLUSIONS: This study shows that repeated stimulation with a-tDCS for five days can reduce pain intensity for a prolonged period in patients with MS who have chronic neuropathic pain.

Comparison of estimated energy requirements using predictive equations with total energy expenditure measured by the doubly labelled water method in acute spinal cord injury.

STUDY DESIGN: Prospective, observational OBJECTIVES: To evaluate agreement between a reference method (doubly labelled water, DLW) of total energy expenditure (TEE) and published equations for estimating energy requirements in acute spinal cord injury (SCI). SETTING: Victoria, Australia METHODS: Twenty participants (18 male) within 8 weeks of traumatic SCI completed DLW, anthropometric and dietary intake assessments. Energy requirements were predicted using Harris-Benedict, Schofield, Henry, Nelson, Buchholz and Chun equations, multiplied by a combined activity and stress factor of 1.3, and the ratio method (kJ/kg body weight). Fat-free mass (FFM) and fat mass (FM) were calculated from TBW-derived DLW and from bioelectrical impedance spectroscopy (BIS). RESULTS: Median time since injury was 41 days. Median TEE was 9.1 MJ. Fair agreement was found between TEE and predicted energy requirements for the Chun (rc = 0.39), the Harris-Benedict equation (rc = 0.30), the ratio method (rc = 0.23) and the Buchholz (rc = 0.31) and Nelson equations (rc = 0.35), which incorporate measures of FFM and/or FM. Other equations showed weak concordance with DLW. When two hypermetabolic patients were removed, agreement between TEE and predicted energy requirements using the Buchholz equation increased to substantial (rc = 0.72) and using the Nelson (rc = 0.53) and Chun equations (rc = 0.53) increased to moderate. The Buchholz equation had the smallest limits of agreement (-2.4-2.3 MJ/d). CONCLUSION: The population-specific Buchholz equation that incorporates FFM, predicted from either BIS or DLW, demonstrated the best agreement in patients with acute SCI. SPONSORSHIP: The study was funded by grants from the Institute for Safety, Compensation and Recovery Research (ISCRR Project # NGE-E-13-078) and Austin Medical Research Foundation. M Panisset was supported by an Australian Postgraduate Award.

Bedside quantification of fat-free mass in acute spinal cord injury using bioelectrical impedance analysis: a psychometric study.

STUDY DESIGN: Psychometric. OBJECTIVES: Assess the validity of bioimpedance-based measures of fat-free mass (FFM) in acute SCI and of current definitions of obesity based on body mass index (BMI). SETTING: Australia. METHODS: All admissions within eight weeks of a new traumatic SCI were screened. 29% were eligible. 71% of those consented. Twenty participants (18 male) completed deuterium dilution (DD) and bioimpedance-based measurements of FFM. Thirteen also underwent dual-energy x-ray absorptiometry. Strength of relationships and agreement were examined using Lin's concordance coefficient and limits of agreement analysis, respectively. Sensitivity and specificity were calculated for three BMI cutoffs for obesity, using percentage fat mass (%FM) obtained from DD as reference. RESULTS: Median time since injury was 41 days (IQR 28-48). FFM from DD and DXA were highly correlated but not identical. Concordance and agreement between DD and seven bioimpedance-based predictive equations are presented. The best-fitting equation demonstrated a low bias (+0.6 kg) and moderate dispersion (±5.2 kg). The cutoff for overweight in able-bodied people (BMI ≥25 kg/m2) provided sensitivity of 43.8%, compared to 25% for the cut-off for obesity (BMI ≥30 kg/m2). FM from bioimpedance gave the highest sensitivity (88.9%). CONCLUSIONS: BMI demonstrates poor specificity to classify obesity in acute SCI. Present findings support the utility of bioimpedance-based measurements for estimating FFM in acute SCI for group comparisons. These results are generalizable to traumatic SCI 4-8 weeks post injury; however, the present data reflect a high proportion of high cervical injuries. Further research is indicated to establish validity for assessment of individuals and for longitudinal monitoring. SPONSORSHIP: The present study was funded by a grant from the Institute for Safety, Compensation and Recovery Research (ISCRR Project #NGE-E-13-078). M Panisset was supported by an Australian Postgraduate Award. K Desneves was supported by the Austin Medical Research Foundation.

Effects Of treadmill training on hindlimb muscles of spinal cord-injured mice.

INTRODUCTION: Treadmill training is known to prevent muscle atrophy after spinal cord injury (SCI), but the training duration required to optimize recovery has not been investigated. METHODS: Hemisected mice were randomized to 3, 6, or 9 weeks of training or no training. Muscle fiber type composition and fiber cross-sectional area (CSA) of medial gastrocnemius (MG), soleus (SOL), and tibialis anterior (TA) were assessed using ATPase histochemistry. RESULTS: Muscle fiber type composition of SCI animals did not change with training. However, 9 weeks of training increased the CSA of type IIB and IIX fibers in TA and MG muscles. CONCLUSIONS: Nine weeks of training after incomplete SCI was effective in preventing atrophy of fast-twitch muscles, but there were limited effects on slow-twitch muscles and muscle fiber type composition. These data provide important evidence of the benefits of exercising paralyzed limbs after SCI. Muscle Nerve, 2016 Muscle Nerve 55: 232-242, 2017.

The use of laboratory gait analysis for understanding gait deterioration in people with multiple sclerosis.

Laboratory gait analysis or three-dimensional gait analysis (3DGA), which uses motion capture, force plates and electromyography (EMG), has allowed a better understanding of the underlying mechanisms of gait deterioration in patients with multiple sclerosis (PwMS). This review will summarize the current knowledge on multiple sclerosis (MS)-related changes in kinematics (angles), kinetics (forces) and electromyographic (muscle activation) patterns and how these measures can be used as markers of disease progression. We will also discuss the potential causes of slower walking in PwMS and the implications for 3DGA. Finally, we will describe new technologies and methods that will increase precision and clinical utilization of 3DGA in PwMS. Overall, 3DGA studies have shown that functionality of the ankle joint is the most affected during walking and that compensatory actions to maintain a functional speed may be insufficient in PwMS. However, altered gait patterns may be a strategy to increase stability as balance is also affected in PwMS.

Individualised pelvic floor muscle training in women with pelvic organ prolapse (POPPY): a multicentre randomised controlled trial.

BACKGROUND: Pelvic organ prolapse is common and is strongly associated with childbirth and increasing age. Women with prolapse are often advised to do pelvic floor muscle exercises, but evidence supporting the benefits of such exercises is scarce. We aimed to establish the effectiveness of one-to-one individualised pelvic floor muscle training for reducing prolapse symptoms. METHODS: We did a parallel-group, multicentre, randomised controlled trial at 23 centres in the UK, one in New Zealand, and one in Australia, between June 22, 2007, and April 9, 2010. Female outpatients with newly-diagnosed, symptomatic stage I, II, or III prolapse were randomly assigned (1:1), by remote computer allocation with minimsation, to receive an individualised programme of pelvic floor muscle training or a prolapse lifestyle advice leaflet and no muscle training (control group). Outcome assessors, and investigators who were gynaecologists at trial sites, were masked to group allocation; the statistician was masked until after data analysis. Our primary endpoint was participants' self-report of prolapse symptoms at 12 months. Analysis was by intention-to-treat analysis. This trial is registered, number ISRCTN35911035. FINDINGS: 447 eligible patients were randomised to the intervention group (n=225) or the control group (n=222). 377 (84%) participants completed follow-up for questionnaires at 6 months and 295 (66%) for questionnaires at 12 months. Women in the intervention group reported fewer prolapse symptoms (ie, a significantly greater reduction in the pelvic organ prolapse symptom score [POP-SS]) at 12 months than those in the control group (mean reduction in POP-SS from baseline 3.77 [SD 5.62] vs 2.09 [5.39]; adjusted difference 1.52, 95% CI 0.46-2.59; p=0.0053). Findings were robust to missing data. Eight adverse events (six vaginal symptoms, one case of back pain, and one case of abdominal pain) and one unexpected serious adverse event, all in women from the intervention group, were regarded as unrelated to the intervention or to participation in the study. INTERPRETATION: One-to-one pelvic floor muscle training for prolapse is effective for improvement of prolapse symptoms. Long-term benefits should be investigated, as should the effects in specific subgroups. FUNDING: Chief Scientist Office of the Scottish Government Health and Social Care Directorates, New Zealand Lottery Board, and National Health and Medical Research Council (Australia).

Postural control at 4 years in very preterm children compared with term-born peers.

AIM: To compare postural control at 4 years' corrected age in very preterm children (VPT; <30wks gestational age) with term-born (>37wks gestational age) comparison participants. METHOD: Ninety VPT children (45 males, 45 females; mean age at assessment 4y 1mo; mean birthweight 1022g; mean gestational age 27.3wks) and 36 term comparison participants (17 males, 19 females; mean age at assessment 4y; mean birthweight 3507g; mean gestational age 39.4wks) were assessed for postural stability with a portable force plate, the Wii Balance Board. Tasks included static two-limbed standing with eyes open, eyes closed, eyes open on a foam mat, eyes closed on a foam mat, a cognitive dual task, and single leg standing on each limb. The cognitive dual task involved showing the participants a series of pictures that appeared on screen at 2-second intervals. Impaired postural control was defined as increased postural sway measured by centre of pressure path-length velocity. Functional performance was assessed during dynamic jumping and hopping tasks using the outcome measure flight time, with shorter time indicating worse performance. RESULTS: VPT children had impaired static and dynamic balance, with increased postural sway under all conditions, and reduced flight times compared with children born at term. When results were adjusted for body weight, the only group differences in postural control were in the cognitive dual task (cm/s; mean difference 0.6; 95% confidence interval [CI] 0.02, 1.2; p=0.04) and flight times (ms; jumping; mean difference -26.0; 95% CI -47.1, -5.0; p=0.02; left leg hopping; mean difference -30.1; 95% CI -48.5, -11.8; p=0.002). INTERPRETATION: VPT children demonstrated reduced postural control at 4 years of age compared with term-born children when presented with a cognitive dual task. They also performed worse during jumping and hopping tasks.

Effects of training on upper limb function after cervical spinal cord injury: a systematic review.

OBJECTIVE: To summarize the evidence for the effectiveness of exercise training in promoting recovery of upper extremity function after cervical spinal cord injury. DATA SOURCES: Medline, Cochrane, CINAHL, EMBASE and PEDro were used to search the literature. REVIEW METHODS: Two reviewers independently selected and summarized the included studies. Methodological quality of the selected articles was scored using the Downs and Black checklist. RESULTS: A total of 16 studies were included, representing a total of 426 participants. Overall, the internal validity and reporting of the studies was fair to good, while power and external validity were poor. Interventions included exercise therapy, electrical stimulation, functional electrical stimulation, robotic training and repetitive transcranial magnetic stimulation. Most of the studies reported improvements in muscle strength, arm and hand function, activity of daily living or quality of life after intervention. CONCLUSIONS: Training including exercise therapy, electrical stimulation, functional electrical stimulation of the upper limb following cervical spinal cord injury leads to improvements in muscle strength, upper limb function and activity of daily living or quality of life. Further research is needed into the effects of repetitive transcranial magnetic stimulation and robotic training on upper limb function.

High-level mobility skills in children and adolescents with traumatic brain injury.

AIM: To evaluate the reliability, validity and responsiveness of the High-level Mobility Assessment Tool (HiMAT) in children and adolescents with traumatic brain injury (TBI) and to compare the mobility skills of children with TBI to those of healthy peers. METHOD: The mobility skills of 52 children with moderate and severe TBI (36 males; mean age = 12 years, range = 6-17) were assessed using the HiMAT and the Pediatric Evaluation of Disability Inventory (PEDI). Inter-rater reliability, re-test reliability and responsiveness of the HiMAT were evaluated in sub-groups by comparing results scored at several time-points. The HiMAT scores of children with TBI were compared with those of a healthy comparative cohort. RESULTS: The HiMAT demonstrated excellent inter-rater reliability (ICC = 0.93), re-test reliability (ICC = 0.98) and responsiveness to change (p = 0.002). The PEDI demonstrated a ceiling effect in mobility assessment of ambulant children with TBI. The HiMAT scores of children with TBI were lower than those of their healthy peers (p < 0.001). INTERPRETATION: The HiMAT is a reliable, valid and sensitive measure of high-level mobility skills following childhood TBI. The high-level mobility skills of children with TBI are less proficient than their peers.

Prevalence of neurogenic heterotopic ossification in traumatic head- and spinal-injured patients admitted to a tertiary referral hospital in Australia.

A study was undertaken to investigate the prevalence of neurogenic heterotopic ossification (NHO) in patients with traumatic brain injury (TBI) or traumatic spinal cord injury (TSCI) admitted to nonspecialized units. Methods consisted of a retrospective audit of patients, using the International Statistical Classification of Diseases and Related Health Problems, 10th Revision, Australian Modification (ICD-10-AM) coding system, admitted to The Townsville Hospital with TBI/TSCI between July 1, 2006, and December 31, 2012. Fifty-eight patients with length of stay of 60 days or longer were admitted to The Townsville Hospital with TBI/TSCI over this period with mean age of 60 years (range, 31-87 years); 55 were TBI and 3 were TSCI patients. Three thousand one hundred fourteen TBI/TSCI patients with length of stay of less than 60 days and mean age of 43 years (range, 18-93 years) were also identified (2903 were TBI and 211 were TSCI patients). Overall, none had a diagnosis of NHO; 6 patients, identified by the ICD-10-AM codes, with a diagnosis of heterotopic ossification did not have an associated TBI/TSCI. Findings of 0% of NHO prevalence in TSCI/TBI patients admitted to the large tertiary referral hospital suggest that NHO may have been missed, possibly because of the TSCI/TBI ICD-10-AM codes, not being specifically designed for documentation of the TBI/TSCI complications. If NHO remains undiagnosed in nonspecialized units because of the method of coding, it may increase functional limitation in already compromised individuals.

Upper limb reinnervation in C6 tetraplegia using a triple nerve transfer: case report.

Restoration of elbow extension, grasp, key pinch, and release are major goals in low-level tetraplegia. Traditionally, these functions are achieved using tendon transfers. In this case these goals were achieved using nerve transfers. We present a 21-year-old man with a C6 level of tetraplegia. The left upper limb was treated 6 months after injury with a triple nerve transfer. A teres minor nerve branch to long head of triceps nerve branch, brachialis nerve branch to anterior interosseous nerve, and supinator nerve branch to posterior interosseous nerve transfer were used successfully to reconstruct elbow extension, key pinch, grasp, and release simultaneously.

Rehabilitation in adults with burn injury: an overview of systematic reviews.

PURPOSE: To systematically evaluate evidence from published systematic reviews for the effectiveness of rehabilitation interventions in adults with burn injury. MATERIALS AND METHODS: A comprehensive literature review conducted using medical and health science electronic databases up to 31 July 2022. Two independent reviewers selected studies, extracted data, and assessed methodological study quality using A Measurement Tool to Assess Systematic Reviews (AMSTAR-2), and the certainty of evidence for reported outcomes using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) tool. RESULTS: Twenty-one systematic reviews evaluated five categories of interventions: physical, psychological, technology-aided modalities, educational and occupational programs, complementary and alternative medicine. Outcomes included fitness level, hand function, oedema, pain, pruritus, psychological state, quality of life, range of motion, return to work, strength, scar characteristics, level of impairment and burn knowledge. The methodological quality was rated as "critically low" for all reviews. Quality of evidence for the effectiveness of evaluated interventions ranged from "moderate to very low." CONCLUSIONS: Beneficial effects of inhaled aromatherapy and extracorporeal shockwave therapy on pain reduction; inhaled or massage aromatherapy, music therapy on anxiety were reported. Safety of interventions was not evaluated, due to the lack of adverse event reporting in primary studies and the included reviews.

Burn injury is a leading cause of severe morbidity, and long-term disability, with significant health and economic burden.There is emerging evidence to support the use of complementary and alternative medicine interventions (such as aromatherapy and music therapy) for alleviating anxiety.Extracorporeal shockwave therapy with comprehensive rehabilitation therapy has positive effects on pain reduction.These interventions may be considered as adjunctive tools to enhance burn rehabilitation care and improve patient outcomes. However, further robust studies are required to strengthen the evidence, explore adverse effects and associated cost efficiency.

Postural behaviour in people with multiple sclerosis: A complexity paradox.

BACKGROUND: Balance deficits are a major concern for people with multiple sclerosis (pwMS). Measuring complexity of motor behaviour can offer an insight into MS-related changes in adaptability of the balance control system when dealing with increasingly complex tasks. QUESTION: Does postural behaviour complexity differ between pwMS at early stages of the disease and healthy controls (HC)? Does postural behaviour complexity change across increasingly complex tasks? METHODS: Forty-eight pwMS and 24 HC performed four increasingly complex postural tasks with eyes open (EO), eyes closed (EC), on firm (FS) and compliant surface (CS). Lumbar and sternum sensors recorded 3D acceleration, from which complexity index (CI) was calculated using multiscale sample entropy (MSE) in the frontal and sagittal planes. RESULTS: We found that only the complexity index in both planes during the eyes closed on compliant surface (EC-CS) task was significantly lower in pwMS compared to HC. We also found that complexity in pwMS was significantly lower during EC-CS compared to the other three tasks when using both lumbar and sternum sensors. SIGNIFICANCE: Increasing the complexity of postural tasks reduces the complexity of postural behaviour in pwMS. This paradox may reflect reduced adaptability of the sensorimotor integration processes at early stages of MS. CI can provide a different perspective on balance deficits and could potentially be a more sensitive biomarker of MS progression and an early indicator of balance deficit.

Extracorporeal Shock Wave Therapy (ESWT) as a treatment for recurrent Neurogenic Heterotopic Ossification (NHO).

PRIMARY OBJECTIVE: To describe the effects of extracorporeal shock wave therapy (ESWT) on neurogenic heterotopic ossification (NHO). RESEARCH DESIGN: A single case study was considered the most appropriate methodology in this situation. METHODS AND PROCEDURES: The subject was a 43 year old female 10 years post-traumatic brain injury with recurring NHO around the hip joint. Baseline assessments of pain using a 10-point VAS, range of motion of the hip using a goniometer and walking ability (number of steps over a standard distance) were conducted. Four applications of ESWT using a Minispec™ Extracorporeal Shock Wave Lithotripsy machine (Medispec Int. USA) administered over 6 weeks to the anterolateral aspect of the right hip. Follow-up assessments were conducted weekly over the period of intervention and then monthly for 5 months. MAIN OUTCOMES AND RESULTS: Immediately following treatment, pain was reduced to 0 on the VAS scale; hip range of motion increased and the number of steps over a standard distance reduced, indicating increased step length. At 5-month follow-up, without further ESWT intervention, these results were maintained. CONCLUSION: This case study suggests that ESWT may be a non-invasive, low risk intervention for the management of NHO.