Non-pharmacological therapies for postviral syndromes, including Long COVID: a systematic review and meta-analysis protocol

INTRODUCTION

Postviral syndromes (PVS) describe the sustained presence of symptoms following an acute viral infection, for months or even years. Exposure to the SARS-CoV-2 virus and subsequent development of COVID-19 has shown to have similar effects with individuals continuing to exhibit symptoms for greater than 12 weeks. The sustained presence of symptoms is variably referred to as 'post COVID-19 syndrome', 'post-COVID condition' or more commonly 'Long COVID'. Knowledge of the long-term health impacts and treatments for Long COVID are evolving. To minimise overlap with existing work in the field exploring treatments of Long COVID, we have only chosen to focus on non-pharmacological treatments.

AIMS

This review aims to summarise the effectiveness of non-pharmacological treatments for PVS, including Long COVID. A secondary aim is to summarise the symptoms and health impacts associated with PVS in individuals recruited to treatment studies.

METHODS AND ANALYSIS

Primary electronic searches will be performed in bibliographic databases including: Embase, MEDLINE, PyscINFO, CINAHL and MedRxiv from 1 January 2001 to 29 October 2021. At least two independent reviewers will screen each study for inclusion and data will be extracted from all eligible studies onto a data extraction form. The quality of all included studies will be assessed using Cochrane risk of bias tools and the Newcastle-Ottawa grading system. Non-pharmacological treatments for PVS and Long COVID will be narratively summarised and effect estimates will be pooled using random effects meta-analysis where there is sufficient methodological homogeneity. The symptoms and health impacts reported in the included studies on non-pharmacological interventions will be extracted and narratively reported.

ETHICS AND DISSEMINATION

This systematic review does not require ethical approval. The findings from this study will be submitted for peer-reviewed publication, shared at conference presentations and disseminated to both clinical and patient groups.

PROSPERO REGISTRATION NUMBER

The review will adhere to this protocol which has also been registered with PROSPERO (CRD42021282074).

Telerehabilitation for individuals with spinal cord injury in low-and middle-income countries: a systematic review of the literature

Study design

Systematic review.

Objective

To systematically review the evidence for the effectiveness of telerehabilitation as an intervention for people with spinal cord injury (SCI) in low-and middle-income countries (LMICs).

Setting

Not applicable.

Methods

MEDLINE (Ovid), Embase (Ovid), Pubmed and Global Health databases were used to identify studies published between 1946–2020 meeting the following criteria: (1) patients with SCI diagnosis; (2) in LMIC; (3) an outcome measuring clinical functional ability, quality of life or all-cause mortality reduction. The risk of bias in studies was graded using revised Cochrane risk-of-bias tool in randomised trials (RoB 2) and risk-of-bias tool in non-randomised trials (ROBINS-I). Evidence levels were graded with Grading of Recommendations, Assessment, Development and Evaluations (GRADE).

Results

In total, 107 articles were identified from the initial search. After screening, five studies were included. Some significant improvements to quality of life and pressure ulcer management were observed, alongside some improvement in functional ability with suggested improvement to depression scores. Telerehabilitation alleviated participants’ sense of social isolation, improved satisfaction scores and assisted them to remember techniques for SCI management. Telerehabilitation was valued by health professionals. There was no reduction in all-cause mortality.

Conclusion

There is insufficient evidence to recommend telerehabilitation as an intervention to treat and manage SCI in LMICs, although there is an indication of potential patient benefit. Further research is required to better understand the causal mechanisms underpinning the use of telerehabilitation and establish its efficacy, in the context of resource-limited settings.

Post-COVID syndrome symptoms, functional disability, and clinical severity phenotypes in hospitalized and nonhospitalized individuals: A cross-sectional evaluation from a community COVID rehabilitation service

There is currently limited information on clinical severity phenotypes of symptoms and functional disability in post-coronavirus disease 2019 (COVID) Syndrome (PCS). A purposive sample of 370 PCS patients from a dedicated community COVID-19 rehabilitation service was assessed using the COVID-19 Yorkshire Rehabilitation Scale where each symptom or functional difficulty was scored on a 0-10 Likert scale and also compared with before infection. Phenotypes based on symptom severity were extracted to identify any noticeable patterns. The correlation between symptom severity, functional disability, and overall health was explored. The mean age was 47 years, with 237 (64%) females. The median duration of symptoms was 211 days (interquartile range 143-353). Symptoms and functional difficulties increased substantially when compared to before infection. Three distinct severity phenotypes of mild (n = 90), moderate (n = 186), and severe (n = 94) were identified where the severity of individual symptoms was of similar severity within each phenotype. Symptom scores were strongly positively correlated with functional difficulty scores (0.7, 0.6-0.7) and moderately negatively correlated with overall health (-0.4, -0.3, to -0.5). This is the first study reporting on severity phenotypes in a largely nonhospitalized PCS cohort. Severity phenotypes might help stratify patients for targeted interventions and planning of care pathways.

The effect of Covid-19 mRNA vaccine on serum anti-Müllerian hormone levels

STUDY QUESTION

Does the administration of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) mRNA vaccine have an association with ovarian reserve as expressed by circulating anti-Müllerian hormone (AMH) levels?

SUMMARY ANSWER

Ovarian reserve as assessed by serum AMH levels is not altered at 3 months following mRNA SARS-CoV-2 vaccination.

WHAT IS KNOWN ALREADY

A possible impact of SARS-CoV-2 infection or vaccination through an interaction between the oocyte and the somatic cells could not be ruled out, however, data are limited.

STUDY DESIGN, SIZE, DURATION

This is a prospective study conducted at a university affiliated tertiary medical center between February and March 2021.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Study population included reproductive aged women (18-42 years) that were vaccinated by two Pfizer-BioNTech Covid-19 vaccines (21 days apart). Women with ovarian failure, under fertility treatments, during pregnancy, previous Covid-19 infection or vaccinated were excluded from the study. Blood samples were collected for AMH levels before the first mRNA vaccine administration. Additional blood samples after 3 months were collected for AMH and anti-Covid-19 antibody levels. Primary outcome was defined as the absolute and percentage change in AMH levels.

MAIN RESULTS AND THE ROLE OF CHANCE

The study group consisted of 129 women who received two mRNA vaccinations. Mean AMH levels were 5.3 (±SD 4.29) µg/l and 5.3 (±SD 4.50) µg/l at baseline and after 3 months, respectively (P = 0.11). To account for possible age-specific changes of AMH, sub-analyses were performed for three age groups: <30, 30-35 and >35 years. AMH levels were significantly lower for women older than 35 years at all times (P = 0.001 for pre and post vaccination AMH levels versus younger women). However, no significant differences for the changes in AMH levels before and after vaccinations (Delta AMH) were observed for the three age groups (P = 0.46). Additionally, after controlling for age, no association was found between the degree of immunity response and AMH levels.

LIMITATIONS, REASONS FOR CAUTION

Although it was prospectively designed, for ethical reasons we could not assign a priori a randomized unvaccinated control group. This study examined plasma AMH levels at 3 months after the first vaccination. It could be argued that possible deleterious ovarian and AMH changes caused by the SARS-CoV-2 mRNA vaccinations might take effect only at a later time. Only longer-term studies will be able to examine this issue.

WIDER IMPLICATIONS OF THE FINDINGS

The results of the study provide reassurance for women hesitant to complete vaccination against Covid 19 due to concerns regarding its effect on future fertility. This information could be of significant value to physicians and patients alike.

STUDY FUNDING/COMPETING INTEREST(S)

The study was supported by Sheba Medical Center institutional sources. All authors have nothing to disclose.

TRIAL REGISTRATION NUMBER

The study protocol was approved by the 'Sheba Medical Center' Ethical Committee Review Board (ID 8121-21-SMC) on 8 February 2021 and was registered at the National Institutes of Health (NCT04748172).

A Proposal for Expansion of the Medical Specialty of Rehabilitation Medicine

The workforce of the medical specialty of Rehabilitation Medicine (RM) in the UK is 10 times less than the European average for the specialty of Physical and Rehabilitation Medicine (PRM). This can be explained partly by the difference in the scope of practice within the specialty between the UK and other European countries and USA. This opinion paper aims to compare the rehabilitation needs in chronic medical conditions and compare the scope of practice between countries within Europe and other regions of the world. The potential advantages of a broader remit specialty to improve rehabilitation care for patients by involving rehabilitation physicians in various medical conditions is explored. Recommendations have been put forward in the Rehabilitation Medicine Expansion Proposal (RMEP), which is likely to make the medical specialty of RM/ PRM more satisfying for the doctors working in the specialty and a more attractive career choice for those entering training in the specialty. There is a need for an international universal framework for the scope of the specialty to have a greater impact on improving the lives of those with chronic medical conditions.

The COVID-19 Yorkshire Rehabilitation Scale (C19-YRS): Application and psychometric analysis in a post-COVID-19 syndrome cohort

As our understanding of the nature and prevalence of post‐coronavirus disease 2019 (COVID‐19) syndrome (PCS) is increasing, a measure of the impact of COVID‐19 could provide valuable insights into patients' perceptions in clinical trials and epidemiological studies as well as routine clinical practice. To evaluate the clinical usefulness and psychometric properties of the COVID‐19 Yorkshire Rehabilitation Scale (C19‐YRS) in patients with PCS, a prospective, observational study of 187 consecutive patients attending a post‐COVID‐19 rehabilitation clinic was conducted. The C19‐YRS was used to record patients' symptoms, functioning, and disability. A global health question was used to measure the overall impact of PCS on health. Classical psychometric methods (data quality, scaling assumptions, targeting, reliability, and validity) were used to assess the C19‐YRS. For the total group, missing data were low, scaling and targeting assumptions were satisfied, and internal consistency was high (Cronbach's α = 0.891). Relationships between the overall perception of health and patients' reports of symptoms, functioning, and disability demonstrated good concordance. This is the first study to examine the psychometric properties of an outcome measure in patients with PCS. In this sample of patients, the C19‐YRS was clinically useful and satisfied standard psychometric criteria, providing preliminary evidence of its suitability as a measure of PCS.

A Multidisciplinary NHS COVID-19 Service to Manage Post-COVID-19 Syndrome in the Community

The National Institute for Health and Care Excellence (NICE) describe “post COVID-19 syndrome” or “Long COVID” as a set of persistent physical, cognitive and/or psychological symptoms that continue for more than 12 weeks after illness and which are not explained by an alternative diagnosis. These symptoms are experienced not only by patients discharged from hospital but also those in the community who did not require inpatient care. To support the recovery of this group of people, a unique integrated rehabilitation pathway was developed following extensive service evaluations by Leeds Primary Care Services, Leeds Community Healthcare NHS Trust and Leeds Teaching Hospital NHS Trust. The pathway aligns itself to the NHS England “Five-point plan” to embed post-COVID-19 syndrome assessment clinics across England, supporting the comprehensive medical assessment and rehabilitation intervention for patients in the community. The pathway was first of its kind to be set up in the UK and comprises of a three-tier service model (level 1: specialist MDT service, level 2: community therapy teams and level 3: self-management). The MDT service brings together various disciplines with specialist skill sets to provide targeted individualized interventions using a specific core set of outcome measures including C19-YRS (Yorkshire Rehabilitation Scale). Community and primary care teams worldwide need such an integrated multidisciplinary comprehensive model of care to deal with the growing number of cases of post-COVID-19 syndrome effectively and in a timely manner.

The self-report version and digital format of the COVID-19 Yorkshire Rehabilitation Scale (C19-YRS) for Long Covid or Post-COVID syndrome assessment and monitoring

The C19-YRS was the first scale reported in the literature for patient assessment and monitoring in Long Covid or Post-COVID syndrome. The scale has demonstrated content validity in a previous COVID-19 follow-up study. The growing number of patients with Post-COVID syndrome required the development of a self-report version (and a digital format) so that the scale can be completed by patients themselves. Individuals with Long Covid and clinicians providing care were involved in iterative changes to the scale. The self-report version of the scale captures symptom severity, functional disability and global health status. The C19-YRS digital format comprises a smartphone application for the patient and a web portal for the clinician to assess, triage and monitor patients remotely. The items have been shown to span all the components of the WHO ICF Framework for health condition.

Using EEG Alpha States to Understand Learning During Alpha Neurofeedback Training for Chronic Pain

Objective

Alpha-neurofeedback (α-NFB) is a novel therapy which trains individuals to volitionally increase their alpha power to improve pain. Learning during NFB is commonly measured using static parameters such as mean alpha power. Considering the biphasic nature of alpha rhythm (high and low alpha), dynamic parameters describing the time spent by individuals in high alpha state and the pattern of transitioning between states might be more useful. Here, we quantify the changes during α-NFB for chronic pain in terms of dynamic changes in alpha states.

Methods

Four chronic pain and four healthy participants received five NFB sessions designed to increase frontal alpha power. Changes in pain resilience were measured using visual analogue scale (VAS) during repeated cold-pressor tests (CPT). Changes in alpha state static and dynamic parameters such as fractional occupancy (time in high alpha state), dwell time (length of high alpha state) and transition probability (probability of moving from low to high alpha state) were analyzed using Friedman’s Test and correlated with changes in pain scores using Pearson’s correlation.

Results

There was no significant change in mean frontal alpha power during NFB. There was a trend of an increase in fractional occupancy, mean dwell duration and transition probability of high alpha state over the five sessions in chronic pain patients only. Significant correlations were observed between change in pain scores and fractional occupancy (r = −0.45, p = 0.03), mean dwell time (r = -0.48, p = 0.04) and transition probability from a low to high state (r = -0.47, p = 0.03) in chronic pain patients but not in healthy participants.

Conclusion

There is a differential effect between patients and healthy participants in terms of correlation between change in pain scores and alpha state parameters. Parameters providing a more precise description of the alpha power dynamics than the mean may help understand the therapeutic effect of neurofeedback on chronic pain.

High volume distension injection (HVDI) for chronic mid-portion Achilles tendinopathy: A service evaluation of clinical outcomes

Purpose:

High Volume Distension Injection (HVDI) is a treatment adjunct in chronic mid-portion Achilles tendinopathy. This study analysed whether HVDI is safe and effective in an outpatient clinic setting.

Methods:

Retrospective service evaluation of 18 participants over 18 months. Ultrasound-guided saline, corticosteroid and bupivacaine was injected to disrupt vasculo-neural ingrowth, with post-procedure eccentric exercises. Mean follow-up was 8 weeks. Outcomes used were Numeric rating Scale (NRS) of pain, tendon thickness and Modified Ohberg score (MOS) of neovascularisation measured on Ultrasound and Doppler imaging.

Results:

Mean reduction in NRS was 5.30 ± 2.53 ( P < 0.001). Mean tendon thickness reduction was 0.21 ± 0.17 cm ( P < 0.001). Median MOS improved from 2.00 ± 2.00 to 1.00 ± 3.00 ( P = 0.009). No complications occurred. 11 participants had successful primary HVDI, 3 responded to a second injection. Two non-responders were referred for surgery and two referred for alternative therapy by patient preference.

Conclusion:

Significant reduction in pain, tendon thickness and neovascularity was observed in 78% of patients. Recurrence in 39%. HVDI with eccentric training is safe and effective intervention in outpatient clinic setting.

Ultrasound-guided hydrodilatation for adhesive capsulitis of the shoulder: A case series

Adhesive capsulitis (AC) is a painful and debilitating condition of the glenohumeral joint and has been described as self-limiting. However, recent reports suggest that up to 40% of patients report persistent symptoms, therefore intervention strategies are needed to improve function and quality of life. One such intervention is the hydrodilatation of the glenohumeral joint with a high-volume injection, comprising of local anaesthetic, corticosteroid and normal saline, making a total volume of up to 40 ml. This service evaluation assessed the outcomes in 28 patients (23 females and 5 males; mean age 54.29 years) with AC who underwent ultrasound-guided (USG) hydrodilatation in a clinical outpatient setting. There was a statistically significant improvement in pain and all shoulder movements (all changes p value < 0.01). No adverse effects were encountered. Therefore, the USG glenohumeral joint hydrodilatation procedure in a clinical outpatient setting is a safe and effective intervention for AC.

Applying the WHO ICF Framework to the Outcome Measures Used in the Evaluation of Long-Term Clinical Outcomes in Coronavirus Outbreaks

(1) Objective: The World Health Organization’s (WHO) International Classification of Functioning, Disability and Health (ICF) classification is a unified framework for the description of health and health-related states. This study aimed to use the ICF framework to classify outcome measures used in follow-up studies of coronavirus outbreaks and make recommendations for future studies. (2) Methods: EMBASE, MEDLINE, CINAHL and PsycINFO were systematically searched for original studies assessing clinical outcomes in adult survivors of severe acute respiratory distress syndrome (SARS), middle east respiratory syndrome (MERS) and coronavirus disease-19 (COVID-19) after hospital discharge. Individual items of the identified outcome measures were linked to ICF second-level and third-level categories using ICF linking rules and categorized according to an ICF component. (3) Results: In total, 33 outcome measures were identified from 36 studies. Commonly used (a) ICF body function measures were Pulmonary Function Tests (PFT), Impact of event scale (IES-R) and Hospital Anxiety and Depression Scale (HADS); (b) ICF activity was 6-Minute Walking Distance (6MWD); (c) ICF participation measures included Short Form-36 (SF-36) and St George’s Respiratory Questionnaire (SGRQ). ICF environmental factors and personal factors were rarely measured. (4) Conclusions: We recommend future COVID-19 follow-up studies to use the ICF framework to select a combination of outcome measures that capture all the components for a better understanding of the impact on survivors and planning interventions to maximize functional return.

Development of an integrated rehabilitation pathway for individuals recovering from COVID-19 in the community

OBJECTIVE

COVID-19 is a multisystem illness that has considerable long-term physical, psychological, cognitive, social and vocational sequelae in survivors. Given the scale of this burden and lockdown measures in most countries, there is a need for an integrated rehabilitation pathway using a tele-medicine approach to screen and manage these sequelae in a systematic and efficient way.

METHODS

A multidisciplinary team of professionals in the UK developed a comprehensive pragmatic telephone screening tool, the COVID-19 Yorkshire Rehabilitation Screen (C19-YRS), and an integrated rehabilitation pathway, which spans the acute hospital trust, community trust and primary care service within the National Health Service (NHS) service model.

RESULTS

The C19-YRS telephone screening tool, developed previously, was used to screen symptoms and grade their severity. Referral criteria thresholds were applied to the output of C19-YRS to inform the decision-making process in the rehabilitation pathway. A dedicated multidisciplinary COVID-19 rehabilitation team is the core troubleshooting forum for managing complex cases with needs spanning multiple domains of the health condition.

CONCLUSION

The authors recommend that health services dealing with the COVID-19 pandemic adopt a comprehensive telephone screening system and an integrated rehabilitation pathway to manage the large number of survivors in a timely and effective manner and to enable the provision of targeted interventions.

Entraining Alpha Activity Using Visual Stimulation in Patients With Chronic Musculoskeletal Pain: A Feasibility Study

Entraining alpha activity with rhythmic visual, auditory, and electrical stimulation can reduce experimentally induced pain. However, evidence for alpha entrainment and pain reduction in patients with chronic pain is limited. This feasibility study investigated whether visual alpha stimulation can increase alpha power in patients with chronic musculoskeletal pain and, secondarily, if chronic pain was reduced following stimulation. In a within-subject design, 20 patients underwent 4-min periods of stimulation at 10 Hz (alpha), 7 Hz (high-theta, control), and 1 Hz (control) in a pseudo-randomized order. Patients underwent stimulation both sitting and standing and verbally rated their pain before and after each stimulation block on a 0-10 numerical rating scale. Global alpha power was significantly higher during 10 Hz compared to 1 Hz stimulation when patients were standing (t = -6.08, p < 0.001). On a more regional level, a significant increase of alpha power was found for 10 Hz stimulation in the right-middle and left-posterior region when patients were sitting. With respect to our secondary aim, no significant reduction of pain intensity and unpleasantness was found. However, only the alpha stimulation resulted in a minimal clinically important difference in at least 50% of participants for pain intensity (50%) and unpleasantness ratings (65%) in the sitting condition. This study provides initial evidence for the potential of visual stimulation as a means to enhance alpha activity in patients with chronic musculoskeletal pain. The brief period of stimulation was insufficient to reduce chronic pain significantly. This study is the first to provide evidence that a brief period of visual stimulation at alpha frequency can significantly increase alpha power in patients with chronic musculoskeletal pain. A further larger study is warranted to investigate optimal dose and individual stimulation parameters to achieve pain relief in these patients.

Postdischarge symptoms and rehabilitation needs in survivors of COVID-19 infection: A cross-sectional evaluation

BACKGROUND

There is currently very limited information on the nature and prevalence of post-COVID-19 symptoms after hospital discharge.

METHODS

A purposive sample of 100 survivors discharged from a large University hospital were assessed 4 to 8 weeks after discharge by a multidisciplinary team of rehabilitation professionals using a specialist telephone screening tool designed to capture symptoms and impact on daily life. EQ-5D-5L telephone version was also completed.

RESULTS

Participants were between 29 and 71 days (mean 48 days) postdischarge from hospital. Thirty-two participants required treatment in intensive care unit (ICU group) and 68 were managed in hospital wards without needing ICU care (ward group). New illness-related fatigue was the most common reported symptom by 72% participants in ICU group and 60.3% in ward group. The next most common symptoms were breathlessness (65.6% in ICU group and 42.6% in ward group) and psychological distress (46.9% in ICU group and 23.5% in ward group). There was a clinically significant drop in EQ5D in 68.8% in ICU group and in 45.6% in ward group.

CONCLUSIONS

This is the first study from the United Kingdom reporting on postdischarge symptoms. We recommend planning rehabilitation services to manage these symptoms appropriately and maximize the functional return of COVID-19 survivors.

A Proposal for Multidisciplinary Tele-Rehabilitation in the Assessment and Rehabilitation of COVID-19 Survivors

A global pandemic of a new highly contagious disease called COVID-19 resulting from coronavirus (severe acute respiratory syndrome (SARS)-Cov-2) infection was declared in February 2020. Though primarily transmitted through the respiratory system, other organ systems in the body can be affected. Twenty percent of those affected require hospitalization with mechanical ventilation in severe cases. About half of the disease survivors have residual functional deficits that require multidisciplinary specialist rehabilitation. The workforce to deliver the required rehabilitation input is beyond the capacity of existing community services. Strict medical follow-up guidelines to monitor these patients mandate scheduled reviews within 12 weeks post discharge. Due to the restricted timeframe for these events to occur, existing care pathway are unlikely to be able to meet the demand. An innovative integrated post-discharge care pathway to facilitate follow up by acute medical teams (respiratory and intensive care) and a specialist multidisciplinary rehabilitation team is hereby proposed. Such a pathway will enable the monitoring and provision of comprehensive medical assessments and multidisciplinary rehabilitation. This paper proposes that a model of tele-rehabilitation is integrated within the pathway by using digital communication technology to offer quick remote assessment and efficient therapy delivery to these patients. Tele-rehabilitation offers a quick and effective option to respond to the specialist rehabilitation needs of COVID-19 survivors following hospital discharge.

Long-term clinical outcomes in survivors of severe acute respiratory syndrome and Middle East respiratory syndrome coronavirus outbreaks after hospitalisation or ICU admission: A systematic review and meta-analysis

OBJECTIVE

To determine long-term clinical outcomes in survivors of severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS) coronavirus infections after hospitalization or intensive care unit admission.

DATA SOURCES

Ovid MEDLINE, EMBASE, CINAHL Plus, and PsycINFO were searched.

STUDY SELECTION

Original studies reporting clinical outcomes of adult SARS and MERS survivors 3 months after admission or 2 months after discharge were included.

DATA EXTRACTION

Studies were graded using the Oxford Centre for Evidence-Based Medicine 2009 Level of Evidence Tool. Meta-analysis was used to derive pooled estimates for prevalence/severity of outcomes up to 6 months after hospital discharge, and beyond 6 months after discharge.

DATA SYNTHESIS

Of 1,169 identified studies, 28 were included in the analysis. Pooled analysis revealed that common complications up to 6 months after discharge were: impaired diffusing capacity for carbon monoxide (prevalence 27%, 95% confidence interval (CI) 15–45%); and reduced exercise capacity (mean 6-min walking distance 461 m, CI 450–473 m). The prevalences of post-traumatic stress disorder (39%, 95% CI 31–47%), depression (33%, 95% CI 20–50%) and anxiety (30%, 95% CI 10–61) beyond 6 months after discharge were considerable. Low scores on Short-Form 36 were identified beyond 6 months after discharge.

CONCLUSION

Lung function abnormalities, psychological impairment and reduced exercise capacity were common in SARS and MERS survivors. Clinicians should anticipate and investigate similar long-term outcomes in COVID-19 survivors.

Acceptability and usability of smartphone-based brainwave entrainment technology used by individuals with chronic pain in a home setting

Background:

Brainwave entrainment (BWE) using rhythmic visual or auditory stimulation has many potential clinical applications, including the management of chronic pain, where there is a pressing need for novel, safe and effective treatments. The aim of this study was to gain qualitative feedback on the acceptability and usability of a novel BWE smartphone application, to ensure it meets the needs and wishes of end users.

Methods:

Fifteen participants with chronic pain used the application at home for 4 weeks. Semi-structured telephone interviews were then carried out. A template analysis approach was used to interpret the findings, with an initial coding template structured around the constructs of a theoretical framework for assessing acceptability of healthcare interventions. Structured data analysis generated a final modified coding structure, capturing themes generated across participants’ accounts.

Results:

The four main themes were ‘approach to trying out the app: affective attitude and ethicality’, ‘perceived effectiveness’, ‘opportunity costs and burden’ and ‘intervention coherence and self-efficacy’. All participants were willing to engage with the technology and welcomed it as an alternative approach to medications. Participants appreciated the simplicity of design and the ability to choose between visual or auditory stimulation. All the participants felt confident in using the application.

Conclusion:

The findings demonstrate preliminary support for the acceptability and usability of the BWE application. This is the first qualitative study of BWE to systematically assess these issues.

Evaluating the use of robotic and virtual reality rehabilitation technologies to improve function in stroke survivors: A narrative review

This review evaluates the effectiveness of robotic and virtual reality technologies used for neurological rehabilitation in stroke survivors. It examines each rehabilitation technology in turn before considering combinations of these technologies and the complexities of rehabilitation outcome assessment. There is high-quality evidence that upper-limb robotic rehabilitation technologies improve movement, strength and activities of daily living, whilst the evidence for robotic lower-limb rehabilitation is currently not as convincing. Virtual reality technologies also improve activities of daily living. Whilst the benefit of these technologies over dose-controlled conventional rehabilitation is likely to be small, there is a role for both technologies as part of a broader rehabilitation programme, where they may help to increase the intensity and amount of therapy delivered. Combining robotic and virtual reality technologies in a rehabilitation programme may further improve rehabilitation outcomes and we would advocate randomised controlled trials of these technologies in combination.

Retrospective analysis of functional and tracheostomy (decannulation) outcomes in patients with brain injury in a hyper-acute rehabilitation unit

Objectives

Hyper-Acute Rehabilitation Units (HA-RUs) provide multidisciplinary rehabilitation to patients with acute neurological injuries. This includes managing patients with tracheostomies. This is the first study of its kind to examine clinical outcomes in patients with brain injury and tracheostomy managed in a HARU.

Methods

Retrospective analysis of clinical outcomes in tracheostomy patients admitted to a HARU over a 2-year period.

Results

A total of 208 patients were admitted to the HARU, of whom 99 (60 males and 39 females) had a tracheostomy either at admission or during their stay in the HARU. Mean Glasgow Coma Scale score at admission was 11 (range 5-15) and at discharge was 13 (range 8-15). Mean Functional Independence Measure and Functional Assessment Measure (FIM+FAM) score improved from 52 at admission to 95 at discharge. Mean FIM+FAM cognitive admission cognitive sub-score improved from 23 to 42, and mean motor sub-score from 29 to 42. Changes in scores were deemed to be clinically significant as per thresholds reported in the literature. Of the total patients in this study, 79% were successfully decannulated and 21% needed long-term tracheostomy.

Conclusion

Patients with tracheostomy following brain injury can be appropriately managed in a HARU and show clinically significant improvement in functional outcomes.

Association between Paroxysmal Sympathetic Hyperactivity and tracheostomy weaning in Traumatic Brain Injury

BACKGROUND

Rehabilitation following severe Traumatic Brain Injury (TBI) often involves the use of temporary tracheostomies. Tracheostomy weaning is influenced by physiological parameters, which are abnormal in the concomitant complication of Paroxysmal Sympathetic Hyperactivity (PSH).

OBJECTIVE

To investigate the association between PSH and tracheostomy weaning in severe TBI.

METHODS

This was a retrospective cohort study of consecutive patients with TBI and tracheostomy admitted to a Hyper-Acute Neurorehabilitation Unit over a 34-month period. Duration of tracheostomy wean and influencing characteristics were statistically compared between those with and without PSH.

RESULTS

Fifty-one patients admitted with TBI required a tracheostomy. Of these, 10 patients were also diagnosed with PSH. The mean tracheostomy wean in the PSH group was longer compared to the non-PSH group (72.3, SD 61.0 versus 30.0 days, SD 16.2). This difference was statistically significant (p = 0.007, using Mann Whitney U test). The PSH group had more respiratory and oral secretions, but this was not statistically significant (p = 0.16 and 0.29).

CONCLUSIONS

This is the first study to demonstrate that PSH is associated with prolonged tracheostomy weaning in severe TBI. Awareness of this association should enable those planning rehabilitation to set realistic goals for a patient's tracheostomy weaning programme.

Employing the International Classification of Functioning, Disability and Health framework to capture user feedback in the design and testing stage of development of home-based arm rehabilitation technology

The purpose of this study was to evaluate the International Classification of Functioning, Disability and Health (ICF) as a framework to ensure that key aspects of user feedback are identified in the design and testing stages of development of a home-based upper limb rehabilitation system. Seventeen stroke survivors with residual upper limb weakness, and seven healthcare professionals with expertise in stroke rehabilitation, were enrolled in the user-centered design process. Through semi-structured interviews, they provided feedback on the hardware, software and impact of a home-based rehabilitation device to facilitate self-managed arm exercise. Members of the multidisciplinary clinical and engineering research team, based on previous experience and existing literature in user-centred design, developed the topic list for the interviews. Meaningful concepts were extracted from participants' interviews based on existing ICF linking rules and matched to categories within the ICF Comprehensive Core Set for stroke. Most of the interview concepts (except personal factors) matched the existing ICF Comprehensive Core Set categories. Personal factors that emerged from interviews e.g. gender, age, interest, compliance, motivation, choice and convenience that might determine device usability are yet to be categorised within the ICF framework and hence could not be matched to a specific Core Set category.

Tracheostomy weaning outcomes in relation to the site of acquired brain injury: A retrospective case series

OBJECTIVE

To analyse whether the outcome of tracheostomy weaning is influenced by the site of injury in acquired brain injury.

METHODS

A retrospective case review of all the consecutive admissions to an acute neurorehabilitation unit in a 2-year period was performed. Patients with a diagnosis of acquired brain injury and tracheostomy in situ were included in this study.

RESULTS

One hundred and six patients were included in the analysis. They were considered in two groups based on the site of brain injury: Group S, those with supratentorial brain injury only; and Group I, those with any injury with infratentorial involvement. Fifty-one (82%) patients in Group S were successfully weaned from the tracheostomy, compared to only 27 (61%) of patients in Group I. In other words, the proportion of unsuccessful weans (long-term tracheostomy) was 11 (18%) in Group S compared to 17 (39%) in Group I. The statistical significance of successful weans between the groups was p = 0.01 (Chi-square test). The common reasons for unsuccessful weaning were excessive secretion load and recurrent aspiration pneumonia.

CONCLUSIONS

Patients with isolated supratentorial brain injury have a statistically significant higher chance of successful decannulation when compared to those patients with any infratentorial brain injury involvement.

Home-based Computer Assisted Arm Rehabilitation (hCAAR) robotic device for upper limb exercise after stroke: results of a feasibility study in home setting

Background

Home-based robotic technologies may offer the possibility of self-directed upper limb exercise after stroke as a means of increasing the intensity of rehabilitation treatment. The current literature has a paucity of robotic devices that have been tested in a home environment. The aim of this research project was to evaluate a robotic device Home-based Computer Assisted Arm Rehabilitation (hCAAR) that can be used independently at home by stroke survivors with upper limb weakness.

Methods

hCAAR device comprises of a joystick handle moved by the weak upper limb to perform tasks on the computer screen. The device provides assistance to the movements depending on users ability. Nineteen participants (stroke survivors with upper limb weakness) were recruited. Outcome measures performed at baseline (A0), at end of 8-weeks of hCAAR use (A1) and 1 month after end of hCAAR use (A2) were: Optotrak kinematic variables, Fugl Meyer Upper Extremity motor subscale (FM-UE), Action Research Arm Test (ARAT), Medical Research Council (MRC) and Modified Ashworth Scale (MAS), Chedoke Arm and Hand Activity Inventory (CAHAI) and ABILHAND.

Results

Two participants were unable to use hCAAR: one due to severe paresis and the other due to personal problems. The remaining 17 participants were able to use the device independently in their home setting. No serious adverse events were reported. The median usage time was 433 minutes (IQR 250 – 791 min). A statistically significant improvement was observed in the kinematic and clinical outcomes at A1. The median gain in the scores at A1 were by: movement time 19%, path length 15% and jerk 19%, FM-UE 1 point, total MAS 1.5 point, total MRC 2 points, ARAT 3 points, CAHAI 5.5 points and ABILHAND 3 points. Three participants showed clinically significant improvement in all the clinical outcomes.

Conclusions

The hCAAR feasibility study is the first clinical study of its kind reported in the current literature; in this study, 17 participants used the robotic device independently for eight weeks in their own homes with minimal supervision from healthcare professionals. Statistically significant improvements were observed in the kinematic and clinical outcomes in the study.

Electronic supplementary material

The online version of this article (doi:10.1186/1743-0003-11-163) contains supplementary material, which is available to authorized users.

Management of acute overdose or withdrawal state in intrathecal baclofen therapy

STUDY DESIGN

Individuals who are treated with intrathecal Baclofen (ITB) pump delivery system for intractable spasticity can suffer from severe morbidity as a result of acute overdose or withdrawal of ITB, which can also be life threatening. Current literature has a number of single case studies with different approaches to the management in such states.

OBJECTIVES

The aim of this article is to consolidate available evidence and develop treatment pathways for acute ITB overdose and withdrawal states.

METHODS

We searched MEDLINE, EMBASE, CINAHL and the Cochrane Library databases using the keywords 'intrathecal', 'baclofen', 'withdrawal', 'overdose' to identify studies (published up to December 2010) that focused on presentation or treatment of acute overdose and withdrawal state in ITB therapy. Only original articles in English involving adult population were included.

RESULTS

Initial search revealed 130 articles. After reading the abstract, 13 studies on ITB overdose and 23 studies on ITB withdrawal were deemed suitable for inclusion. All studies were either single-case studies or case series.

CONCLUSION

Acute ITB overdose is managed with immediate cessation of baclofen delivery through the system, reducing the baclofen load by cerebrospinal fluid aspiration and by providing supportive treatment in an intensive care setting. There is no specific antidote for reversing overdose symptoms. Acute ITB withdrawal is managed by restoring the delivery of ITB, providing supportive care in an intensive care setting and using drugs like low dose propofol or benzodiazepines in selected cases. Early involvement of ITB physicians is strongly recommended.

A one-stop approach to the management of soft tissue and degenerative musculoskeletal conditions using clinic-based ultrasonography

BACKGROUND AND OBJECTIVE

One-stop clinics aim at assessment, investigation and initiating treatment in a single hospital visit. They have been proven to be cost-effective and to increase patient satisfaction in various specialties. The aim of this study was to describe the one-stop approach to managing soft tissue and degenerative musculoskeletal conditions using clinic-based musculoskeletal ultrasonography (MSUS).

METHODS

A retrospective case record review was carried out of patients assessed and managed in the musculoskeletal clinic by a musculoskeletal and sports physician over a 10-month period.

RESULTS

A total of 1,166 patients were assessed and managed in a total of 155 outpatient clinics. The age range of patients was 19 to 85 years (median age 45 years). The diagnoses included traumatic or overuse tendinopathy, degenerative arthritis, bursitis, acute/chronic sporting injuries and acute/chronic back pain. A total of 1,012 patients (87%) had conditions related to the appendicular system (shoulder girdle, upper limb, pelvic girdle and lower limb) and 154 patients were referred with spinal pain. All patients with appendicular system problems had a definite diagnosis and treatment initiated on the first visit to the clinic. In 658 (65%) patients, a diagnostic ultrasound was deemed an appropriate investigation to improve the accuracy of diagnosis and more than half of them (352 patients) needed ultrasound-guided injections as part of the management of their conditions. A portable GE Healthcare LOGIQe machine with a 10 MHz linear probe and colour Doppler flow imaging was used to perform all scans. No adverse incidents were reported.

CONCLUSIONS

The use of clinic-based MSUS enables a one-stop approach, reduces repeated hospital appointments and improves quality of care in an outpatient musculoskeletal clinic.

The academic value of rehabilitation medicine meetings

PURPOSE

Twice-yearly meetings of The British Society of Rehabilitation Medicine (BSRM) take place at which posters and free papers are generated, as abstracts, to present novel research findings, audits and case reports. The aim of this study was to evaluate the academic value of these meetings, by determining the subsequent rate of publication in peer-reviewed journals of abstracts presented. This was compared to the publication rate of other European medical specialist society meetings.

METHODS

The authors used MEDLINE, PubMed and Google Scholar search engines to look for publication of abstracts presented at BSRM meetings within peer-reviewed journals over a 7-year period (2000-2006). The abstracts were categorised into sub-groups (original study, audit, review, case report and service description) to determine which type was more likely to be published. The above databases were used also to extract studies on publication rate of other medical specialties in Europe.

RESULTS

In 7 years, a total of 251 abstracts (of which 152 are original studies) have been presented as free papers or posters in a total of 13 meetings. The publication rate for the described study categories were: total 34%, original study 52%, review 50%, case report 5%, audit 0% and service description 0%. Publication rates from other specialist meetings in Europe range from 10% to 70%.

CONCLUSION

The average publication rate for an abstract submitted to a BSRM meeting is 34% for any abstract and 52% for an original study suggesting that the meeting is generating abstracts of comparable academic interest to other specialist societies.

Can an understanding of transactional analysis improve postgraduate clinical supervision?

Clinical supervision in postgraduate medical training is vital in producing competent and safe health-care practitioners. Effective communication between supervisors and trainees at an interpersonal and professional level determines the quality of the supervision process. Transactional analysis, a theory of personality, can be used to enhance understanding of interpersonal interactions and improve the outcomes of clinical training.

Pharmacotherapy for treatment of attention deficits after non-progressive acquired brain injury. A systematic review

Objective: To systematically review the effectiveness of medications used to improve attention in people with non-progressive acquired brain injury.

Design: A systematic review.

Methods: MEDLINE, EMBASE, CINALH, PUBMED and PsychINFO databases were used to identify studies published between 1987 and 2008 meeting the following criteria: studies with subjects older than 18 years; diagnosis of new onset or previous acquired brain injury; medication given to improve attention and use of outcome to measure attention. Studies involving subjects in low arousal states or with neurogenerative conditions were excluded. The studies were categorized into three evidence levels: I — Randomized controlled trials; II — Prospective studies, controlled trials with methodological limitations; and III — Retrospective studies, clinical case series.

Results: Forty-seven articles were identified on initial search. Twenty-six met the pre-specified criteria. Five articles were assessed as meeting the level I evidence criteria, 12 were level II studies and 9 were level III studies. Methylphenidate can improve information processing speed but not all attention aspects in some people after traumatic brain injury. There is weak evidence for use of dopamine agonists to improve neglect/inattention after stroke. There is little evidence on the frequency of adverse effects and long-term functional benefits.

Conclusion: Although there is lack of robust evidence to recommend the routine use of medication to improve attention after traumatic brain injury and stroke, the existing evidence indicates potential for benefit in some patents and therefore further research is warranted.

A comparison of functional assessment instruments and work status in chronic back pain

AIM

The aim of this cross sectional study was to analyse whether low back pain (LBP) functional assessment instruments correlate well with work status measures.

METHODS

This study was a cross sectional study that enrolled 375 patients with chronic LBP attending back pain outpatient clinics of a University Hospital and a specialist rehabilitation centre over a period of one year. The outcome scores measured were Oswestry Disability Index, Roland Morris Disability Questionnaire and Orebro Musculoskeletal Pain Questionnaire. The effect of back pain on their work status was also recorded and correlated to the above instrument values.

RESULTS

There was a only a modest correlation between work status and the three measured outcome scores, with the Spearman rank correlation being 0.47 for OMPQ, 0.43 for ODI and 0.39 for RMQ.

CONCLUSION

The studied standard LBP outcome measures and work status are not interchangeable. The impact on work status should not be assumed based on the severity of these outcome measures and should be recorded as a separate outcome measure in chronic low back pain.

Restoring mobility: theories, technologies and effective treatments

Movement impairment affects the independence and lifestyle of a significant number of people worldwide. A MDT approach towards the problem is needed for optimal restoration of mobility. Educating vulnerable people on preventive strategies and safe techniques after a fall is imperative. Use of appropriate orthosis, assistive technology, physiotherapy and surgical interventions should be timely and evidence based. Assessment of the patient is critical to ensure successful outcomes of technological interventions. Novel technologies such as targeted reinnervation prosthesis and implantable technologies, although at a very early stage in their development, have huge potential to help people with movement impairments due to disorders of neuromuscular control or limb loss.

Flexion reminder device to discourage recurrent posterior dislocation of a total hip replacement: a case report

Introduction

Recurrent dislocation of a total hip replacement prosthesis is a frustrating complication for both the surgeon and the patient. For positional dislocations with no indications for revision surgery, the current best treatment is physiotherapy, the use of abduction braces and avoidance of unsafe hip positions. Abduction braces can be cumbersome and have poor compliance. We report the successful use of a new lightweight flexion reminder device that can be used to treat people with this condition.

Case presentation

A 64-year-old British woman experienced recurrent positional posterior dislocation after primary hip replacement, particularly when involved in activities involving unsafe flexion of the operated hip. She disliked using an abduction brace and hence was given a simple 'flexion reminder device' that could be strapped to the thigh. Beyond the safe flexion limit, the padded top end of the device hitched against the groin crease and reminded her not to flex further, to avoid dislocation. She experienced no discomfort in wearing the device continuously throughout the day and was very satisfied. She has had no further dislocations in the 2 years since she began using it.

Conclusion

In cases of arthroplasty dislocation caused mainly by an unsafe hip position, and with no indication for revision surgery, this new lightweight and easily worn flexion reminder device may be a good option for avoiding such positional dislocations, particularly those caused by unsafe flexion.