Referral of patients with neuromuscular disease to occupational therapy, physical therapy and speech therapy: Usual practice versus multidisciplinary advice

[Physiotherapeutic Care of Adults with Neuromuscular Diseases - an Online Survey of Physiotherapists in the City Area of Munich]

BACKGROUND AND AIM

Physiotherapy has a key role in the symptomatic treatment of neuromuscular disorders (NMD). In the health care of adults with NMD, there may be intransparency of physiotherapy processes due, among other factors, to disciplinary interfaces. This study describes the current state of physiotherapeutic care for adults with NMD and examines the needs of physiotherapists in improving the quality of physiotherapeutic care.

METHODS

An online survey of physiotherapists in the city area of Munich was carried out using Lime Survey. The survey link was distributed in both inpatient and outpatient settings and with use of the snowball principle. The data on the closed and open questions were accordingly evaluated quantitatively descriptively and content-analytically.

RESULTS

A total of 137 physiotherapists participated in the online survey, and information from 124 survey participants was included in the analyses. 62.4% (n=58) of them were involved in the treatment of adults with NMD. The most common physiotherapy prescription was "Physiotherapy for the treatment of central movement disorders" (KG-ZNS) (82.9%; n=34). Home visits and assistive devices were ranked as the most effective interventions. 69.1% (n=56) of survey participants would like more information on NMD, primarily in the form of e-learning (24.0%; n=37) and professional articles (21.4%; n=33). In addition to the identified need for information, there were requests for more in-depth interprofessional communication and increased time resources in physiotherapeutic treatment.

CONCLUSION

The wide range of physiotherapeutic measures applied pursues, among other things, the goal of helping patients maintain their independence and is considered to be of great benefit in the care of adult patients with NMD. It is important to address the identified desire and need for information expressed by physiotherapists on the subject of NMD in the preferred form by means of low-threshold offers. The interprofessional communication should be intensified and time-related aspects should be considered in the issuing of prescriptions as well as with regard to a possible blank prescription option in the future, in order to achieve positive effects in the physiotherapeutic care of adult patients with NMD.

Fragmented care and missed opportunities: the experiences of adults with myasthenia gravis in accessing and receiving allied health care in Australia

PURPOSE

Although allied health services are important adjuncts to medical care for people with myasthenia gravis (MG), the underutilisation of these services is not well understood within the Australian context. It is critical to explore patients' perceptions to develop services that meet consumer needs. This study, therefore, sought to obtain insight into MG patients' perspectives and experiences, in addition to the outcomes, of accessing allied health services.

MATERIALS AND METHODS

Thirteen Australian adults with MG participated in semi-structured interviews. Qualitative analysis was conducted inductively using thematic content analysis.

RESULTS

Four themes were identified: (1) missed opportunities and unmet care needs were common, due to frequent patient-provider communication breakdowns and a lack of referral protocols, (2) personal factors - patient self-advocacy influenced their perceived need, with some lacking confidence to seek help, (3) perceived benefit and health provider capacities - most valued allied health despite differing perceptions of health professionals' attitudes, skills, and willingness to learn, and (4) a resultant fragmentation of care between services was universal.

CONCLUSIONS

Findings highlighted a need for clear referral pathways, coordinated multidisciplinary care, improved access to community-based services and education for allied health professionals about MG.Implications for rehabilitationAdults with myasthenia gravis (MG) report a lack of referral pathways to allied health services, leading to unmet needs and fragmented care.Although there is a perceived benefit to allied health care, experiences are impacted by health provider capacity and attitudes.There needs to be an overall shift towards multidisciplinary care for people with MG, and the development of clear referral pathways.Specific education about MG should be available for allied health professionals to improve their knowledge and skills in treating this population.

Implementation of a new clinical and organisational practice to improve access to primary care services: a protocol for an effectiveness-implementation hybrid study

INTRODUCTION

In Canada, as in most Organisation for Economic Co-operation and Development countries, healthcare systems face significant challenges in ensuring better access to primary care. A regional healthcare organisation in Quebec (Canada) serving a population of approximately 755 459 citizens has implemented a standardised access approach to primary care services for this population. The objective of this new clinical and organisational practice is to ensure that users benefit from the same referral process, regardless of the entry point, in order to be directed to the right services. This new practice integrates a shared decision-making process between the user and the professional, and a collaborative process between different health professionals within and between services. The objective of our research is to identify and characterise the conditions of implementation of this practice.

METHODS

This effectiveness-implementation hybrid investigation will use an embedded single-case study, defined in this case as the process of implementing a clinical and organisational practice within a healthcare organisation. Further to an evaluation conducted during a preliminary phase of the project, this study consists of evaluating the implementation of this new practice in four medical clinics (family medicine groups). A qualitative analysis of the data and a quantitative preimplementation and postimplementation analysis based on performance indicators will be conducted. This study is ultimately situated within a participatory organisational approach that involves various stakeholders and users at each step of the implementation and evaluation process.

ETHICS AND DISSEMINATION

This study was approved by the Ethics Committee of the Sectoral Research in Population Health and Primary Care of the Centre intégré universitaire de santé et de services sociaux de la Capitale-Nationale (#2020-1800). The results of the investigation will be presented to the stakeholders involved in the advisory committees and at several scientific conferences. Manuscripts will be submitted to peer-reviewed journals.

European Survey: Dysphagia Management in Patients with Neuromuscular Diseases

Dysphagia is common in patients with neuromuscular diseases (NMDs). Its management differs by country and clinical setting. The purpose of this study was to describe current practices in the management of dysphagia in NMDs across Europe. An online survey of sixteen questions was developed, including basic information on facilities, existence of a management protocol, availability of dedicated therapists, tools used during screening, assessment, treatment stages, and treatment strategies. The survey was rolled out to European healthcare facilities providing care for NMDs. A total of 140 facilities across 25 European countries completed the survey. Substantial discrepancies in dysphagia management were identified among respondents. Seventy-two percent of the facilities reported having a protocol for at least one of the three management stages whereas only 39% had one for all. Speech and language therapists were reported as involved throughout the entire management stage while participation of other members from multidisciplinary teams varied depending on the stage. Clinical swallowing assessment was the most frequently reported tool in the assessment and treatment stages. For screening, questionnaires were the most frequently used while instrumental examinations were mainly reported in the assessment stage. For the treatment stage, adaptation strategies (diet, food, and posture) were the most reported approaches. In conclusion, the survey highlighted the absence of a defined protocol concerning the management of dysphagia in most of the surveyed healthcare facilities. Standardized training strategies and guidelines are necessary in the future to familiarize clinicians with each stage of the management of dysphagia.

The effect of exercise on balance in patients with stroke, Parkinson, and multiple sclerosis: a systematic review and meta-analysis of clinical trials

BACKGROUND

Stroke, Parkinson, and multiple sclerosis are a range of diseases affecting the nervous system and show balance impairments due to damage of the balance control system. Many early articles have been published on the effect of exercise on balance in patients suffering from neuromuscular diseases. However, a comprehensive study showing a clear result of these three diseases was not found. Hence, the purpose of the present meta-analysis and systematic review is to determine the effect of exercise on balance in people with stroke, Parkinson, and multiple sclerosis.

METHODS

According to the PRISMA 2009 multi-step instructions, keywords related to the purpose of the research were browsed in the MeSH browser databases; IranDoc, MagIran, IranMedex, SID, ScienceDirect, Web of Science (WoS), ProQuest, Medline (PubMed), Scopus, and Google Scholar were searched to extract articles published in Persian and English language. The search process for retrieving the articles in the sources mentioned from January 01, 2000, to December 30, 2020, was done. The heterogeneity index of the studies was determined using the I² test. Given the heterogeneity, the random-effects model was used to combine the articles and the results.

RESULTS

Initially, 7067 articles were found, but after removing duplicate and irrelevant articles, 96 clinical trials with a sample size of the intervention group of 1760 people were included in the study. As a result of the articles' composition, the mean balance score index after exercise in the intervention group showed a significant increase of 0.67 ± 0.12 of the unit (P˂0.01). The highest rate of increase in the balance score after the intervention was reported in patients with myelomeningocele with 1.66 ± 0.3 unit (P˂0.01).

CONCLUSION

Considering the positive effect of using exercise on increasing the balance in patients with stroke, Parkinson, and multiple sclerosis, it is recommended that health care providers implement a regular exercise program to improve the condition of these patients.

Predictors of participation restriction over a 9-year period in adults with myotonic dystrophy type 1

PURPOSE

For slowly progressive neuromuscular disease, prognostic approach and long-term monitoring of participation is a crucial part of rehabilitation services. To improve the prognostic approach, professionals must identify individuals at risk of having higher participation restriction. This study aimed to identify personal and environmental predictors of participation restriction over nine years in adults with myotonic dystrophy type 1 (DM1).

METHODS

A secondary analysis of a longitudinal design comparing baseline with a follow-up nine years later was used with a multidimensional assessment of participation and personal and environmental factors. Based on theoretical models, multiple linear regressions were used.

RESULTS

One hundred and fourteen adults with DM1 were included in the study (63.2% women; 78.9% adult onset; mean (SD) age of 43.5 (10.4) years). When age, sex, phenotype, and education were controlled for, participation restriction was predicted by a longer time to stand and walk, lower grip strength, higher body mass index, absence of perceived impact of myotonia in daily living, use of adapted transportation from community services, and perception of obstacle in physical environment (p < 0.001, adjusted R² = 0.50).

CONCLUSIONS

The majority of predictors of participation restriction can be advantageously modified by rehabilitation and environmental changes, such as politics targeting community services provision or physical environment and services accessibility.Implications for rehabilitationPredictors could better inform rehabilitation professional to recognize individuals at risk of higher participation restriction over time and to target specific interventions based on a prognostic approach.Rehabilitation professionals could inform the people living with myotonic dystrophy type 1 and their relatives of the multifactorial nature of occurrence of participation restriction to diminish the "fatality" associated with a genetic progressive disorder.Predictors allow professionals to assess and intervene in the management of specific factors depending on the rehabilitation goal.Identifying individual with myotonic dystrophy with higher risk of participation restriction could help implement a long-term community based rehabilitation intervention plan targeting both personal and environmental factors.

Self-management program improves participation in patients with neuromuscular disease: A randomized controlled trial

OBJECTIVE

To investigate the effectiveness of Energetic, a self-management group program combining aerobic training, energy conservation management, and relapse prevention to improve social participation in patients with neuromuscular disease (NMD) and chronic fatigue.

METHODS

In this multicenter, assessor-blinded, 2-armed randomized controlled trial with repeated measurements, 53 patients with various types of NMD and chronic fatigue were randomly allocated to Energetic, a 4-month group intervention, or to usual care. The primary endpoint was social participation assessed with the Canadian Occupational Performance Measure (COPM) performance scale immediately postintervention. Secondary outcomes included COPM satisfaction scale, 6-Minute Walk Test (6MWT), and Checklist Individual Strength-subscale fatigue. Participants were followed for 11 months postintervention. Data were analyzed with linear models that account for repeated measurements.

RESULTS

Directly after intervention, the mean group difference for COPM-performance was 1.7 (95% confidence interval [CI] 1.0-2.4; p < 0.0001) in favor of the intervention group (n = 29), adjusted for baseline, sex, diagnosis, and work status. This effect was retained at 11 months follow-up (0.9; 95% CI 0.0-1.7; p = 0.049). The COPM satisfaction scale and 6MWT improved more in the intervention group compared to usual care. After 3 and 11 months follow-up, most beneficial effects on social participation and functional endurance were retained.

CONCLUSION

Energetic led to sustainable improvements in social participation and functional endurance compared to usual care in patients with NMD and chronic fatigue.Clinicaltrials.gov IDENTIFIER: NCT02208687.

CLASSIFICATION OF EVIDENCE

This study provides Class III evidence that a combination of aerobic training, energy conservation management, and relapse prevention improves social participation in patients with NMD and chronic fatigue.

Assistive technology based on client-centered for occupational performance in neuromuscular conditions

Knowledge of the patient's own perception of functioning and dependence, and of environmental factors, is of significant value. The main goals of this study are (1) to obtain a general profile of the occupational performance of persons with neuromuscular disorders (NMD) and their needs related to that performance and (2) to determine the support resources (assistive technologies [AT], adjustment, and/or caregiver) required to improve or maintain their level of independence.This cross-sectional study involved 24 persons with NMD. The functional independence measure (FIM), the checklist of a home's accessibility level, and a specific questionnaire were administered.The sample included 14 women (58.3%) and 10 men (41.7%). A mean of 61.7 (standard deviation = 17.2) was obtained for FIM motor, over 91, indicating a moderate level of dependence. The AT most frequently used was a wheelchair (70.8%). Architectural barriers were detected in the majority of users' homes (87.5%).Concise assessment of the independence needs of people with NMD, according to their occupational performance, and prescription of resources to meet those needs are required. This procedure should be implemented in healthcare programs, including care to a caregiver.

Improving service delivery for neuromuscular diseases: a survey of consumers at a tertiary Australian hospital

Patients with neuromuscular diseases benefit from coordinated multidisciplinary care to achieve best outcomes. The integration of multi-specialty healthcare delivered in a single clinic can be challenging for service providers due to cost and resource limitation. Our cross-sectional survey of 53 adult patients with neuromuscular disease across Queensland revealed only 27% support the introduction of an integrated multidisciplinary clinic. The most cited reason for opposition to a multidisciplinary clinic was a perceived loss of contact with one's usual doctor. Modifying service delivery in neuromuscular disease is a complex undertaking and will need input from numerous stakeholders.

Same-day physical therapy consults in an outpatient neuromuscular disease physician clinic

Background

Team-based care has been shown to offer more comprehensive benefits to patients when compared to standard physician-based care alone in clinics for chronic conditions. However, apart from grant-funded multidisciplinary clinics, there are no reports on the usage of same-day physical therapy (PT) consults within a daily outpatient neuromuscular disease (NMD) physician clinic.

Objective

To determine the impact of same-day PT consults at the University of Utah’s outpatient Clinical Neurosciences Center.

Design

A qualitative assessment and survey of patient satisfaction.

Methods

An eight question Health Insurance Portability and Accountability Act-compliant patient satisfaction survey using a 5-point Likert scale was administered. Demographic data and Press-Ganey Provider Satisfaction surveys were retrospectively collected from electronic medical records for patients receiving same-day PT encounters in the neuromuscular division over 1 year.

Results

Mean (standard deviation) age was 54.22 (19.81) years for 134 patient encounters, median age was 60 years, with 76 male (57%) and 58 female (43%) patients. Mean Likert score for 61 self-reported patient satisfaction surveys for same-day PT consults was 4.87 (97.4%). Press-Ganey Provider Satisfaction scores improved from 89.9% (N=287) for the year prior to 90.8% (N=320) for the corresponding year (P=0.427). A total of 46 (75.4%) patients have either never before received PT care or never before received PT care for their NMD, 67.4% of whom were male.

Conclusion

Same-day PT consults in an outpatient NMD physician clinic demonstrated excellent patient satisfaction and improved access to specialty care. This model could potentially be implemented in other academic medical centers to improve access to rehabilitation services for patients with NMD.

Exploring the Psychosocial Impact of Wheelchair and Contextual Factors on Quality of Life of People with Neuromuscular Disorders

Neuromuscular disorders (NMDs) are a group of heterogeneous diseases that show differences in incidence, hereditary, etiology, prognosis, or functional impairments. Wheelchair use (manual or powered) is influenced by several factors, including personal and contextual factors, and comprehensive evaluation of their impact is required in order to optimize prescription and provision of wheelchairs. The authors therefore assessed the influence of wheelchair use on the quality of life (QoL) of 60 participants with NMD using the Psychosocial Impact of Assistive Devices Scale (PIADS). The Functional Independence Measure (FIM) and a specially developed questionnaire were used to obtain information about contextual factors and participants' activity profile of activities of the participants. The results showed that using a wheelchair has psychosocial benefits, with the main determinants of benefit being type of wheelchair (powered), non-ambulation ability, and independence in mobility. Ensuring a good match between user and assistive technology (AT; e.g., wheelchair), as well as the effectiveness of the particular device, will increase the likelihood that the user will adopt it and use it effectively in daily life. Clinical prescription of AT would be improved by making appropriate use of outcome measures.

Effectiveness and cost-effectiveness of a self-management group program to improve social participation in patients with neuromuscular disease and chronic fatigue: protocol of the Energetic study

Background

Chronic fatigue is present in more than 60% of the patients with a neuromuscular disease and can be their most disabling symptom. In combination with other impairments, fatigue often results in low levels of physical activity and decreased social participation, leading to high societal costs. ‘Energetic’ is a self-management group program aimed at improving social participation, physical endurance and alleviating fatigue in these patients. The primary aim of this study is to evaluate the effectiveness and cost-effectiveness of the Energetic program.

Methods/Design

A multicentered, assessor-blinded, two-armed randomized controlled trial is conducted with evaluations at inclusion and four, seven and fifteen months later. The study includes patients with a neuromuscular disease and chronic fatigue and, when present, their caregivers. The participants are randomized (ratio 1:1) to either an intervention group, receiving the Energetic program, or a control group, receiving usual care (i.e., no specific intervention). The Energetic program covers four months and includes four modules: 1) individually tailored aerobic exercise training; 2) education about aerobic exercise; 3) self-management training in applying energy conservation strategies; and 4) implementation and relapse prevention in daily life. Two months after cessation of the program a booster session is provided. The primary outcome is the perceived performance score of the Canadian Occupational Performance Measure (COPM). Secondary outcomes include the COPM-satisfaction score, and measures of fatigue, physical endurance, activity engagement, mood, and self-efficacy. Caregiver burden is also evaluated as a secondary outcome. Health-related quality of life and medical and societal costs are assessed to estimate cost-effectiveness of the program.

Discussion

The Energetic study is the first randomized controlled trial to evaluate the effectiveness and cost-effectiveness of a combined physical and self-management group training program for improving social participation, physical endurance and alleviating fatigue in patients with neuromuscular diseases. It will generate new insights in (cost-)effective rehabilitation strategies for these incurable conditions.

Trial registration

Clinicaltrials.gov NCT02208687.

Prevalence of Lifestyle Risk Factors in Myotonic Dystrophy Type 1

Background:

The prevalence of unhealthy lifestyle habits such as smoking has seldom been described in neuromuscular disorders, including myotonic dystrophy type 1 (DM1). However, it is essential to document the unhealthy lifestyle habits as they can exacerbate existing impairments and disabilities. The objectives are: 1) To determine the prevalence of risk factors among individuals with DM1; 2) To compare the prevalence among classic and mild phenotypes.

Method:

A survey was done on a sample of two-hundred (200) patients with DM1 as part of a larger study. Lifestyle risk factors included being overweight or obese, tobacco smoking, illicit drug use, excessive alcohol consumption and physical inactivity. A registered nurse administered the validated public health survey. Categorization of risk factors were based on national standards and compared with provincial and regional prevalences.

Results:

50% of DM1 patients were overweight or obese, 23.6% were regular smokers, and 76% were physically inactive. Except for overweight and obesity, significant differences were observed between patients with classic and mild phenotypes for all the other lifestyle risk factors: those with the classic phenotype being more often regular smokers, consuming more often illicit drugs and being less physically active.

Conclusions:

The results of this study will provide guidance for the development of better adapted and focussed health promotion interventions in the future.

Diagnostic value of "dysphagia limit" for neurogenic dysphagia: 17 years of experience in 1278 adults

OBJECTIVE

Neurogenic dysphagia (ND) is a prevalent condition that accounts for significant mortality and morbidity worldwide. Screening and follow-up are critical for early diagnosis and management which can mitigate its complications and be cost-saving. The aims of this study are to provide a comprehensive investigation of the dysphagia limit (DL) in a large diverse cohort and to provide a longitudinal assessment of dysphagia in a subset of subjects.

METHODS

We developed a quantitative and noninvasive method for objective assessment of dysphagia by using laryngeal sensor and submental electromyography. DL is the volume at which second or more swallows become necessary to swallow the whole amount of bolus. This study represents 17 years experience with the DL approach in assessing ND in a cohort of 1278 adult subjects consisting of 292 healthy controls, 784 patients with dysphagia, and 202 patients without dysphagia. A total of 192 of all patients were also reevaluated longitudinally over a period of 1-19 months.

RESULTS

DL has 92% sensitivity, 91% specificity, 94% positive predictive value, and 88% negative predictive value with an accuracy of 0.92. Patients with ALS, stroke, and movement disorders have the highest sensitivity (85-97%) and positive predictive value (90-99%). The clinical severity of dysphagia has significant negative correlation with DL (r=-0.67, p<0.0001).

CONCLUSIONS

We propose the DL as a reliable, quick, noninvasive, quantitative test to detect and follow both clinical and subclinical dysphagia and it can be performed in an EMG laboratory.

SIGNIFICANCE

Our study provides specific quantitative features of DL test that can be readily utilized by the neurologic community and nominates DL as an objective and robust method to evaluate dysphagia in a wide range of neurologic conditions.

Frequency and circumstances of falls in people with inclusion body myositis: a questionnaire survey to explore falls management and physiotherapy provision

OBJECTIVES

To survey the incidence and circumstances of falls for people with inclusion body myositis (IBM) in the UK, and to investigate the provision of physiotherapy and falls management.

DESIGN

Postal questionnaire survey.

SETTING

Participants completed questionnaires at home.

PARTICIPANTS

Ninety-four people diagnosed with IBM were screened against the inclusion criteria. Seventy-two potential participants were sent a questionnaire, and 62 were completed and returned. Invited participants were sent an adapted Falls Event Questionnaire pertaining to falls, perceived causes of falls and the provision of physiotherapy. Questionnaires were returned anonymously.

MAIN OUTCOME MEASURES

The proportions of respondents who reported a fall or a near fall, along with the frequencies of falls and near falls were calculated. Descriptive data of falls were collected pertaining to location and cause. Data analysis was performed to investigate provision of physiotherapy services.

RESULTS

The response rate was 86% [62/72, mean (standard deviation) age 68 (8) years]. Falls were reported by 98% (61/62) of respondents, with 60% (37/62) falling frequently. In this study, age was not found to be an indicator of falls risk or frequency. Twenty-one percent (13/62) of respondents had not seen a physiotherapist in relation to their IBM symptoms, and of those that had, 31% (15/49) had not seen a physiotherapist until more than 12 months after IBM was diagnosed. Only 18% (11/61) of fallers reported that they had received falls management input.

CONCLUSIONS

Falls are a common occurrence for people with IBM, independent of age and years since symptoms first presented, and are poorly addressed by appropriate physiotherapy management. National falls guidelines are not being followed, and referral rates to physiotherapy need to improve.

Exploring employment in consultation reports of patients with neuromuscular diseases

OBJECTIVES

To explore consultation reports for patient and employment characteristics and recommendations on employment regarding patients with neuromuscular diseases (NMDs).

DESIGN

Retrospective study of multidisciplinary reports.

SETTING

An outpatient neuromuscular clinic at a university hospital.

PARTICIPANTS

Reports (N=102) of patients with NMDs.

INTERVENTIONS

Based on one-off consultations by occupational therapists, physical therapists, and speech therapists and a multidisciplinary meeting, recommendations were developed regarding therapy content and volume in primary care or rehabilitation settings.

MAIN OUTCOME MEASURES

A checklist has been developed to examine employment characteristics. A general questionnaire has been used including demographic variables and data on employment.

RESULTS

Of the 102 reports available, 86 were included for analysis. Sixty-nine reports contained information on employment. Thirty-seven patients (43%) with NMD were employed, most in white-collar or moderately strenuous jobs. Of the 37 employed patients, 28 (76%) worked using adaptations. Thirty-two (87%) had employment problems; of these, 15 (40%) needed improvement in 1 or more environmental factors. Twenty patients (54%) needed advice regarding participation in employment, of whom 19 were referred to primary care or rehabilitation settings for treatment to enhance employment participation.

CONCLUSIONS

Eighty percent of the included consultation reports contained information on employment. Less than half the patients with NMD were employed, most in office-related jobs, using some kind of adaptations. Nineteen of 20 patients who agreed to recommendations regarding therapy were adequately referred by occupational therapists and physical therapists for treatment of employment problems.

Implementation of multidisciplinary advice to allied health care professionals regarding the management of their patients with neuromuscular diseases

PURPOSE

Patients with neuromuscular diseases (NMDs) do not always receive appropriate allied health care. This is partially because of the large heterogeneity among these conditions, some of which are quite rare. Individual allied health care professionals, therefore, have relatively little opportunity to develop relevant experience with these patients. To overcome this problem, we developed specialist multidisciplinary advice regarding management of patients with NMD for occupational therapy (OT), physical therapy (PT) and speech therapy (ST) in a primary care or rehabilitation setting. The aims of the study were to explore to what extent this allied health care advice was implemented with a focus on the amount of therapy received and to explore possible barriers to implementation.

METHODS

One-hundred two patients visited the Neuromuscular Centre Nijmegen for OT, PT and ST consultations. Integrated allied health care advice was written on the basis of these consultations and a multidisciplinary meeting. All patients, their therapists and rehabilitation physicians received this advice. Following the advice, questionnaires were sent out at baseline and at 6 months follow up, collecting data on implementation of the amount of therapy suggested and on possible barriers for adherence.

RESULTS

Advice for ST and OT was fully implemented in primary care, but only partially (58%) in a rehabilitation setting. Advice to reduce the amount of PT was implemented in only 15% of the cases. Possible barriers were related to the advice itself (feasibility of treatment duration, correctness and completeness), the patient (motivation) and the professional (experience in treatment of NMDs). Therapists expressed a desire to have the opportunity to discuss the treatment advice with the multidisciplinary team.

CONCLUSIONS

The extent to which multidisciplinary advice was implemented differed for OT and ST compared to PT and for the setting (primary care or rehabilitation). Possible barriers were identified at different levels. We recommend follow-up telephone calls to provide therapists opportunity for discussion.

Mechanisms of exercise limitation and pulmonary rehabilitation for patients with neuromuscular disease

Indications for exercise and pulmonary rehabilitation extend to neuromuscular diseases tough these conditions pose particular challenges given the associated skeletal muscle impairment and respiratory muscle dysfunction. These challenges are compounded by the variety of exercise prescriptions (aerobic, muscle strengthening, and respiratory muscle training) and the variety of neuromuscular disorders (muscular, motor neuron, motor nerve root, and neuromuscular transmission disorders). Studies support a level II evidence of effectiveness (i.e., likely to be effective) for a combination of aerobic exercise and strengthening exercises in muscular disorders, and for strengthening exercises in amyotrophic lateral sclerosis. The potential deleterious effects of work overload in the dystrophinopathies have not been confirmed in Becker muscular dystrophy. Adjunctive pharmacologic interventions (e.g., theophylline, steroids, PDE5 inhibitors, creatine), training recommendations (e.g., interval or lower intensity training) and supportive techniques (e.g., noninvasive ventilation, neuromuscular electrical stimulation, and diaphragm pacing) may result in more effective training but require more study before formal recommendations can be made. The exercise prescription should include avoidance of inspiratory muscle training in hypercapnia or low vital capacity, and should match the desired outcome (e.g., extremity training for task-specific performance, exercise training to enhance exercise performance, respiratory muscle training where respiratory muscle involvement contributes to the impairment).

The Evidence for Occupational Therapy for Adults with Neuromuscular Diseases: A Systematic Review

A systematic review was conducted to assess the evidence base of occupational therapy for adults with neuromuscular diseases. A comprehensive search for controlled and uncontrolled studies was performed in the Cochrane, MEDLINE, CINHAL, and EMBASE databases. After screening 3,534 titles and abstracts, six articles were retrieved for more detailed evaluation. Only two studies met all of the predefined criteria and were subjected to methodological assessment. These studies provide indications for the efficacy of hand training in muscle diseases. There is a lack of scientific evidence regarding the question of whether patients with neuromuscular diseases are better capable of participating in meaningful activities and roles through occupational therapy. Recommendations for future research are given.