Evidence in Rehabilitation Medicine: Between Facts and Prejudices

Advancements in autologous peripheral nerve transplantation care: a review of strategies and practices to facilitate recovery

Autologous peripheral nerve transplantation, a pioneering technique in nerve injury treatment, has demonstrated remarkable progress. We examine recent nursing strategies and methodologies tailored to various anatomical sites, highlighting their role in postoperative recovery enhancement. Encompassing brachial plexus, upper limb, and lower limb nerve transplantation care, this discussion underscores the importance of personalized rehabilitation plans, interdisciplinary collaboration, and innovative approaches like nerve electrical stimulation and nerve growth factor therapy. Moreover, the exploration extends to effective complication management and prevention strategies, encompassing infection control and pain management. Ultimately, the review concludes by emphasizing the advances achieved in autologous peripheral nerve transplantation care, showcasing the potential to optimize postoperative recovery through tailored and advanced practices.

Global statements to produce and implement evidence in the post-COVID-era provide a path forward for rehabilitation - A joint initiative of Cochrane Rehabilitation and the leading journals in the field

This article is a simultaneous joint publication in Journal of Rehabilitation Medicine, Annals of Physical and Rehabilitation Medicine, American Journal of Physical Medicine & Rehabilitation, Developmental Neurorehabilitation, European Journal of Physical and Rehabilitation Medicine, Journal of Occupational Rehabilitation, Musculoskeletal Science & Practice and Neurorehabilitation and Neural Repair. The articles are identical except for stylistic changes in keeping with each journal's style. Either version may be used in citing this article.

Recommendation of Neurorehabilitation according to the Padovan-Method Neurofunctional Reorganisation® for Treating Neurodevelopmental Disorders: A Systematic Review

OBJECTIVE

The PADOVAN-METHOD NEUROFUNCTIONAL REORGANI¬SATION® is a promising approach in speech therapy treating neuro¬developmental disorders with traumatic or congenital origin. Its use is based on a long-time experience of certified therapists. However, its efficacy and safety has not been assessed in a systematic review. This report aims to gain evidence for the use of the therapy method. Methods and analysis: Guidelines of PRISMA, the Cochrane Collaboration Handbook, MECIR and GRADE were followed. General databases (Cochrane Library, PubMed, AWMF, Anthromedics, etc.) and further 38 databases including grey literature were searched. Hand search was done additionally and contact to experts used to retrieve unpublished manuscripts. All trials investigating the effect of the method in comparison to either no intervention, alternative as state of the art or placebo intervention in English, Portuguese and German language were included. No restriction regarding study design was applied. Data related to the intervention outcome and the study method was extracted and analysed idependently. Risk of Bias was assessed using ROBINS-I for non-RCTs, adherence to CARE-Guidelines was analysed for case series or reports and keeping the Declaration of Helsinki was checked for all items. Results are presented both in evidence profiles and summary of findings tables according to GRADE.

RESULTS

Amongst 98 records assessed for eligibility, four studies and 14 case reports were identified with a total of n = 196 participants. Duration of reported interventions was between two days and two years. Microcephalia, down-syndrome, unspecified neurological disorders and myo-functional disorders were main conditions of the patients with neurodevelopmental disorders. Only indirect overlapping of operationalised criteria was found. Conclusions are therefore limited.

CONCLUSION

The Padovan-Method® is a holistic therapy approach claiming its feasibility to a large group of disorders making a proof of efficacy difficult. An application of therapy according to the Padovan-Method® by trained therapists might be considered by clinicians (weak recommendation) and a contribution to a relief of symptoms or improvements of condition of named conditions might be gained. Therefore, development and validation of therapy protocols and further investigation are required. PROSPERO Registration: CRD42020156124.

Intensive rehabilitation programme for patients with subacute stroke in an inpatient rehabilitation facility: describing a protocol of a prospective cohort study

INTRODUCTION

Rehabilitation is recognised as a cornerstone of multidisciplinary stroke care. Intensity of therapy is related to functional recovery although there is high variability on the amount of time and techniques applied in therapy sessions. There is a need to better describe stroke rehabilitation protocols to develop a better understanding of current practice increasing the internal validity and generalisation of clinical trial results. The aim of this study is to describe an intensive rehabilitation programme for patients with stroke in an inpatient rehabilitation facility, measuring the amount and type of therapies (physical, occupational and speech therapy) provided and reporting functional outcomes.

METHODS AND ANALYSIS

This will be a prospective observational cohort study of patients with subacute stroke admitted to our inpatient rehabilitation facility during 2 years. A therapy recording tool was developed in order to describe the rehabilitation interventions performed in our unit. This tool was designed using the Delphi method, literature search and collaboration with senior clinicians. Therapists will record the time spent on different activities available in our unit during specific therapy sessions. Afterwards, the total time spent in each activity, and the total rehabilitation time for all activities, will be averaged for all patients. Outcome variables were divided into three different domains: body structure and function outcomes, activity outcomes and participation outcomes and will be assessed at baseline (admission at the rehabilitation unit), at discharge from the rehabilitation unit and at 3 and 6 months after stroke.

ETHICS AND DISSEMINATION

This study was approved by the Medical Research Committee at Hospital del Mar Research Institute (Project ID: 34/C/2017). The results of this study will be presented at national and international congress and submitted for publication in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT04191109.

A systematic review that is ``rapid'' and ``living'': A specific answer to the COVID-19 pandemic

OBJECTIVE

This study aims to describe "rapid living" systematic reviews, an innovative methodological design used to systematically synthesize emerging evidence in the field of rehabilitation during the COVID-19 pandemic.

STUDY DESIGN AND SETTING

A methodological paper, with a formative approach to rapid living systematic reviews.

RESULTS

Based on our experience, we propose the following definition of rapid living SR: ``A dynamic method of knowledge synthesis that allows for the constant updating of new emerging evidence and refinement of its methodological quality.'' This method has the benefit of accelerating the conduct of traditional systematic reviews and allows for a synergistic adaptation of methodology based on the quality of the evidence with a flexibility to update results, methods and collaborations.

CONCLUSION

Our proposed methodology has been helpful to synthesize the rapidly evolving evidence in the field of rehabilitation during the pandemic. Similarly, it may be useful when a rapid answer is urgently needed to make informed decisions. The COVID-19 disease has shown that modern medical science has the ability to produce new knowledge at a rate never seen before. Therefore, our proposed rapid living systematic reviews provide the scientific community with a method to rapidly synthesize evidence when facing health emergencies.

"Rehabilitation Research Framework for Patients With COVID-19" Defined by Cochrane Rehabilitation and the World Health Organization Rehabilitation Programme

The coronavirus disease 2019 (COVID-19) pandemic resulted in a surge of research activity. Since its outset, efforts have been made to guide the rapid generation of research in medicine. There are gaps in some areas of rehabilitation research for patients with COVID-19. The development of a specific research framework might serve to help monitor the status of research (mapping), shape and strengthen research by pointing to under-investigated areas, and promote rehabilitation research in this context. This article introduces and discusses the COVID-19 Rehabilitation Research Framework (CRRF) and presents the methodology used for its development. The questions have been developed among the World Health Organization (WHO) Rehabilitation Programme, Cochrane Rehabilitation, and the experts of its Rehabilitation-COVID-19 Evidence-based Response Action International Multiprofessional Steering Committee. The framework is divided into 2 parts and includes 20 questions organized in 4 groups: epidemiology, and evidence at the micro- (individual), meso- (health services), and macro- (health systems) levels. The CRRF offers a comprehensive view of the research areas relevant to COVID-19 and rehabilitation that are necessary to inform best practice and ensure rehabilitation services and health systems can best serve the population with COVID-19. The collaboration between Cochrane Rehabilitation and the WHO Rehabilitation Programme in establishing the CRRF brought together perspectives from the health systems, health management, and clinical evidence. The authors encourage researchers to use the CRRF when planning studies on rehabilitation in the context of COVID-19.

Municipal return to work management in cancer survivors: a controlled intervention study

INTRODUCTION

Resuming work during or after cancer treatment has become an important target in cancer rehabilitation.

PURPOSE

The aim was in a controlled trial to study the return to work (RTW) effect of an early, individually tailored vocational rehabilitation intervention targeted to improve readiness for RTW in cancer survivors.

MATERIAL AND METHODS

Participants diagnosed with breast, cervix, ovary, testicular, colon-rectal, and head-and-neck cancers as well as being employed were allocated to a vocational rehabilitation intervention provided by municipal social workers (n = 83) or to usual municipal RTW management (n = 264). The intervention contained three elements: motivational communication inspired by Acceptance and Commitment Therapy by which RTW barriers were addressed, municipal cancer rehabilitation and finally employer and workplace contact. RTW effect was assessed as relative cumulative incidence proportions (RCIP) in the control and intervention group within 52 weeks of follow-up, estimated from the week where treatment ended at the hospital. RCIP was interpreted and reported as relative risk (RR) with 95% confidence intervals (CI) adjusted for gender, age cancer diagnosis, education, comorbidity, and sick leave weeks.

RESULTS

Across cancer diagnoses 69 (83.1%) and 215 (81.4%) returned to work in the intervention and control group, respectively. No statistical effect was seen (RR 1.08 (95% CI 0.98-1.19)). Repeating the analyses solely for participants with breast cancer (n = 290) showed a significant effect of the intervention (RR 1.12 (95% CI 1.01-1.23)).

CONCLUSION

More than 80% returned to work in both groups. However, no statistical difference in RTW effect was seen across cancer diagnoses within one year from being exposed to an early, individually tailored vocational rehabilitation intervention compared with usual municipal RTW management.

TRIAL REGISTRATION NUMBER

ISRCTN50753764.

Systematic Review of Clinical Practice Guidelines for Individuals With Amputation: Identification of Best Evidence for Rehabilitation to Develop the WHO's Package of Interventions for Rehabilitation

OBJECTIVES

To report the results of the systematic search performed to identify interventions and related evidence for rehabilitation of individuals with amputation based on the current evidence from clinical practice guidelines (CPG).

DATA SOURCES

Pubmed, Pedro, CINAHL, Embase, Google Scholar, and multiple guideline databases (date restriction, 2008-2018).

STUDY SELECTION

Exclusion criteria were no CPG, not reporting on rehabilitation, published before 2008, developed for health conditions other than amputation, presence of conflict of interest (financial or nonfinancial), lack of information on the strength of the recommendation, and lack of quality assessed by the "Appraisal of Guidelines for Research and Evaluation."

DATA EXTRACTION

Data extraction was done using a standardized form, which comprised information on the recommendation, the strength of recommendation and the quality of the evidence used to inform the recommendation.

DATA SYNTHESIS

We included 4 guidelines, providing a total of 217 recommendations (20 on assessments, 131 on interventions, and 66 on service provision). Most recommendations concerned pain management, education, pre- and postoperative management, and residual limb care. The strength of recommendation was generally weak to intermediate. The level of evidence mostly compromised expert opinions, with only 6.9% (15 of 217) being provided by randomized controlled trials, systematic reviews, or meta-analyses.

CONCLUSIONS

The field of amputation is well covered for recommended interventions, but the level of evidence is generally low and is based mostly on expert opinion. Some important domains are not covered (eg, vocation and education, sexual and/or intimate relationships, activities of daily living or leisure activities, education concerning socket/liner fitting). There is also a lack of description of the contents of training and rehabilitation programs. This should be taken into account for the development of future guidelines.

"ACEing" the Evidence Within Physical Medicine and Rehabilitation (PM&R)

Introduction

While evidence-based medicine (EBM) is important in all fields of medicine, it can be specifically challenging for the field of physical medicine and rehabilitation (PM&R), a rapidly developing field where the standard hierarchy of evidence does not always apply and randomized controlled trials can be difficult to design. We developed an EBM curriculum for residents that improved EBM competency and was specific to the field of PM&R.

Methods

We developed a blended learning longitudinal approach to EBM designed specifically for PM&R residents, with a pre- and postcourse assessment by the Evidence-Based Practice Questionnaire (EBPQ) and Assessing Competency in EBM (ACE) tool. Interactive presentations paired with structured presession assignments were held for five introductory sessions, followed by monthly EBM and journal club sessions over 1 academic year.

Results

Fourteen residents of varying postgraduate years of training participated in the EBM curriculum from 2018 to 2019. EBPQ scores after completion of 1 academic year of this EBM curriculum were significantly improved compared to precurriculum EBPQ scores. Comparison of pre- and post-EBPQ and ACE tool scores stratified by postgraduate year did not show a significant correlation between resident levels and self-reported prior EBM education.

Discussion

This longitudinal blended learning EBM curriculum resulted in an increase in residents' self-reported behaviors and knowledge/skills regarding EBM. The curriculum was also effective in advancing competency of the residents to an EBM Advanced level using the ACE tool. The curriculum can be easily replicated in other PM&R residency programs.

Does Type of Sponsorship of Randomized Controlled Trials Influence Treatment Effect Size Estimates in Rehabilitation: A Meta-Epidemiological Study

BACKGROUND

Sponsorship bias could affect research results to inform decision makers when using the results of these trials. The extent to which sponsorship bias affect results in the field of physical therapy has been unexplored in the literature. Therefore, the main aim of this study was to evaluate the influence of sponsorship bias on the treatment effects of randomized controlled trials in physical therapy area.

METHODS

This was a meta-epidemiological study. A random sample of randomized controlled trials included in meta-analyses of physical therapy area were identified. Data extraction including assessments of appropriate influence of funders was conducted independently by two reviewers. To determine the association between biases related to sponsorship biases and effect sizes, a two-level analysis was conducted using a meta-meta-analytic approach.

RESULTS

We analyzed 393 trials included in 43 meta-analyses. The most common sources of sponsorship for this sample of physical therapy trials were government (n = 205, 52%), followed by academic (n = 44, 11%) and industry (n = 39, 10%). The funding was not declared in a high percentage of the trials (n = 85, 22%). The influence of the trial sponsor was assessed as being appropriate in 246 trials (63%) and considered inappropriate/unclear in 147 (37%) of them. We have moderate evidence to say that trials with inappropriate/unclear influence of funders tended to have on average a larger effect size than those with appropriate influence of funding (effect size = 0.15; 95% confidence interval = -0.03 to 0.33).

CONCLUSIONS

Based on our sample of physical therapy trials, it seems that most of the trials are funded by either government and academia and a small percentage are funded by the industry. Treatment effect size estimates were on average 0.15 larger in trials with lack of appropriate influence of funders as compared with trials with appropriate influence of funding. Contrarily to other fields, industry funding was relatively small and their influence perhaps less marked. All these results could be explained by the relative youth of the field and/or the absence of clear industry interests. In front of the call for action by the World Health Organization to strengthen rehabilitation in health systems, these results raise the issue of the need of public funding in the field.

Surface EMG in Clinical Assessment and Neurorehabilitation: Barriers Limiting Its Use

This article addresses the potential clinical value of techniques based on surface electromyography (sEMG) in rehabilitation medicine with specific focus on neurorehabilitation. Applications in exercise and sport pathophysiology, in movement analysis, in ergonomics and occupational medicine, and in a number of related fields are also considered. The contrast between the extensive scientific literature in these fields and the limited clinical applications is discussed. The "barriers" between research findings and their application are very broad, and are longstanding, cultural, educational, and technical. Cultural barriers relate to the general acceptance and use of the concept of objective measurement in a clinical setting and its role in promoting Evidence Based Medicine. Wide differences between countries exist in appropriate training in the use of such quantitative measurements in general, and in electrical measurements in particular. These differences are manifest in training programs, in degrees granted, and in academic/research career opportunities. Educational barriers are related to the background in mathematics and physics for rehabilitation clinicians, leading to insufficient basic concepts of signal interpretation, as well as to the lack of a common language with rehabilitation engineers. Technical barriers are being overcome progressively, but progress is still impacted by the lack of user-friendly equipment, insufficient market demand, gadget-like devices, relatively high equipment price and a pervasive lack of interest by manufacturers. Despite the recommendations provided by the 20-year old EU project on "Surface EMG for Non-Invasive Assessment of Muscles (SENIAM)," real international standards are still missing and there is minimal international pressure for developing and applying such standards. The need for change in training and teaching is increasingly felt in the academic world, but is much less perceived in the health delivery system and clinical environments. The rapid technological progress in the fields of sensor and measurement technology (including sEMG), assistive devices, and robotic rehabilitation, has not been driven by clinical demands. Our assertion is that the most important and urgent interventions concern enhanced education, more effective technology transfer, and increased academic opportunities for physiotherapists, occupational therapists, and kinesiologists.

Improving Patient Outcomes Following Total Knee Arthroplasty: Identifying Rehabilitation Pathways Based on Modifiable Psychological Risk and Resilience Factors

Total knee arthroplasty (TKA) is a commonly implemented elective surgical treatment for end-stage osteoarthritis of the knee, demonstrating high success rates when assessed by objective medical outcomes. However, a considerable proportion of TKA patients report significant dissatisfaction postoperatively, related to enduring pain, functional limitations, and diminished quality of life. In this conceptual analysis, we highlight the importance of assessing patient-centered outcomes routinely in clinical practice, as these measures provide important information regarding whether surgery and postoperative rehabilitation interventions have effectively remediated patients' real-world "quality of life" experiences. We propose a novel precision medicine approach to improving patient-centered TKA outcomes through the development of a multivariate machine-learning model. The primary aim of this model is to predict individual postoperative recovery trajectories. Uniquely, this model will be developed using an interdisciplinary methodology involving non-linear analysis of the unique contributions of a range of preoperative risk and resilience factors to patient-centered TKA outcomes. Of particular importance to the model's predictive power is the inclusion of a comprehensive assessment of modifiable psychological risk and resilience factors that have demonstrated relationships with TKA and other conditions in some studies. Despite the potential for patient psychological factors to limit recovery, they are typically not routinely assessed preoperatively in this patient group, and thus can be overlooked in rehabilitative referral and intervention decision-making. This represents a research-to-practice gap that may contribute to adverse patient-centered outcomes. Incorporating psychological risk and resilience factors into a multivariate prediction model could improve the detection of patients at risk of sub-optimal outcomes following TKA. This could provide surgeons and rehabilitation providers with a simplified tool to inform postoperative referral and intervention decision-making related to a range of interdisciplinary domains outside their usual purview. The proposed approach could facilitate the development and provision of more targeted rehabilitative interventions on the basis of identified individual needs. The roles of several modifiable psychological risk and resilience factors in recovery are summarized, and intervention options are briefly presented. While focusing on rehabilitation following TKA, we advocate for the broader utilization of multivariate prediction models to inform individually tailored interventions targeting a range of health conditions.

The Cochrane Corners by Cochrane Rehabilitation

Cochrane Rehabilitation (CR) is pursuing the goal of disseminating Cochrane evidence, in line with the Cochrane Knowledge Translation (KT) strategy theme 2: "Packaging, push, and support implementation", through several projects: the CR eBook project, blogshots, and Cochrane Corners. A Cochrane Corner is a KT vehicle in which the contents of the Cochrane Library are summarized and presented by a rehabilitation professional, using the qualitative statements proposed by Cochrane Norway to communicate the magnitude of rehabilitation intervention effects on specific outcomes, based on the certainty of evidence, and followed by a section on "clinical implication for rehabilitation professionals" (both for clinical and research practice). Our Cochrane Corners aim to inform about evidence produced by Cochrane in the field of rehabilitation from a rehabilitation professional perspective. After setting internal rules for Cochrane Corners, designing a template and preparing a guide for authors, the production of Cochrane Corners started. As of December 2019, CR signed Publication Agreements with 13 rehabilitation relevant Journals, contributed to Editorials as introductory articles for the launch of Cochrane Corners in some of these Journals and published 34 Cochrane Corners, in print or ahead of print, whereas 7 additional Cochrane Corners have been submitted to the Journals and will be published soon. This initiative provided a significant opportunity for CR to communicate with members of other groups within Cochrane as well as with journal editors. The impact of Cochrane Corners on the readers will need to be evaluated in the future: unfortunately, we have no instruments to measure it at present.