Which Remote Rehabilitation Interventions Work Best for Chronic Musculoskeletal Pain and Depression? A Bayesian Network Meta-Analysis

OBJECTIVE: To evaluate the effectiveness of remote rehabilitation interventions for people living with chronic musculoskeletal pain and depression. DESIGN: A systematic review with network meta-analysis (NMA) of randomized controlled trials. LITERATURE SEARCH: We searched the Cochrane Central Register of Controlled Trials, CINAHL, EMBASE, LILACS MEDLINE, PSYNDEX, and PsycINFO databases from inception to May 2023. STUDY SELECTION CRITERIA: Randomized controlled trials that evaluated the effectiveness of remote rehabilitation interventions in people with chronic musculoskeletal pain and depression. DATA SYNTHESIS: We used Bayesian random-effects models for the NMA. Effect estimates were comparisons between rehabilitation interventions and waitlist. We performed a sensitivity analysis based on bias in the randomization process, large trials (>100 patients per arm) and musculoskeletal condition. RESULTS: Fifty-eight randomized controlled trials involving 10 278 participants (median sample size: 137; interquartile range [IQR]: 77-236) were included. Interactive voice response cognitive behavioral therapy (CBT; standardized mean difference [SMD] -0.66, 95% credible interval [CrI] -1.17 to -0.16), CBT in person (SMD -0.50, 95% CrI -0.97 to -0.04), and mobile app CBT plus exercise (SMD -0.37, 95% CrI -0.69 to -0.02) were superior to waitlist at 12-week follow-up for reducing pain (> 98% probability of superiority). For depression outcomes, Internet-delivered CBT and telecare were superior to waitlist at 12-week follow-up (SMD -0.51, 95% CrI -0.87 to -0.13) (> 99% probability of superiority). For pain outcomes, the certainty of evidence ranged from low to moderate. For depression outcomes, the certainty of evidence ranged from very low to moderate. The proportion of dropouts attributed to adverse events was unclear. No intervention was associated with higher odds of dropout. CONCLUSION: Interactive voice response CBT and mobile app CBT plus exercise showed similar treatment effects with in-person CBT on pain reduction among people living with chronic musculoskeletal pain and depression had over 98% probability of superiority than waitlist control at 12-week follow-up. Internet-delivered CBT and telecare had over 99% probability of superiority than waitlist control for improving depression outcomes at 12-week follow-up. J Orthop Sports Phys Ther 2024;54(6):1-16. Epub 26 February 2024. doi:10.2519/jospt.2024.12216.

Assessing the Effectiveness of Rehabilitation Interventions through the World Health Organization Disability Assessment Schedule 2.0 on Disability-A Systematic Review

(1) Background: The World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0) is a tool designed to measure disability in accordance with the International Classification of Functioning, Disability and Health. Measuring disability is becoming increasingly important due to its high prevalence, which continues to rise. Rehabilitation interventions can reduce disability and enhance functioning. (2) Objective: The present study aims to assess the impact of rehabilitation interventions on reducing disability, as measured by the WHODAS 2.0 questionnaire. It also seeks to identify which specific rehabilitation interventions are more effective and to explore other disability assessment questionnaires. (3) Methods: Following the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) methodology, we conducted a systematic review, with the protocol registered with the identifier CRD42023495309, focused on "WHODAS" and "rehabilitation" using PubMed and Web of Science electronic databases. (4) Results: We identified 18 articles from various regions encompassing patients with various health conditions, related to stroke, the cardiovascular system (cardiovascular disease, chronic heart failure), the pulmonary system (chronic obstructive pulmonary disease), the neurologic system (Parkinson's disease, cerebral palsy, neurodegenerative disease), the musculoskeletal system (orthopaedic surgery), cancer, and chronic pain, and among frail elderly. These patients have received a wide range of rehabilitation interventions: from conventional therapy to virtual reality, robot-assisted arm training, exergaming, and telerehabilitation. (5) Discussion and Conclusions: A wide range of rehabilitation techniques can effectively improve disability with various comorbidities, offering numerous benefits. The WHODAS 2.0 questionnaire proves to be an efficient and reliable tool for measuring disability, and scores have a tendency to decrease after rehabilitation.

Exercise therapy including the cervical extensor muscles in individuals with neck pain: A systematic review

OBJECTIVE

To review the use (dosage parameters and combination with other therapeutic interventions) of cervical extensor muscle exercises and their effect on pain, disability (primary outcomes), range of motion, endurance and strength (secondary outcomes) in people with neck pain.

DATA SOURCES

An extensive literature search was conducted through MEDLINE (Ovid), Scopus (Elsevier) and Physiotherapy Evidence Database (PEDro) up to May 2023. The reference lists of all included studies and relevant reviews were screened for additional studies.

REVIEW METHODS

Randomised controlled trials reporting the use of cervical extensor muscle exercises (alone or combined) applied to adults with idiopathic or traumatic neck pain were included. Study selection, data extraction and critical appraisal (PEDro assessment scale) were performed by two blinded reviewers. Data extraction included dosage parameters, other modalities combined with these exercises and outcomes.

RESULTS

Thirty-five randomised controlled trails (eight of which were complementary analyses) with 2409 participants fulfilled the inclusion criteria. Twenty-six were of moderate to high quality. In most studies, cervical extensor muscle exercises were combined with various other therapeutic modalities and applied at different dosages. Only two studies (one high and one low quality) specifically assessed their effectiveness. The high-quality study showed significant improvements in neck pain and disability, pressure point threshold and neck mobility after both low load and high load training for 6 weeks.

CONCLUSION

The results suggest cervical extensor muscle exercises may reduce neck pain and disability; however firm conclusions cannot be drawn because of the few studies that addressed this question and the heterogeneity of the dosage parameters.

Rehabilitation Exercises Supported by Monitor-Augmented Reality for Patients with High-Grade Glioma Undergoing Radiotherapy: Results of a Randomized Clinical Trial

BACKGROUND

Exercise has been shown to improve quality of life (QoL) and even treatment outcomes in cancer patients. However, the evidence to support the benefits of exercise in patients with high-grade glioma (HGG) is limited. Therefore, we performed a randomized clinical trial (RCT) to examine the effect of augmented-reality-based rehabilitation exercises on physical and functional fitness, cognitive function, fatigue, mood, QoL, selected blood parameters, brain derived neurotrophic factor (BDNF), and S100 protein in patients with HGG.

METHODS

Adult patients with HGG scheduled to undergo radiotherapy after tumor resection were randomized to participate in an exercise program (experimental group, n = 25) or to receive usual care (controls, n = 22). Physical and mental fitness was measured at baseline, after the completion of radiotherapy, and at 3 months. The following tests were administered: Handgrip Strength Test; 6-Minute Walk Test; Time Up and Go test; Functional Independent Measure scale; Addenbrooke's Cognitive Examination III (ACE III); Hospital Anxiety and Depression Scale; Functional Cancer Therapy Assessment-Brain; and Functional Assessment of Chronic Illness Therapy-Fatigue. We also measured blood parameters, BDNF, and S100 protein levels.

RESULTS

No significant changes were observed in the exercise group. However, the controls experienced a significant decrease in HGS and in the ACE III attention domain. No significant changes were observed in QoL, fatigue, BDNF, or S100 levels in either group.

CONCLUSIONS

Augmented-reality-based exercise during radiation therapy may prevent loss of muscle strength and attention in patients with HGG.

Rehabilitation interventions for glioma patients: a mini-review

Glioma is a group of tumors that originate from glial cells within the central nervous system and comprise 27% of all tumors and 80% of malignant tumors. With remarkable progress in surgical practices, chemotherapy, and radiation therapy, patients with glioma are experiencing greater survival times, which means they need more rehabilitative care. In fact, people with this condition may experience a variety of symptoms that can affect their functions and drastically reduce their quality of life. In fact, patients suffering from glioma has a distinctive symptom complex highlighting the requirement for customized care. Growing evidence shows that rehabilitation therapy can improve the functional prognosis and quality of life of glioma patients. However, there is limited evidence of the success of rehabilitation protocols designed specifically for individuals with glioma. It is essential to determine the most comprehensive rehabilitation programs as well as the sufficient resources, dosage, and duration. The goal of this mini-review was to classify and map rehabilitation interventions used to treat multiple disabling sequalae in individuals affected by glioma. We aim to provide a comprehensive overview of the rehabilitation protocols used for this population, so that clinicians have a guide to support treatment and an inspiration for further research. This document is intended to be a reference point for professionals involved in the management of adult patients with gliomas. Further exploration is needed to form improved care models for recognizing and addressing functional restrictions in this population.

Post-fracture rehabilitation pathways and association with mortality among adults with cerebral palsy

OBJECTIVE

Rehabilitation may mitigate the high mortality rates and health declines post-fracture for adults with cerebral palsy, but this is understudied. The objectives were to characterize the post-fracture rehabilitation pathways and identify their association with 1-year survival among adults with cerebral palsy.

METHODS

A retrospective cohort study of adults with cerebral palsy with a fragility fracture with continuous health plan enrollment ≥1-year prior to and ≥1 day after their fracture date was performed using a random 20% Medicare fee-for-service dataset. Participants were categorized as a home discharge or inpatient rehabilitation admission post-fracture. For the home discharge cohort, weekly exposure to outpatient physical/occupational therapy (PT/OT) was examined up to 6-month post-fracture. Cox regression examined the association between time-varying PT/OTuse within 6-month post-fracture and mortality from 30 days to 1-year post-fracture before and after adjusting for confounders (e.g. medical complexity).

RESULTS

Of 3598 adults with cerebral palsy with an incident fragility fracture, 74% were discharged home without inpatient rehabilitation; they were younger, but more medically complex compared to the 26% admitted to inpatient rehabilitation. Among the home discharge cohort (n = 2662), 43.1% initiated PT/OTwithin 6-month post-fracture, and cumulative PT/OTexposure post-fracture was associated with improved survival; for example, per 3 weeks of PT/OTexposure, the adjusted mortality rate was 40% lower (95% confidence interval (CI) = 0.41-0.89).

CONCLUSIONS

Most adults with cerebral palsy with a fragility fracture were discharged home rather than to inpatient rehabilitation, and only 43.1% of that group initiated outpatient PT/OTwithin 6 months post-fracture. Receiving outpatient PT/OTwas associated with improved 1-year survival.

Art skill-based rehabilitation training for upper limb sensorimotor recovery post-stroke: A feasibility study

Objective

The objective of this study was to assess the feasibility of delivering Art skill-based Rehabilitation Training (ART), a novel upper limb motor training program, to patients with stroke as an adjunct to standard care in an inpatient setting.

Design

Feasibility study.

Setting

Inpatient stroke rehabilitation unit at a university hospital.

Participants

Thirty-eight patients admitted to a stroke rehabilitation unit with upper limb motor impairment were enrolled in the ART program facilitated by trained non-healthcare professionals between December 2017 and June 2021.

Intervention

The ART program included nine, one-hour sessions of supervised tracing and freehand drawing tasks completed with both hands. This program was intended to be delivered at a frequency of three times per week over a duration of 3 weeks or for the length of inpatient stay.

Main outcome measures

Feasibility outcomes included ART program adherence, acceptability, and safety.

Results

Thirty-two (84%) participants with subacute stroke completed the ART program and 30 (79%) were included in the study analysis. Participants completed 93–100% of the ART tasks in a median [IQR] of 8 [6–10] ART sessions over a median [IQR] duration of 15 [7–19] days. ART program facilitators effectively provided upper limb assistance to patients with more severe upper limb impairments. Adherence and acceptability were high and no study-related adverse events occurred.

Conclusion

The ART program was feasible to deliver and highly acceptable to patients with stroke. Further research is warranted to explore the impact of ART on upper limb sensorimotor function and use.

Does group-based cognitive therapy improve functional ability, pain, catastrophic thoughts and quality of life in patients with persistent low back pain and psychological risk factors? A randomised controlled trial in a secondary care setting

OBJECTIVE

To investigate the effects of a group-based cognitive behavioural intervention for patients with persistent low back pain (LBP) and psychological risk factors referred to secondary care.

DESIGN

A randomised controlled trial.

SETTING

Silkeborg Regional Hospital, Denmark.

SUBJECTS

A total of 136 participants with chronic LBP and psychological risk factors.

INTERVENTIONS

Participants were randomised to the standard care group, including examination by a rheumatologist and/or a physiotherapist, or the intervention group, including standard care plus a multidisciplinary group-based pain management programme.

MAIN MEASURES

Patient-reported outcomes were collected at baseline and after 6 and 12 months. The primary outcome was disability (Roland Morris Disability Questionnaire). Secondary outcomes included low back pain intensity, pain catastrophising, health-related quality of life, and sick leave.

RESULTS

Among 136 participants, 68 (mean age: 41.7 years (SD 11.8)) were randomised to standard care and 68 (mean age: 46.0 years (SD 10.8)) were randomised to the intervention group. Except for age, baseline characteristics were comparable between groups. 12-month follow-up was completed by 92.6% in the intervention group and 80.9% in the standard care group. Both groups achieved significant improvements on disability, with a reduction of -4.8 points (SD 6.1) in the intervention group compared to -3.7 points (SD 5.2), resulting in an insignificant difference between groups. No significant differences were found in the secondary outcomes.

CONCLUSION

A group-based pain management programme was no more effective than standard care for patients with persistent LBP and psychological risk factors.

Physical therapies in the decongestive treatment of lymphedema: A randomized, non-inferiority controlled study

OBJECTIVE

To assess whether the treatment with intermittent pneumatic compression plus multilayer bandages is not inferior to classical trimodal therapy with manual lymphatic drainage in the decongestive lymphedema treatment.

STUDY DESIGN

Randomized, non-inferiority, controlled study to compare the efficacy of three physical therapies' regimens in the Decongestive Lymphatic Therapy.

PARTICIPANTS

194 lymphedema patients, stage II-III with excess volume > 10% were stratified within upper and lower limb and then randomized to one of the three treatment groups. Baseline characteristics were comparable between the groups.

INTERVENTION

all patients were prescribed 20 sessions of the following regimens: Group A (control group): manual lymphatic drainage + Intermittent Pneumatic Compression + Bandages; Group B: pneumatic lymphatic drainage + Intermittent Pneumatic Compression + Bandages; and Group C: only Intermittent Pneumatic Compression + Bandages.

END-POINT

Percentage reduction in excess volume (PREV).

RESULTS

All patients improved after treatment. Global mean of PREV was 63.9%, without significant differences between the groups. The lower confidence interval of the mean difference in PREV between group B and group A, and between group C and group A were below 15%, thus meeting the non-inferiority criterion. Most frequent adverse events were discomfort and lymphangitis, without differences between groups. A greater baseline edema, an upper-limb lymphedema and a history of dermatolymphangitis were independent predictive factors of worse response in the multivariate analysis.

CONCLUSIONS

Decongestive lymphatic therapy performed only with intermittent pneumatic compression plus bandages is not inferior to the traditional trimodal therapy with manual lymphatic drainage. This approach did not increase adverse events.

Using a bimanual lever-driven wheelchair for arm movement practice early after stroke: A pilot, randomized, controlled, single-blind trial

OBJECTIVE

Many patients with subacute stroke rely on the nonparetic arm and leg to propel manual wheelchairs. We designed a bimanual, lever-driven wheelchair (LARA) to promote overground mobility and hemiparetic arm exercise. This study measured the feasibility of using LARA to increase arm movement, achieve mobility, and improve arm motor recovery (clinicaltrials.gov/ct2/show/NCT02830893).

DESIGN

Randomized, assessor-blind, controlled trial.

SETTING

Two inpatient rehabilitation facilities.

SUBJECTS

Nineteen patients with subacute stroke (1 week to 2 months post-stroke) received 30 minutes extra arm movement practice daily, while admitted to inpatient rehabilitation (n = 10) or before enrollment in outpatient therapy (n = 9).

INTERVENTIONS

Patients were randomized to train with the LARA wheelchair (n = 11) or conventional exercises with a rehabilitation therapist (n = 8).

MAIN MEASURES

Number of arm movements per training session; overground speed; Upper Extremity Fugl-Meyer score at three-month follow-up.

RESULTS

Participants who trained with LARA completed 254 (median) arm movements with the paretic arm each session. For three participants, LARA enabled wheelchair mobility at practical indoor speeds (0.15-0.30 m/s). Fugl-Meyer score increased 19 ± 13 points for patients who trained with LARA compared to 14 ± 7 points with conventional exercises (P = 0.32). Secondary measures including shoulder pain and increased tone did not differ between groups. Mixed model analysis found significant interaction between LARA training and treatment duration (P = 0.037), informing power analysis for future investigation.

CONCLUSIONS

Practising arm movement with a lever-driven wheelchair is a feasible method for increasing arm movement early after stroke. It enabled wheelchair mobility for a subset of patients and shows potential for improving arm motor recovery.

The effectiveness of a family-centred intervention after traumatic brain injury: A pragmatic randomised controlled trial

Objectives:

To determine the effectiveness of a family-centred intervention for patients with traumatic brain injury and family members.

Design:

Open-labelled, two-armed randomised controlled trial.

Settings:

Outpatient clinic and family residences.

Participants:

Sixty-one patients (33 women) with traumatic brain injury, with mean (SD) age 43.8 (12.2), and 63 family members (33 women), with mean (SD) age 42.6 (11.3), were assign to intervention (n = 30 families) and control group (n = 31 families).

Intervention:

An eight-session single-family intervention to improve individual and family functioning.

Outcome measures:

Self-reported questionnaires at start-of-treatment, median (IQR) 11.4 (8.4, 15.9) months post-injury, and at two follow-ups, 2.7 (2.3, 3.8) and 9.2 (8.2, 9.9) months after start-of-treatment. Primary outcome measures were the SF-36 Mental Component Summary (MCS) and Caregiver Burden Scale (CGB). Secondary outcome measures were the Family Adaptability and Cohesion Evaluation Scale (FACES) and Quality of Life after Brain Injury Questionnaire (QOLIBRI). Group differences were analysed with linear mixed-model analysis for repeated measurements.

Results:

No significant between-group differences were found. The intervention group significantly improved on the MCS, the CGB and FACES in the treatment period, whereas the controls did not. The mean (SD) MCS change in the treatment period was 2.4 (1.1) points P = 0.028 in the intervention group. Mean (SE) MCS scores were 47.9 (1.26) and 47.3 (1.27) in the intervention and control group at last follow-up.

Conclusions:

Receiving an eight-session family intervention, in addition to specialised rehabilitation for the patients, was not superior to rehabilitation at a specialised traumatic brain injury outpatient clinic.

Investigating feasibility and preliminary efficacy of a simulator-based driving intervention for people with acquired brain injury: A randomised controlled pilot study

OBJECTIVE

To investigate the feasibility and preliminary efficacy of a driving simulator intervention on driving outcomes following acquired brain injury.

DESIGN

Pilot randomised controlled trial.

SETTING

Occupational therapy driver assessment and rehabilitation service.

SUBJECTS

Individuals post-acquired brain injury aiming to return to driving.

INTERVENTION

Eight sessions of simulated driver training over four weeks, in addition to usual care. Control: Usual care only.

MAIN MEASURES

Feasibility outcomes: Participant recruitment and retention; data completeness; therapy attendance and fidelity; adverse events. Performance outcomes: on-road driving performance; Simulator Sickness Questionnaire; Brain Injury Driving Self-Awareness Measure and Driving Comfort Scale - Daytime, assessed at baseline and five weeks post-randomisation.

RESULTS

Out of 523 individuals screened, 22 (4%) were recruited and randomised, with 20 completing their allocated group (n = 12 Simulator, n = 8 Usual Care). For those who completed training, session attendance was 100% with simulator sickness rated, on average, as mild. Six individuals (50%) in the Simulator group failed the on-road assessment, versus two (25%) in the Usual Care group (P = 0.373). On average, the Simulator group reported a positive change in confidence ratings (M = 5.77, SD = 13.96) compared to the Usual Care group, who reported a negative change (M = -6.97, SD = 8.47), P = 0.034. The Simulator group (M = 0.67, SD = 3.34) demonstrated no significant change in self-awareness relative to the Usual Care group (M = -0.83, SD = 1.83, P = 0.325).

CONCLUSIONS

With adjustments to inclusion criteria and recruitment strategies, it may be feasible to deliver the intervention and conduct a larger trial. There is potential benefit of simulator training for improving driver confidence after acquired brain injury.

Effects on walking performance and lower body strength by short message service guided training after stroke or transient ischemic attack (The STROKEWALK Study): a randomized controlled trial

OBJECTIVE

To evaluate whetherdaily mobile-phone delivered messages with training instructions during three months increase physical activity and overall mobility in patients soon after stroke or transient ischemic attack.

DESIGN

Randomised controlled trial with intention-to-treat analyses.

SETTING

University hospital. Data collection from November 2016 until December2018.

SUBJECTS

Seventy-nine patients (mean (SD) age 63.9 (10.4) years, 29 were women) were allocated to either intervention (n = 40) or control group (n = 39). Participants had to be independent (modified Ranking Scale ⩽2) and able to perform the six-minute walking test at discharge from the hospital.

INTERVENTIONS

The intervention group received standard care and daily mobile phone instructional text messages to perform regular outdoor walking and functional leg exercises. The control group received standard care; that is, primary care follow-up.

MAIN MEASURES

Walking performance by six-minute walking test (m), lower body strength by five times chair-stand test (s), the short physical performance battery (0-12 points) and 10-metres walk test (m/s) were assessed at baseline and after three months.

RESULTS

The estimated median difference in the six-minute walking test was in favour of the intervention group by 30 metres (95% CI, 55 to 1; effect size 0.64; P = 0.037) and in the chair-stand test by 0.88 seconds (95% CI, 0.02 to 1.72; effect size 0.64; P = 0.034). There were no differences between groups on the short physical performance battery or in 10-metres walking time.

CONCLUSIONS

Three months of daily mobile phone text messages with guided training instructions improved composite mobility measures; that is, walking performanceand lower body strength.

CLINICAL TRIAL REGISTRY

The study is registered with ClinicalTrials.gov, number NCT02902367.

Vision therapy as part of neurorehabilitation after acquired brain injury - a clinical study in an outpatient setting

Introduction: Oculomotor (OM) functions may be affected by acquired brain injury (ABI). The ability to benefit from rehabilitation or to perform daily activities may be affected by OM dysfunctions and associated symptoms. The purpose of this study was to investigate the effects of vision therapy (VT) as part of neurorehabilitation after ABI.Materials and Methods: The study included two groups of outpatients (median 49.5-52.0 years, range 27-67) admitted to neurorehabilitation due to moderate to severe ABI. One group received VT while the other group served as controls to monitor the course of OM dysfunctions without VT.Results: The intervention group showed significant improvements in convergence (Z = 2.26, p = .02), vergence facility (Z = -2.16, p = .03) and vergence reserves (Z = -2.44, p < .01 and t = -4.47, DF = 15, p < .01) along with a significant reduction in vision-related symptoms (Z = 2.97, p < .01).Discussion: We conclude that OM issues were frequent and that targeted VT, as part of neurorehabilitation, can be an efficient treatment resulting in improved functions and reduced symptoms. Further study will be required to understand how improved functions link to performance and satisfaction with everyday activities.

Managing shoulder pain in manual wheelchair users: a scoping review of conservative treatment interventions

Objective:

To review the literature that has explored conservative treatments for the management of shoulder pain in manual wheelchair users.

Methods:

Five databases were systematically searched in february 2020 for terms related to shoulder pain and manual wheelchair use. Articles were screened and included if they investigated the conservative treatment of shoulder pain in wheelchair users. Participants’ physical characteristics, experimental design and primary and secondary outcome measures were extracted from studies. Studies were grouped according to treatment type to identify gaps in the literature and guide future research.

Results:

The initial search identified 407 articles, of which 21 studies met the inclusion criteria. Exercise-based treatment interventions were most prevalent (n = 12). A variety of exercise modalities were employed such as strengthening and stretching (n = 7), ergometer training (n = 3), Pilates classes (n = 1) and functional electrical stimulation (n = 1). Only three studies supplemented exercise with an additional treatment type. The Wheelchair Users Shoulder Pain Index was used by 18 studies as the primary measure of shoulder pain. Only seven of these included an objective measure of shoulder function. Participant characteristics varied among studies, and physical activity levels were frequently not reported.

Conclusions:

Despite the high prevalence of shoulder pain in manual wheelchair users, the number of studies to have explored conservative treatment types is low. Exercise is the most commonly used treatment, which is encouraging as physical inactivity can exacerbate other health conditions. Few studies have adopted interdisciplinary treatment strategies or included objective secondary measures to better understand the mechanisms of pain.

The effect on subjective quality of life of occupational therapy based on adjusting the challenge-skill balance: a randomized controlled trial

OBJECTIVE

To verify the effect of adjusting the challenge-skill balance with respect to rehabilitation process.

DESIGN

A single-blind, two-arm, parallel-group, randomized controlled trial.

SETTING

Recovery rehabilitation unit of Harue Hospital, Japan.

SUBJECTS

The trial included 72 clients (mean (SD): age, 74.64 (9.51) years; Functional Independence Measure score, 98.26 (15.27)) with cerebral or spinal disease or musculoskeletal disease.

INTERVENTIONS

Clients were randomly divided into two groups: the experimental group, who received occupational therapy with adjustment of the challenge-skill balance, and the control group who received conventional occupational therapy. Time from admission to discharge was considered the implementation period; the final evaluation was conducted at three months after discharge.

MAIN MEASURES

The primary outcome was subjective quality of life (Ikigai-9). Secondary outcomes were the health-related quality of life (EuroQol-5 Dimensions, Five Levels (EQ-5D-5L)), the Flow State Scale for Occupational Tasks, and the Functional Independence Measure. A cost-effectiveness analysis was conducted using total cost and quality-adjusted life-year based on the EQ-5D-5L.

RESULTS

Significant differences were observed between the experimental and control groups with respect to the Ikigai-9 score (P = 0.008) and EQ-5D-5L (P = 0.038), and the effect sizes were 0.76 (95% confidence interval [CI]: 0.27-1.24) and 0.62 (95% CI: 0.14-1.10), respectively. No significant between-group differences in other outcomes were observed, for example, the Functional Independence Measure score improved in both experimental and control groups (119.80 (5.50) and 118.84 (6.97), respectively. The incremental cost-effectiveness ratio was US$5518.38.

CONCLUSIONS

Adjusting the challenge-skill balance may be a useful approach to improve the participant's subjective quality of life in the rehabilitation process.

Heterogeneity and Its Impact on Rehabilitation Outcomes and Interventions for Community Reintegration in People With Spinal Cord Injuries: An Integrative Review

Background: Various injury characteristics such as cause, level, severity, and time since injury divide individuals with spinal cord injury (SCI) into many subgroups. The heterogeneity among individuals' injuries and personal characteristics has significant implications for SCI rehabilitation practice, specifically directed toward community reintegration, which is a key goal of rehabilitation interventions for people with disabilities. Purpose: This study aims to summarize the evidence on attributes that make the SCI population heterogeneous, the impact of these attributes on community reintegration, and the implications of heterogeneity for rehabilitation interventions directed toward optimizing community reintegration. Methods: We used an integrative review approach to conduct this study. MEDLINE, PubMed, CINAHL, EMBASE, Google Scholar, and PsycINFO were searched from inception until May 2017. Out of 670 articles retrieved, 49 provided evidence on the impact of various attributes that make SCI heterogeneous on rehabilitation outcomes related to community reintegration. Results: An array of injury-related, personal, social, and environmental factors are associated with various rehabilitation outcomes that affect community reintegration of people with SCI. There is level 1 evidence that social support, self-efficacy, and self-esteem facilitate community reintegration among people with SCI while there is level 5 evidence that presence of psychological or medical complications decreases it. There is lack of clarity on the impact of injury-related factors on community reintegration. Conclusion: This integrative review found that social support and individuals' self-efficacy can improve community reintegration of people with SCI. However, evidence regarding the impact of injury characteristics on community reintegration is still underdeveloped. Approaches directed at community reintegration should involve components of psychosocial, physical, and vocational rehabilitation while considering personal and societal aspects of an individual's life.

Measuring clinical competencies in facilitating group-based rehabilitation interventions: development of a new competency checklist

OBJECTIVE

Group-based intervention formats are common in rehabilitation, but no tool for objectively measuring clinical competencies in group facilitation currently exists. We aimed to develop a psychometrically sound group facilitation competency checklist for use in clinical, training, and research settings.

METHOD

The Delphi method of expert consensus was used to establish checklist items that clearly describe competencies considered important for effective group facilitation. Inter-rater reliability was determined with two experienced psychologists who used the checklist to rate the competencies of psychology trainees facilitating a memory skills group.

RESULTS

After two Delphi rounds, consensus was reached on 17 items, defined as at least 80% agreement among the panel of 15 experts. The four checklist item categories were (a) Facilitating focused group discussion, (b) Communication skills, (c) Interpersonal style, and (d) Session structure. One item was removed after piloting. Inter-rater reliability was excellent (88% agreement) using a simple coding method (competent/incompetent). When using a detailed coding method that discriminated between 'done adequately' and 'done well', inter-rater reliability was weaker (κ = 0.481, 55% agreement); however, it improved to almost perfect after the raters calibrated their standards.

CONCLUSION

The new group facilitation competency checklist is fit for purpose for measuring clinical competencies in delivering group-based rehabilitation interventions and can be used in the training of effective group facilitators.

Promoting activity, independence and stability in early dementia and mild cognitive impairment (PrAISED): development of an intervention for people with mild cognitive impairment and dementia

This series of articles for rehabilitation in practice aims to cover a knowledge element of the rehabilitation medicine curriculum. Nevertheless, they are intended to be of interest to a multidisciplinary audience. The competency addressed in this article is an understanding of how to develop an intervention for people with mild cognitive impairment and dementia to promote their independence, stability, and physical activity.

INTRODUCTION

Older adults with dementia are at a high risk of falls. Standard interventions have not been shown to be effective in this patient population potentially due to poor consideration of dementia-specific risk factors. An intervention is required that addresses the particular needs of older people with dementia in a community setting.

METHODS

We followed guidelines for the development of an intervention, which recommend a structured approach considering theory, evidence and practical issues. The process used 15 information sources. Data from literature reviews, clinician workshops, expert opinion meetings, patient-relative interviews, focus groups with people with dementia and clinicians, a cross-sectional survey of risk factors, a pre-post intervention study and case studies were included. Data were synthesized using triangulation to produce an intervention suitable for feasibility testing. Practical consideration of how an intervention could be delivered and implemented were considered from the outset.

RESULTS

Elements of the intervention included individually tailored, dementia-appropriate, balance, strength and dual-task exercises, functional training, and activities aimed at improving environmental access, delivered using a motivational approach to support adherence and long-term continuation of activity. We focussed on promoting safe activity rather than risk or prevention of falls.

CONCLUSION

We used a systematic process to develop a dementia-specific intervention to promote activity and independence while reducing falls risk in older adults with mild dementia.

A feasibility randomized controlled trial of ReaDySpeech for people with dysarthria after stroke

Objective:

To evaluate the feasibility of a multicentre randomized controlled trial of ReaDySpeech, an online speech therapy programme for people with dysarthria.

Design:

Feasibility randomized controlled trial, 2:1 minimization procedure.

Setting:

Four UK NHS services across hospital and community.

Participants:

Forty participants with dysarthria at least one week post-stroke.

Interventions/comparator:

ReaDySpeech with usual care (n = 26) versus usual care only (n = 14).

Main outcomes:

Feasibility measures included the following: recruitment and retention rate, time taken to carry out assessments, success of outcome assessor blinding, fidelity and adherence. Participant baseline and outcome measures collected before and after 8–10 weeks of intervention were the Frenchay Dysarthria Assessment II, Therapy Outcome Measure, Communication Outcomes After Stroke Scale, EQ-5D-5L and Dysarthria Impact Profile.

Results:

Recruited 40 participants out of 74 eligible people, 1–13 weeks post stroke and mean age 69 years (37–99). Retention was very high (92%). Assessor blinding was not achieved with intervention allocation correctly guessed for 70% of participants (26/37). Time to carry out assessments was acceptable to participants. ReaDySpeech was delivered to 16 of 26 allocated participants, who completed 55% of prescribed activities, but both interventions were delivered at low intensity (mean 6.6 face-to-face sessions of 40-minute duration).

Conclusion:

Recruitment and retention in this randomized controlled trial of computerized therapy for dysarthria is feasible for acute stroke. However, further feasibility work is needed to evaluate whether it is possible to recruit chronic stroke; increase intervention delivery, intensity and adherence; achieve outcome assessor blinding by video-recording and to determine sample size for a larger trial of effectiveness.

Does the addition of two exercise-focussed home visits to usual care improve outcomes for patients with balance impairments? A randomized controlled trial

OBJECTIVE

To investigate whether two additional home visits improve outcomes for rehabilitation outpatients with balance impairments compared to usual care.

DESIGN

Randomized controlled trial.

SETTING

Outpatient rehabilitation.

PARTICIPANTS

Fifty with balance impairments.

INTERVENTIONS

Both groups received usual care including weekly group exercise over eight weeks. The intervention group received two home visits to individualize home exercises.

OUTCOME MEASURES

Primary outcome measure was the Balance Outcome Measure for Elder Rehabilitation (BOOMER) score, and secondary outcomes included force platform measures using the NeuroCom Balance Master^®, assessed at baseline, after intervention and three-month follow-up.

RESULTS

There was no between-group difference for BOOMER score. There were significant between-group differences in favour of the intervention group for limits of stability reaction time at week 9 (mean difference (MD) -0.27, 95% confidence interval (CI) -0.44 to -0.09) and week 22 (MD -0.28, 95% CI -0.45 to -0.10) and for limits of stability maximal excursion at week 9 (MD 8.66, 95% CI 1.67 to 15.65) and week 22 (MD 14.58, 95% CI 7.59 to 21.57). Significant between-group differences favoured the control group for Clinical Test of Sensory Interaction of Balance at week 9 (MD 0.40, 95% CI 0.13 to 0.66) and week 22 (MD 0.45, 95% CI 0.18 to 0.72) and step quick turn time at week 9 (MD 0.56, 95% CI 0.02 to 1.10).

CONCLUSION

Two exercise-focussed home visits improved some dynamic balance outcomes in older patients with balance impairments. Some outcomes showed significant improvements with small effect sizes in favour of the control group which may be chance findings or because they completed a standard home exercise programme.

How have research questions and methods used in clinical trials published in Clinical Rehabilitation changed over the last 30 years?

Research in rehabilitation has grown from a rare phenomenon to a mature science and clinical trials are now common. The purpose of this study is to estimate the extent to which questions posed and methods applied in clinical trials published in Clinical Rehabilitation have evolved over three decades with respect to accepted standards of scientific rigour. Studies were identified by journal, database, and hand searching for the years 1986 to 2016.

A total of 390 articles whose titles suggested a clinical trial of an intervention, with or without randomization to form groups, were reviewed. Questions often still focused on methods to be used (57%) rather than what knowledge was to be gained. Less than half (43%) of the studies delineated between primary and secondary outcomes; multiple outcomes were common; and sample sizes were relatively small (mean 83, range 5 to 3312). Blinding of assessors was common (72%); blinding of study subjects was rare (19%). In less than one-third of studies was intention-to-treat analysis done correctly; power was reported in 43%. There is evidence of publication bias as 83% of studies reported either a between-group or a within-group effect. Over time, there was an increase in the use of parameter estimation rather than hypothesis testing and there was evidence that methodological rigour improved.

Rehabilitation trialists are answering important questions about their interventions. Outcomes need to be more patient-centred and a measurement framework needs to be explicit. More advanced statistical methods are needed as interventions are complex. Suggestions for moving forward over the next decades are given.

Training in positivity for stroke? A qualitative study of acceptability of use of Positive Mental Training (PosMT) as a tool to assist stroke survivors with post-stroke psychological problems and in coping with rehabilitation

BACKGROUND

Post-stroke psychological problems predict poor recovery, while positive affect enables patients to focus on rehabilitation and may improve functional outcomes. Positive Mental Training (PosMT), a guided self-help audio shows promise as a tool in promoting positivity, optimism and resilience.

OBJECTIVE

To assess acceptability of training in positivity with PosMT for prevention and management of post-stroke psychological problems and to help with coping with rehabilitation.

METHODS

A modified PosMT tool consisted of 12 audio tracks each lasting 18 minutes, one listened to every day for a week. Survivors and carers were asked to listen for 4 weeks, but could volunteer to listen for more. Interviews took place about experiences of the tool after 4 and 12 weeks.

SUBJECTS

10 stroke survivors and 5 carers from Stroke Support Groups in the UK.

RESULTS

Three stroke survivors did not engage with the tool. The remainder reported positive physical and psychological benefits including improved relaxation, better sleep and reduced anxiety after four weeks. Survivors who completed the programme gained a positive outlook on the future, increased motivation, confidence and ability to cope with rehabilitation. No adverse effects were reported.

CONCLUSIONS

The PosMT shows potential as a tool for coping with rehabilitation and overcoming post-stroke psychological problems including anxiety and depression.

Progressive multi-component home-based physical therapy for deconditioned older adults following acute hospitalization: a pilot randomized controlled trial

OBJECTIVE

To determine whether a progressive multicomponent physical therapy intervention in the home setting can improve functional mobility for deconditioned older adults following acute hospitalization.

DESIGN

Randomized controlled trial.

SETTING

Patient homes in the Denver, CO, metropolitan area.

PARTICIPANTS

A total of 22 homebound older adults age 65 and older (mean ± SD; 85.4 ±7.83); 12 were randomized to intervention group and 10 to the control group.

INTERVENTION

The progressive multicomponent intervention consisted of home-based progressive strength, mobility and activities of daily living training. The control group consisted of usual care rehabilitation.

MEASUREMENTS

A 4-meter walking speed, modified Physical Performance Test, Short Physical Performance Battery, 6-minute walk test.

RESULTS

At the 60-day time point, the progressive multicomponent intervention group had significantly greater improvements in walking speed (mean change: 0.36 m/s vs. 0.14 m/s, p = 0.04), modified physical performance test (mean change: 6.18 vs. 0.98, p = 0.02) and Short Physical Performance Battery scores (mean change: 2.94 vs. 0.38, p = 0.02) compared with the usual care group. The progressive multicomponent intervention group also had a trend towards significant improvement in the 6-minute walk test at 60 days (mean change: 119.65 m vs. 19.28 m; p = 0.07). No adverse events associated with intervention were recorded.

CONCLUSIONS

The progressive multicomponent intervention improved patient functional mobility following acute hospitalization more than usual care. Results from this study support the safety and feasibility of conducting a larger randomized controlled trial of progressive multicomponent intervention in this population. A more definitive study would require 150 patients to verify these conclusions given the effect sizes observed.

Effectiveness of facial exercise therapy for facial nerve dysfunction after superficial parotidectomy: a randomized controlled trial

OBJECTIVES

To compare the effectiveness of a daily home-based facial exercise therapy with a supervised rehabilitation technique for the treatment of postoperative facial dysfunction in patients undergoing conventional superficial parotidectomy.

DESIGN

Prospective, randomized trial, controlled.

SETTING

Surgery and Rehabilitation Units, university hospital.

SUBJECTS

Consecutive patients ( n=79, mean age 48 years) who underwent superficial parotidectomy with facial nerve dissection were randomly divided into two groups.

INTERVENTION

Control group (CG) were given a daily homework manual to perform ordinary postoperative facial mimic exercises autonomously in front of the mirror at home. Experimental group (EG) patients with moderate-severe paresis received supervised rehabilitation therapy that consisted in weekly sessions with facial exercises and massages and performed daily facial exercises at home. EG patients with slight paresis were instructed to undertake self-massage and mirror exercises.

MAIN OUTCOME MEASURES

Postoperative dysfunction of facial nerve and branches was quantified measuring the prevalence, magnitude and duration of paresis by the House-Brackmann Facial Nerve Grading System up to 12^th months.

RESULTS

Facial paresis incidence at 1^st week was 77.2%, being the marginal-mandibular nerve the most affected (64.5%). No statistically significant differences were found at any time of the study when comparing the frequency, magnitude and duration of paresis between EG and CG and among patients who had presented moderate-severe paresis. In the absence of intraoperative nerve injury, complete recovery of facial mobility was observed within 12 months, regardless of treatment group.

CONCLUSION

Rehabilitation therapy and mirror facial exercises performed autonomously at home were equally effective for postoperative functional recovery.

Feasibility and effect of supplementing a modified OTAGO intervention with multisensory balance exercises in older people who fall: a pilot randomized controlled trial

OBJECTIVE

To investigate the feasibility and comparative effect of supplementing a modified OTAGO falls rehabilitation programme with multisensory balance exercises and informed sample size calculation for a definitive trial.

DESIGN

Single-blinded randomized controlled trial with pre/postcomparisons using a per-protocol analysis.

SETTING

Secondary care-based falls clinic, London, UK.

SUBJECTS

Community-dwelling older people (n = 21) experiencing ≥2 non-syncopal falls during previous 12 months.

INTERVENTION

Modified OTAGO exercise classes supplemented with supervised home-based rehabilitation consisting of multisensory balance or stretching exercises. Group classes and home sessions each occurred twice-weekly for eight weeks.

MEASUREMENTS

A computerised randomization was used for group allocation. A rater, blinded to intervention, performed the assessment including the Functional Gait Assessment (primary outcome), Physiological Profile Assessment, and questionnaires relating to symptoms, balance confidence, and psychological state (secondary outcomes).

RESULTS

Significant within-group improvements were noted for the Functional Gait (p < 0.01, r = -0.63) and Physiological Profile Assessments (p < 0.05, r = -0.63) in the OTAGO+multisensory rehabilitation group only and for balance confidence scores in the OTAGO+stretching group (p < 0.01, r = -0.63). Between-group differences were noted for the Functional Gait (p < 0.01, r = -0.71) and Physiological Profile (p < 0.05, r = -0.54) assessments with the OTAGO+multisensory group showing significantly greater improvement. The drop-out rate was similar for both groups (~30%). No serious adverse events were reported.

CONCLUSIONS

Supplementing the OTAGO programme with multisensory balance exercises is feasible in older people who fall and may have a beneficial effect on falls risk as measured using the Functional Gait and Short-form Physiological Profile Assessments. An adequately powered randomized controlled trial would require 36 participants to detect an effect size of 1.35 on the Functional Gait Assessment.

Effect of occupational therapy on functional and emotional outcomes after hip fracture treatment: a randomized controlled trial

OBJECTIVE

To explore whether an occupational therapy intervention combined with physiotherapy rehabilitation improved hip fracture patient outcomes regarding emotional distress, fatigue, independence and function.

DESIGN

Randomized controlled trial.

SETTING

Inpatient trauma ward in a rehabilitation and trauma hospital.

PARTICIPANTS

One hundred and twenty-two patients admitted into hospital for hip fracture.

INTERVENTION

Patients were randomly assigned to a standard care group (SC, n = 61) or a combined treatment group (CT, n = 61). The SC group received conventional hospital care for hip fracture patients and the CT group underwent occupational therapy as well.

MAIN MEASURES

Patients' emotional distress (GHQ-28), perceived fatigue (the first item of the BASDAI using a 0-100 visual analogue scale scale), level of independence (Modified Barthel Index) and function (Harris Hip Score) were measured at baseline and one, three and six months after the intervention.

RESULTS

Patients in the CT group experienced a considerable decrease of emotional distress at three and six months (p = 0.005 and p < 0.001, respectively). A between-group analysis showed significant differences in emotional distress at one, three and six months (p < 0.001). Although fatigue levels decreased in the SC group, the most significant decline was reported by the CT group at six months (p < 0.001, mean difference = 14 points). Regarding independence level, significant differences were found within groups at each stage, but also between groups at one month in favor of the CT group. Function improved in both groups compared with baseline (p < 0.001), but no significant differences were found in functionality between groups.

CONCLUSION

Although both groups reported significant improvements, patients in the CT group had better scores in emotional distress and dependence throughout follow-up and better scores in all measures at six months.

An occupation-based strategy training approach to managing age-related executive changes: a pilot randomized controlled trial

OBJECTIVE

To determine the feasibility of recruitment and retention of healthy older adults and the effectiveness of an intervention designed to manage age-related executive changes.

DESIGN

A pilot randomized controlled trial.

SETTING

Research centre and participants' homes.

PARTICIPANTS

Nineteen healthy, community dwelling older adults with complaints of cognitive difficulties and everyday problems, but no evidence of mild cognitive impairment, dementia or depression on objective testing.

INTERVENTIONS

Seventeen hours of group and individual training. Participants in the experimental arm received education about self-management, successful aging and an occupation-based meta-cognitive strategy-training program. Participants in the control arm received education about brain health and participated in cognitively stimulating exercises.

MAIN MEASURES

Changes on untrained, everyday life goals were identified using the Canadian Occupational Performance Measure. Generalization of benefits was measured using the Stanford Chronic Disease Questionnaire, general self-efficacy and changes in executive function (Delis-Kaplan Executive Function System Tower Test, Word Fluency and Trail-Making Test).

RESULTS

20% (19/96) of healthy older adults approached were eligible, consented and were enrolled in the study, 90% (17/19) were retained to three-month follow-up. Participants in the experimental arm reported significantly more improvement on untrained goals (11/22 compared with 9/46, χ(2)=4.92, p<0.05), maintenance of physical activity (p<0.05) and better preparation for doctors' visits (p<0.05) relative to the control group. There were no significant between group differences on objective measures of executive function.

CONCLUSIONS

These data support the feasibility of a larger trial where a sample of 72 (36 participants in each arm) would be required to confirm or refute these findings.