Stretch for the treatment and prevention of contractures

Global perspectives on risk factors for major joint burn contractures: A literature review

Contractures are a frequent consequence of burn injuries, yet our knowledge of associated risk factors is limited. This paper provides an extensive review of relevant literature from both High-Income Countries (HICs) and Low-Middle Income Countries (LMICs). Ninety-four papers (up to June 2019) and eight subsequent publications (up to March 2022) were included, 76% of which were from HICs. The majority of publications were either descriptive studies (4 from HICs, 9 from LMICs) or papers citing putative risk factors (37 from HICs, 10 from LMICs). Seventeen publications (all from HICs) reported on the effects of individual non-surgical therapeutic interventions, often with conflicting results. Two published systematic reviews emphasised the poor quality of evidence available. Only fifteen studies (3 from LMICs) examined potential contracture risk factors with statistical comparisons of outcomes; significant findings from these included demographic, burn, comorbidities, and treatment risk factors. LMIC papers included socioeconomic and healthcare system factors as potential risks for contracture; these were rarely considered in HIC publications. Methodological issues identified from this review of literature included differences in contracture definitions, populations studied, standards of care, joints included and the timing and nature of contracture assessments.This review is the first to collate existing knowledge on risk factors for burn contractures from both HIC and LMIC settings, revealing a surprising lack of robust evidence for many accepted risk factors. In LMICs, where burns are particularly common, universal health provision is lacking and specialist burn care is both scarce and difficult to access; consequently, socioeconomic factors may have more immediate impact on contracture outcomes than specific burn treatments or therapies. Much more work is indicated to fully understand the relative impacts of risk factors in different settings so that context-appropriate contracture prevention strategies can be developed.

Does the format of result presentation and type of conclusion in Cochrane plain language summaries matter? A randomised controlled trial

OBJECTIVES

This study aimed to investigate whether the format and type of conclusion in Cochrane plain language summaries (PLSs) influence readers' perception of treatment benefit and decision-making.

DESIGN

An online parallel group, three-arm randomised controlled trial was conducted.

SETTING

The study was conducted online.

PARTICIPANTS

The participants were physiotherapy students.

INTERVENTIONS

The participants read two Cochrane PLSs, one with a positive conclusion (strong evidence of benefit) and another with a negative conclusion (strong evidence of non-benefit). Each participant read the results of both reviews presented in one of three formats: (1) numerical, (2) textual or (3) numerical and textual.

MAIN OUTCOME MEASURES

The primary outcome measure was the participants' perception of treatment benefit.

RESULTS

All three groups of participants perceived the treatment to have positive effects when the Cochrane PLS had a positive conclusion, regardless of the format of presentation (mean perception of treatment benefit score: textual 7.7 (SD 2.3), numerical 7.9 (SD 1.8), numerical and textual 7.7 (SD 1.7), p=0.362). However, when the Cochrane PLS had a negative conclusion, all three groups of participants failed to perceive a negative effect (mean perception of treatment benefit score: textual 5.5 (SD 3.3), numerical 5.6 (SD 2.7), numerical and textual 5.9 (SD 2.8), p=0.019).

CONCLUSIONS

The format of Cochrane PLSs does not appear to significantly impact physiotherapy students' perception of treatment benefit, understanding of evidence, persuasiveness or confidence in their decision. However, participants' perception of treatment benefit does not align with the conclusion when the Cochrane PLS indicates strong evidence of non-benefit from the intervention.

TRIAL REGISTRATION NUMBER

CTRI/2022/10/046476.

Effectiveness of an individually tailored complex intervention to improve activities and participation in nursing home residents with joint contractures (JointConEval): a multicentre pragmatic cluster-randomised controlled trial

OBJECTIVE

This study aims to examine the effects of the individually tailored complex intervention Participation Enabling Care in Nursing (PECAN) on activities and participation of residents with joint contractures.

DESIGN

Multicentre pragmatic cluster-randomised controlled trial.

SETTING

35 nursing homes in Germany (August 2018-February 2020).

PARTICIPANTS

562 nursing home residents aged ≥65 years with ≥1 major joint contracture (303 intervention group, 259 control group).

INTERVENTIONS

Nursing homes were randomised to PECAN (18 clusters) or optimised standard care (17 clusters) with researcher-concealed cluster allocation by facsimile. The intervention targeted impairments in activities and participation. Implementation included training and support for selected staff. Control group clusters received brief information.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary endpoint PaArticular Scales combined residents' activities and participation at 12 months. The secondary outcome comprised quality of life. Safety measures were falls, fall-related consequences and physical restraints. Residents, staff and researchers were unblinded. Data collection, data entry and statistical analysis were blinded. Primary analyses were intention-to-treat at cluster level and individual level using a generalised mixed-effect regression model and imputation of missing data.

RESULTS

Primary outcome analyses included 301 intervention group residents and 259 control group residents. The mean change on the Activities Scale was -1.47 points (SD 12.2) in the intervention group and 0.196 points (SD 12.5) in the control group and -3.87 points (SD 19.7) vs -3.18 points (SD 20.8) on the Participation Scale. The mean differences of changes between the groups were not statistically significant: Activities Scale: -1.72 (97.5% CI -6.05 to 2.61); Participation Scale: -1.24 (97.5% CI -7.02 to 4.45). We found no significant difference in the secondary outcome and no effects on safety measures.

CONCLUSION

The complex intervention did not improve the activities and participation of nursing home residents on the PaArticular Scales at 12 months. Current nursing conditions in Germany may hamper implementation.

TRIAL REGISTRATION NUMBER

DRKS00015185.

Motor performance, motor impairments, and quality of life after eccentric resistance training in neurological populations: A systematic review and meta-analyses

BACKGROUND

Many overlapping factors impair motor performance and quality of life in neurological patients. Eccentric resistance training (ET) has potential benefits for improving motor performance and treating motor impairments better than some traditional rehabilitation approaches.

OBJECTIVE

To estimate the effect of ET in neurological settings.

METHODS

Seven databases were reviewed up to May 2022 according to PRSIMA guidelines to find randomized clinical trials involving adults with a neurological condition, who underwent ET as set by the American College of Sports Medicine. Motor performance (main outcome) was assessed as strength, power and capacities during activity. Secondary outcomes (impairments) were muscle structure, flexibility, muscle activity, tone, tremor, balance and fatigue. Tertiary outcomes were risk of fall, and self-reports of quality of life.

RESULTS

Ten trials were included, assessed using Risk of Bias 2.0 tool, and used to compute meta-analyses. Effective effects in favour of ET were found for strength and power, but not for capacities during activity. Mixed results were found for secondary and tertiary outcomes.

CONCLUSION

ET may be a promising intervention to better improve strength/power in neurological patients. More studies are needed to improve the quality of evidence underlying changes responsible for these results.

Supported-standing interventions for children and young adults with non-ambulant cerebral palsy: A scoping review

AIM

To describe the evidence, outcomes, and lived experience of supported standing for children and young adults with cerebral palsy aged 25 years or younger, classified in Gross Motor Function Classification System levels IV and V.

METHOD

This scoping review included searches in eight electronic databases and manual searching from database inception to May 2020 and updated on 21st February 2022. Two of three reviewers independently screened titles and abstracts and extracted and appraised data. Methodological quality and risk of bias were appraised using tools appropriate to study type. Content analysis and frequency effect sizes were calculated for qualitative and descriptive evidence.

RESULTS

From 126 full-text references, 59 citations (one study was reported over two citations) were included: 16 systematic reviews, 17 intervention studies reporting over 18 citations, eight analytical cross-sectional studies, five descriptive cross-sectional/survey studies, five qualitative studies, and one mixed-methods study were identified, along with six clinical guidelines. Maintenance of bone mineral density and contracture prevention outcomes were supported by the most experimental studies and evidence syntheses, while evidence supporting other outcomes was primarily quasi-experimental or descriptive. Qualitative evidence suggests that programmes are influenced by attitudes, device, child, and environmental factors.

INTERPRETATION

Individualized assessment and prescription are essential to match personal and environmental needs. Although experimental evidence is limited due to many factors, lived-experience and cohort data suggest that successful integration of standing programmes into age-appropriate and meaningful activities may enhance function, participation, and overall health.

SPINE: An Initiative to Reduce Pressure Sore Recurrence

The recurrence rate after pressure sore reconstruction remains high. Primary inciting factors can be organized into efforts aimed at wound prevention: spasticity relief, pressure off-loading, infection and contamination prevention, nutrition optimization, and maximizing extremity function. This article presents our detailed protocol, SPINE, to address each inciting factor with a summary of cases at our facility and review best practices from evidence-based medicine in the literature.

Acute Effects of Static and Proprioceptive Neuromuscular Facilitation Stretching of the Plantar Flexors on Ankle Range of Motion and Muscle-Tendon Behavior in Children with Spastic Cerebral Palsy-A Randomized Clinical Trial

Stretching is considered a clinically effective way to prevent muscle contracture development in children with spastic cerebral palsy (CP). Therefore, in this study, we assessed the effects of a single session of proprioceptive neuromuscular facilitation (PNF) or static stretching (SS) on ankle joint range of motion (RoM) and gastrocnemius muscle-tendon behavior in children with CP. During the SS (n = 8), the ankle joint was held in maximum dorsiflexion (30 s). During the PNF stretching (n = 10), an isometric contraction (3-5 s) was performed, followed by stretching (~25 s). Ten stretches were applied in total. We collected data via dynamometry, 3D motion capture, 2D ultrasound, and electromyography, before and after the stretching sessions. A mixed ANOVA was used for the statistical analysis. Both ankle RoM and maximum dorsiflexion increased over time (F(1,16) = 7.261, p < 0.05, η² = 0.312; and F(1,16) = 4.900, p < 0.05, η² = 0.234, respectively), without any difference between groups. An interaction effect (F(1,12) = 4.768, p = 0.05, η² = 0.284) was observed for muscle-tendon unit elongation (PNF: -8.8%; SS: +14.6%). These findings suggest a positive acute effect of stretching on ankle function. However, SS acutely increased muscle-tendon unit elongation, while this decreased after PNF stretching, indicating different effects on the spastic muscles. Whether PNF stretching has the potential to cause positive alterations in individuals with CP should be elucidated in future studies.

Brazilian Academy of Neurology practice guidelines for stroke rehabilitation: part I

The Guidelines for Stroke Rehabilitation are the result of a joint effort by the Scientific Department of Neurological Rehabilitation of the Brazilian Academy of Neurology aiming to guide professionals involved in the rehabilitation process to reduce functional disability and increase individual autonomy. Members of the group participated in web discussion forums with predefined themes, followed by videoconference meetings in which issues were discussed, leading to a consensus. These guidelines, divided into two parts, focus on the implications of recent clinical trials, systematic reviews, and meta-analyses in stroke rehabilitation literature. The main objective was to guide physicians, physiotherapists, speech therapists, occupational therapists, nurses, nutritionists, and other professionals involved in post-stroke care. Recommendations and levels of evidence were adapted according to the currently available literature. Part I discusses topics on rehabilitation in the acute phase, as well as prevention and management of frequent conditions and comorbidities after stroke.

How Does Stroke Affect Skeletal Muscle? State of the Art and Rehabilitation Perspective

Long-term disability caused by stroke is largely due to an impairment of motor function. The functional consequences after stroke are caused by central nervous system adaptations and modifications, but also by the peripheral skeletal muscle changes. The nervous and muscular systems work together and are strictly dependent in their structure and function, through afferent and efferent communication pathways with a reciprocal “modulation.” Knowing how altered interaction between these two important systems can modify the intrinsic properties of muscle tissue is essential in finding the best rehabilitative therapeutic approach. Traditionally, the rehabilitation effort has been oriented toward the treatment of the central nervous system damage with a central approach, overlooking the muscle tissue. However, to ensure greater effectiveness of treatments, it should not be forgotten that muscle can also be a target in the rehabilitation process. The purpose of this review is to summarize the current knowledge about the skeletal muscle changes, directly or indirectly induced by stroke, focusing on the changes induced by the treatments most applied in stroke rehabilitation. The results of this review highlight changes in several muscular features, suggesting specific treatments based on biological knowledge; on the other hand, in standard rehabilitative practice, a realist muscle function evaluation is rarely carried out. We provide some recommendations to improve a comprehensive muscle investigation, a specific rehabilitation approach, and to draw research protocol to solve the remaining conflicting data. Even if a complete multilevel muscular evaluation requires a great effort by a multidisciplinary team to optimize motor recovery after stroke.

Psychometric validation of the Chinese version of the PaArticular Scales among elderly residents in long-term care facilities with joint contractures

Background

Joint contractures, which affect activity, participation, and quality of life, are common complications of neurological conditions among elderly residents in long-term care facilities. This study examined the reliability and validity of the Chinese version of the PaArticular Scales in a population with joint contractures.

Methods

A cross-sectional study design was used. The sample included elderly residents older than 64 years with joint contractures in an important joint who had lived at one of 12 long-term care facilities in Taiwan for more than 6 months (N = 243). The Chinese version of the PaArticular Scales for joint contractures was generated from the English version through five stages: translation, review, back-translation, review by a panel of specialists, and a pretest. Test-retest reliability, internal consistency reliability, construct validity, and criterion validity were evaluated, and the results were compared with those for the World Health Organization Quality of Life scale and the World Health Organization Disability Assessment Schedule.

Results

The Chinese version of the PaArticular Scales had excellent reliability, with a Cronbach α coefficient of 0.975 (mean score, 28.98; standard deviation, 17.34). An exploratory factor analysis showed three factors and one factor with an eigenvalue > 1 that explained 75.176 and 62.83 % of the total variance in the Activity subscale and Participation subscale, respectively. The subscale-to-total scale correlation analysis showed Pearson correlation coefficients of 0.881 for the Activity subscale and 0.843 for the Participation subscale. Pearson’s product-moment correlation revealed that the correlation coefficient (r) between the Chinese version of the PaArticular Scales and the World Health Organization Disability Assessment Schedule was 0.770, whereas that for the World Health Organization Quality of Life scale was − 0.553; these values were interpreted as large coefficients.

Conclusions

The underlying theoretical model of the Chinese version of the PaArticular Scales functions well in Taiwan and has acceptable levels of reliability and validity. However, the Chinese version must be further tested for applicability and generalizability in future studies, preferably with a larger sample and in different clinical domains.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-021-02297-5.

The Case for Retiring Flexibility as a Major Component of Physical Fitness

Flexibility refers to the intrinsic properties of body tissues that determine maximal joint range of motion without causing injury. For many years, flexibility has been classified by the American College of Sports Medicine as a major component of physical fitness. The notion flexibility is important for fitness has also led to the idea static stretching should be prescribed to improve flexibility. The current paper proposes flexibility be retired as a major component of physical fitness, and consequently, stretching be de-emphasized as a standard component of exercise prescriptions for most populations. First, I show flexibility has little predictive or concurrent validity with health and performance outcomes (e.g., mortality, falls, occupational performance) in apparently healthy individuals, particularly when viewed in light of the other major components of fitness (i.e., body composition, cardiovascular endurance, muscle endurance, muscle strength). Second, I explain that if flexibility requires improvement, this does not necessitate a prescription of stretching in most populations. Flexibility can be maintained or improved by exercise modalities that cause more robust health benefits than stretching (e.g., resistance training). Retirement of flexibility as a major component of physical fitness will simplify fitness batteries; save time and resources dedicated to flexibility instruction, measurement, and evaluation; and prevent erroneous conclusions about fitness status when interpreting flexibility scores. De-emphasis of stretching in exercise prescriptions will ensure stretching does not negatively impact other exercise and does not take away from time that could be allocated to training activities that have more robust health and performance benefits.

Safety, Feasibility, and Efficacy of an Eccentric Exercise Intervention in People with Multiple Sclerosis with Ankle Contractures

Background

The primary aim of this study was to investigate the safety and feasibility of an eccentric exercise program for people with multiple sclerosis (MS) who have ankle contractures, ie, reduced ankle range of motion (ROM). Secondary aims were to explore the efficacy of this eccentric exercise on ankle joint ROM and functional mobility.

Methods

Five adults with MS with ankle contractures (three women and two men; mean ± SD age, 50.8 ± 9.4; MS duration, 7.6 ± 5.6 years) completed two eccentric exercise training sessions (10-45 minutes) per week for 12 weeks. The training involved walking backward downhill on an inclined treadmill (gradient, 10°-14°) at a self-selected pace. The intervention was assessed for safety (adverse events), feasibility (recruitment rates, adherence rates, enjoyment levels, difficulty, and discomfort), and clinical outcomes, including passive/active ankle ROM and distance walked in 6 minutes.

Results

There were no adverse events during or after the eccentric exercise training. There was a 100% adherence rate. All participants enjoyed the training and experienced low levels of muscle soreness/discomfort. The training program improved passive/active ankle ROM in all participants; however, improvements did not translate to improvements in walking for all participants.

Conclusions

Walking backward and downhill is a safe and feasible training modality for people with MS with ankle contractures. Clinical outcomes (greater passive/active ankle ROM) after this eccentric exercise training were evident. However, translation to clinically meaningful changes in walking function requires further examination.

Acute Effects of a Brief Physical Exercise Intervention on Somatosensory Perception, Lumbar Strength, and Flexibility in Patients with Nonspecific Chronic Low-Back Pain

BACKGROUND

Evidence-based clinical guidelines consider physical exercise one of the best nonpharmacological interventions for low-back pain (LBP), but it is necessary to clarify the exercise-induced hypoalgesia effect of different modalities of exercise in chronic pain populations.

PURPOSE

This study focused on exploring acute changes in tactile and pressure-pain perception and lumbar strength and flexibility in patients with nonspecific chronic LBP (NSCLBP) after performing one of three 20-minute physical exercise modalities.

METHODS

A total of 81 patients with NSCLBP were pseudorandomly distributed into three groups of 20-minute physical exercise - 1) aerobic (n=21, mean age 42±9.72 years, nine men), 2) stretching (n=21, mean age 40±11.37 years, ten men), and 3) strengthening (n=20, mean age 35.80±11.56 years, ten men) - and 4) a control group (n=19, mean age 38.64±10.24 years, eight men), and completed self-reported questionnaires during the same period. Tactile and pressure-pain thresholds and isometric lumbar muscle endurance and flexibility were assessed before and after this brief exercise-based intervention.

RESULTS

All groups were comparable in terms of sociodemographic and clinical data, cardiovascular capacity, and self-reported data onphysical disability, mood, motivation, psychological response to stimulus properties of physical exercise, and physical activity enjoyment. Our analyses revealed higher tactile sensitivity (p<0.001) and pressure-pain thresholds (p<0.001) at the forefinger than other body locations. We also found lower pain sensitivity (p=0.010) and pressure pain-intensity ratings (p=0.001) and higher lumbar flexibility (p<0.001) after intervention. After calculation of absolute pre-post differences, higher tactile sensitivity was observed at the gluteus medius muscle than the erector spinal muscle only after aerobic intervention (p=0.046).

CONCLUSION

These results add some evidence about different modalities of exercise-induced hypoalgesia in NSCLBP. However, the fact that we also found improvements in the control group limits our conclusions.

A consensus process to agree best practice for managing physical wellbeing in people with a prolonged disorder of consciousness

BACKGROUND

Current practice for physical wellbeing of people in a Prolonged Disorder of Consciousness (PDOC) is variable. A scoping literature review identified no agreed standard of care for physical management of those in a PDOC. This study addressed this deficit using a consensus process applied using nominal group technique.

AIM

The aims of this project were therefore to promote best practice for physical management in PDOC, by identifying consensus for: 1. a pathway of care and 2. current best practice recommendations.

DESIGN

A consensus process using nominal group technique.

SETTING

Representation from national, purposively selected, rehabilitation services assessing and managing people in a PDOC in the UK.

POPULATION

The population to whom the consensus process relates are people in a PDOC, requiring physical management.

METHODS

An initial meeting (1) with selected clinical experts from national centres was conducted to set terms of reference. A consensus meeting (2) using nominal group technique (n=33) then followed. Experts were initially asked to review systematic review findings reproduced as statements. Following systematic refinement they were then asked to vote on the importance and relevance of statements.

RESULTS

Following the nominal group process, 25 initial recommendations were refined to 19, which expressed the principles of physical management for people with a Prolonged Disorder of Consciousness. Statements are grouped into 'acute-care' (6-recommendations), 'post-acute care' (10-recommendations) and 'long-term care' (3-recommendations). Across the participants, agreement with the final recommendation statements ranged from 100-61% (n=33-20), 15 of the statements were supported by 85% or more experts (n=29). In addition, a clinical pathway of care, incorporating the recommendation principles was produced (agreement from 28 experts, 83%).

CONCLUSIONS

The recommendations provide a basis for standardising current practice. They provide a standard against which care and effectiveness can be evaluated. An accessible guideline document is planned for publication to enable implementation into practice, supported by online resources.

CLINICAL REHABILITATION IMPACT

Recommendations have been produced under the headings of 'acute care', 'post-acute care' and 'longterm care'. In addition, a pathway for provision of care interventions has been identified for the physical management of people in a prolonged disorder of consciousness.

Nonsurgical Treatment Options for Muscle Contractures in Individuals With Neurologic Disorders: A Systematic Review With Meta-Analysis

Objective

To investigate whether nonsurgical treatment can reduce muscle contractures in individuals with neurologic disorders. The primary outcome measure was muscle contractures measured as joint mobility or passive stiffness.

Data Sources

Embase, MEDLINE, Cumulative Index to Nursing and Allied Health, and Physiotherapy Evidence Database in June-July 2019 and again in July 2020.

Study Selection

The search resulted in 8020 records, which were screened by 2 authors based on our patient, intervention, comparison, outcome criteria. We included controlled trials of nonsurgical interventions administered to treat muscle contractures in individuals with neurologic disorders.

Data Extraction

Authors, participant characteristics, intervention details, and joint mobility/passive stiffness before and after intervention were extracted. We assessed trials for risk of bias using the Downs and Black checklist. We conducted meta-analyses investigating the short-term effect on joint mobility using a random-effects model with the pooled effect from randomized controlled trials (RCTs) as the primary outcome. The minimal clinically important effect was set at 5°.

Data Synthesis

A total of 70 trials (57 RCTs) were eligible for inclusion. Stretch had a pooled effect of 3° (95% CI, 1-4°; prediction interval (PI)=−2 to 7°; I²=66%; P<.001), and robot-assisted rehabilitation had an effect of 1 (95% CI, 0-2; PI=−8 to 9; I²=73%; P=.03). We found no effect of shockwave therapy (P=.56), physical activity (P=.27), electrical stimulation (P=.11), or botulinum toxin (P=.13). Although trials were generally of moderate to high quality according to the Downs and Black checklist, only 18 of the 70 trials used objective measures of muscle contractures. In 23 trials, nonobjective measures were used without use of assessor-blinding.

Conclusions

We did not find convincing evidence supporting the use of any nonsurgical treatment option. We recommend that controlled trials using objective measures of muscle contractures and a sufficiently large number of participants be performed.

Recommendations for Hospital-Based Physical Therapists Managing Patients With COVID-19

OBJECTIVE

The COVID-19 pandemic is rapidly evolving and has led to increased numbers of hospitalizations worldwide. Hospitalized patients with COVID-19 experience a variety of symptoms, including fever, muscle pain, tiredness, cough, and difficulty breathing. Elderly people and those with underlying health conditions are considered to be more at risk of developing severe symptoms and have a higher risk of physical deconditioning during their hospital stay. Physical therapists have an important role in supporting hospitalized patients with COVID-19 but also need to be aware of challenges when treating these patients. In line with international initiatives, this article aims to provide guidance and detailed recommendations for hospital-based physical therapists managing patients hospitalized with COVID-19 through a national approach in the Netherlands.

METHODS

A pragmatic approach was used. A working group conducted a purposive scan of the literature and drafted initial recommendations based on the knowledge of symptoms in patients with COVID-19 and current practice for physical therapist management for patients hospitalized with lung disease and patients admitted to the intensive care unit. An expert group of hospital-based physical therapists in the Netherlands provided feedback on the recommendations, which were finalized when consensus was reached among the members of the working group.

RESULTS

The recommendations include safety recommendations, treatment recommendations, discharge recommendations, and staffing recommendations. Treatment recommendations address 2 phases of hospitalization: when patients are critically ill and admitted to the intensive care unit, and when patients are severely ill and admitted to the COVID ward. Physical therapist management for patients hospitalized with COVID-19 comprises elements of respiratory support and active mobilization. Respiratory support includes breathing control, thoracic expansion exercises, airway clearance techniques, and respiratory muscle strength training. Recommendations toward active mobilization include bed mobility activities, active range-of-motion exercises, active (assisted) limb exercises, activities-of-daily-living training, transfer training, cycle ergometer, pre-gait exercises, and ambulation.

Intramuscular Fat in the Medial Gastrocnemius Muscle of People Who Have Had a Stroke

Objective: To compare intramuscular fat fraction in people who have ankle contractures following stroke with the intramuscular fat fraction in control participants.

Design: mDixon MRI images were used to quantify intramuscular fat fractions in the medial gastrocnemius muscles of people who had experienced a hemiparetic stroke (n = 14, mean age 60 ± 13 years) and control participants (n = 18, mean age 66 ± 12 years).

Results: Intramuscular fat fractions were similar in the paretic and non-paretic sides of stroke patients (mean on paretic side 14.5%, non-paretic side 12.8%, difference 1.6%, 95% confidence interval −0.7 to 4.1%). The intramuscular fat fraction on the paretic side was higher than in the control group (mean intramuscular fat fraction in control muscles 7.6%; difference 7.8%, 95% confidence interval 4.6–10.9%). The difference between intramuscular fat fractions in non-paretic and control legs increased with age. Body mass index was similar in stroke patients and controls. There was no association between medial gastrocnemius intramuscular fat fraction and dorsiflexion range.

Conclusion: Muscles of stroke patients had elevated intramuscular fat fractions compared to muscles from control participants which were not explained by differences in body mass index. There is no clear relationship between intramuscular fat in the medial gastrocnemius muscle and dorsiflexion range of motion.

Rehabilitation after distal radius fractures: is there a need for immobilization and physiotherapy?

Although the literature generally agrees that displaced distal radius fractures require surgery, no single consensus exists concerning the length of immobilization and type of post-operative physiotherapeutic rehabilitation program. Palmar locking plate fixation represents a very stable fixation of the distal radius, and was assessed biomechanically in various studies. Surprisingly, most authors report additional immobilization after plate fixation. One reason might be due to the pain caused during active wrist mobilization in the early post-operative stages or secondly to protect the osteosynthesis in the early healing stages preventing secondary loss of reduction. This article addresses the biomechanical principles, current available evidence for early mobilization/immobilization and impact of physiotherapy after operatively treated distal radius fractures.

Adapted physical activity and therapeutic exercise in late-onset Pompe disease (LOPD): a two-step rehabilitative approach

Aerobic exercise, training to sustain motor ability, and respiratory rehabilitation may improve general functioning and quality of life (QoL) in neuromuscular disorders. Patients with late-onset Pompe disease (LOPD) typically show progressive muscle weakness, respiratory dysfunction and minor cardiac involvement. Characteristics and modalities of motor and respiratory rehabilitation in LOPD are not well defined and specific guidelines are lacking. Therefore, we evaluated the role of physical activity, therapeutic exercise, and pulmonary rehabilitation programs in order to promote an appropriate management of motor and respiratory dysfunctions and improve QoL in patients with LOPD. We propose two operational protocols: one for an adapted physical activity (APA) plan and the other for an individual rehabilitation plan, particularly focused on therapeutic exercise (TE) and respiratory rehabilitation.

Conference report on contractures in musculoskeletal and neurological conditions

Limb contractures are debilitating complications associated with various muscle and nervous system disorders. This report summarizes presentations at a conference at the Shirley Ryan AbilityLab in Chicago, Illinois, on April 19-20, 2018, involving researchers and physicians from diverse disciplines who convened to discuss current clinical and preclinical understanding of contractures in Duchenne muscular dystrophy, stroke, cerebral palsy, and other conditions. Presenters described changes in muscle architecture, activation, extracellular matrix, satellite cells, and muscle fiber sarcomeric structure that accompany or predispose muscles to contracture. Participants identified ongoing and future research directions that may lead to understanding of the intersecting factors that trigger contractures. These include additional studies of changes in muscle, tendon, joint, and neuronal tissues during contracture development with imaging, molecular, and physiologic approaches. Participants identified the requirement for improved biomarkers and outcome measures to identify patients likely to develop contractures and to accurately measure efficacy of treatments currently available and under development.

Intentions of Canadian health professionals towards recommending exercise for people living with ALS

Background

To provide a nationwide overview of the attitudes, social pressure, perceived ability and intentions of health professionals toward exercise prescription for people living with ALS (pALS).

Methods

An online survey of physician and non-physician health professionals (HPs) working in academic ALS clinics across Canada.

Results

The response rate was 48% (84/176) with 30% of respondents identifying as physicians, 63% as other HPs and the remainder as administrative or research personnel. Respondents were sharply divided in their intentions to provide exercise counsel: 24% unlikely and 45% likely. Respondents with low intentions were HPs that considered this activity outside their scope of practice. Measures of intention and attitude were more positive for flexibility compared to strength and aerobic exercise. Perceptions of social pressure and ability to provide exercise counsel were significantly correlated with intention across the three exercise modes in all respondents. Qualitative themes identified as barriers to exercise prescription were lack of confidence or competence (31% physicians, 32% HP), patient tolerance (30% HP), lack of evidence (22% physicians) and lack of infrastructure (22% physicians).

Conclusions

While “lack of evidence” for the benefit of exercise was a deterrent for physicians, the larger issue for all respondents was building competence and confidence in exercise prescription for pALS.

Electronic supplementary material

The online version of this article (10.1186/s12883-019-1426-z) contains supplementary material, which is available to authorized users.

Effectiveness of stretching and bracing for the treatment of osteoarthritis-associated joint contractures prior to joint replacement: a systematic review protocol

INTRODUCTION

Many patients with osteoarthritis (OA) develop restrictions in passive range of motion (ROM) of their affected joints (called contractures), leading to increased pain and reduced function. Effective treatment to reverse OA-associated contractures is lacking. Our aim is to evaluate the effectiveness of stretching and bracing on native (non-operated) joint contractures in people with radiographically diagnosed OA.

METHODS AND ANALYSIS

We will search the following databases without time restriction: Cochrane Library (CENTRAL, Database of Abstracts of Reviews of Effects, Health Technology Assessment Database), MEDLINE, Embase, CINAHL, SCI-EXPANDED (ISI Web of Knowledge) and PEDro. Other sources will include WHO International Clinical Trials Registry Platform, reference lists of included studies, relevant systematic reviews and textbooks. We will include randomised controlled trials (RCTs), controlled clinical trials, controlled before-and-after studies, cohort studies and case-control studies that include participants ≥18 years of age with radiographic evidence of OA. Participants with inflammatory arthropathies or those that have undergone joint arthroplasty will be excluded. Interventions will include therapist-administered or patient-administered stretching, use of an orthosis (static or dynamic), use of serial casting and/or adjunctive modalities. Outcomes will include joint ROM (active and passive), pain (rest and/or activity related), stiffness, activity limitations, participation restrictions, quality of life and adverse events. Studies will be reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Study inclusion, data extraction and quality assessment will be performed independently by two reviewers. Risk of bias will be assessed using appropriate tools for each study design. Data synthesis will be performed using Cochrane Review Manager software. If sufficient data are available, meta-analysis will be conducted. We will summarise the quality of evidence using Grading of Recommendations Assessment, and the effect size of interventions for RCT and non-RCT studies.

ETHICS AND DISSEMINATION

Ethics approval not required because individual patient data are not included. Findings will be disseminated in a peer-reviewed journal.

PROSPERO REGISTRATION NUMBER

CRD42019127244.

Occupational Therapy Treatment to Improve Upper Extremity Function in Individuals with Early Systemic Sclerosis: A Pilot Study

OBJECTIVE

To determine the feasibility and preliminary effects of occupational therapy to improve upper extremity function in patients with early systemic sclerosis (SSc; scleroderma) who have upper extremity contractures.

METHODS

A single-group pilot clinical rehabilitation trial was conducted at the University of Michigan Scleroderma Center. Patients with SSc and ≥1 upper extremity contracture (n = 21) participated in a total of 8 weekly in-person occupational therapy sessions. The therapy consisted of thermal modalities, tissue mobilization, and upper extremity mobility exercises. The participants were instructed to perform upper extremity exercises at home between sessions. Feasibility was measured by the percent enrollment as well as session attendance and session duration. The primary outcome measure was the Shortened Disabilities of the Arm, Shoulder and Hand measure (QuickDASH); secondary and exploratory outcomes included the Patient-Reported Outcomes Measurement Information System (PROMIS) physical function measures; objective measures of upper extremity mobility, strength, and coordination; and skin thickening. Linear mixed models were used to determine the effects of treatment on the primary and secondary outcomes.

RESULTS

Fifty percent of potentially eligible subjects (24 of 48) were interested in participating. Twenty-one (88%) of the 24 subjects were enrolled, and 19 (91%) of these 21 subjects completed all sessions. The mean ± SD age of the participants was 47.9 ± 16.1 years; 100% had diffuse SSc, and the mean disease duration was 3.1 years. At 8 weeks, participants had statistically significant improvement in the QuickDASH and PROMIS physical function measure (P = 0.0012 and P = 0.004, respectively). Approximately one-half of participants in the sample achieved improvement in the QuickDASH and PROMIS measure that exceeded minimally important differences.

CONCLUSION

In-person treatment sessions were feasible in the patients with SSc and resulted in statistically significant and clinically meaningful improvements in upper extremity and physical function. In future studies, the effects of SSc should be compared with those in a control condition, and the durability of treatment effects should be examined.

Conduct and reporting of citation searching in Cochrane systematic reviews: A cross-sectional study

Background

The search for studies for a systematic review should be conducted systematically and reported transparently to facilitate reproduction. This study aimed to report on the conduct and reporting of backward citation searching (ie, checking reference lists) and forward citation searching in a cross section of Cochrane reviews. Citation searching uses the citation network surrounding a source study to identify additional studies.

Methods

Cochrane reviews were identified by searching the Cochrane Database of Systematic Reviews using the wildcard symbol and date limiting to the 3‐month period November 2016 to January 2017. Cochrane reviews thus identified were screened for mention of citation searching. Descriptive detail on the conduct and reporting of citation searching was captured in data extraction forms and described and evaluated.

Results

Two hundred fifteen Cochrane reviews were identified. One hundred seventy‐two reviews reported backward citation searching, and 18 reviews reported forward citation searching. Web of Science was the most frequently reported citation index. The studies used for backward citation searching consisted mainly of studies meeting the inclusion criteria. One‐third of reviews that reported forward citation searching used selected studies of importance. Reporting of citation searching was compliant with the Methodological Expectations of Cochrane Intervention Reviews (MECIR) standards, but full transparency requires additional detail that only a minority of reviews reported.

Conclusion

The conduct of backward citation searching was more uniform than forward citation searching. This might be due to lack of MECIR guidance for forward citation searching. Reporting was generally compliant with MECIR, but this is not always sufficient to ensure full transparency.

Small amounts of involuntary muscle activity reduce passive joint range of motion

When assessing passive joint range of motion in neurological conditions, concomitant involuntary muscle activity is generally regarded small enough to ignore. This assumption is untested. If false, many clinical and laboratory studies that rely on these assessments may be in error. We determined to what extent small amounts of involuntary muscle activity limit passive range of motion in 30 able-bodied adults. Subjects were seated with the knee flexed 90° and the ankle in neutral, and predicted maximal plantarflexion torque was determined using twitch interpolation. Next, with the knee flexed 90° or fully extended, the soleus muscle was continuously electrically stimulated to generate 1, 2.5, 5, 7.5, and 10% of predicted maximal torque, in random order, while the ankle was passively dorsiflexed to a torque of 9 N·m by a blinded investigator. A trial without stimulation was also performed. Ankle dorsiflexion torque-angle curves were obtained at each percent of predicted maximal torque. On average (mean, 95% confidence interval), each 1% increase in plantarflexion torque decreases ankle range of motion by 2.4° (2.0 to 2.7°; knee flexed 90°) and 2.3° (2.0 to 2.5°; knee fully extended). Thus 5% of involuntary plantarflexion torque, the amount usually considered small enough to ignore, decreases dorsiflexion range of motion by ~12°. Our results indicate that even small amounts of involuntary muscle activity will bias measures of passive range and hinder the differential diagnosis and treatment of neural and nonneural mechanisms of contracture.

NEW & NOTEWORTHY The soleus muscle in able-bodied adults was tetanically stimulated while the ankle was passively dorsiflexed. Each 1% increase in involuntary plantarflexion torque at the ankle decreases the range of passive movement into dorsiflexion by >2°. Thus the range of ankle dorsiflexion decreases by ~12° when involuntary plantarflexion torque is 5% of maximum, a torque that is usually ignored. Thus very small amounts of involuntary muscle activity substantially limit passive joint range of motion.

Effect of a Combined Stretching and Strength Training Program on Gait Function in Children with Cerebral Palsy, GMFCS Level I & II: A Randomized Controlled Trial

Background and objectives: Ambulant children with cerebral palsy (CP) often develop impaired gait, and reduced active knee extension is often a part of the problem. This study aimed to evaluate the effect of a combined intervention program including stretching and progressive resistance exercise (PRE) targeting active knee extension on gait function, in children with spastic CP. Materials and methods: Thirty-seven children (21 boys, 16 girls, mean age 10.2 (±2.3) years), classified by Gross Motor Function Classification System I-III, were randomized to an intervention (n = 17) and a comparison group (n = 20). The intervention group received a 16-week combined exercise program (3 sessions per week) including stretching of hamstrings and PRE targeting the lower extremities, followed by a 16-week maintenance program (1 session per week). The comparison group received care as usual. Gait function was evaluated by three-dimensional gait analysis (3DGA); knee, hip and pelvic kinematics in the sagittal plane, step length and speed, Gait Deviation Index (GDI), and Six-Minute Walk test (6MWT) at 0, 16, and 32 weeks. Results: There were no statistically significant differences between the intervention group and the comparison group for any of the gait parameters measured at 16 and 32 weeks. There was a significant increase in gait distance measured by 6MWT within both groups; however, no differences between the groups were found. Conclusion: A 16-week combined stretching and PRE program followed by a 16-week maintenance program did not improve gait function in ambulant children with CP.

Dynamic Lycra® orthoses as an adjunct to arm rehabilitation after stroke: a single-blind, two-arm parallel group, randomized controlled feasibility trial

Objective:

The aim of this study was to explore the feasibility of conducting a randomized controlled trial of dynamic Lycra^® orthoses as an adjunct to arm rehabilitation after stroke and to explore the magnitude and direction of change on arm outcomes.

Design:

This is a single-blind, two-arm parallel group, feasibility randomized controlled trial.

Setting:

In-patient rehabilitation.

Subjects:

The study participants were stroke survivors with arm hemiparesis two to four weeks after stroke receiving in-patient rehabilitation.

Interventions:

Participants were randomized 2:1 to wear Lycra^® gauntlets for eight hours daily for eight weeks, plus usual rehabilitation (n = 27), or to usual rehabilitation only (n = 16).

Main measures:

Recruitment, retention, fidelity, adverse events and completeness of data collection were examined at 8 and 16 weeks; arm function (activity limitation; Action Research Arm Test, Motor Activity Log) and impairment (Nine-hole Peg Test, Motricity Index, Modified Tardieu Scale). Structured interviews explored acceptability.

Results:

Of the target of 51, 43 (84%) participants were recruited. Retention at 8 weeks was 32 (79%) and 24 (56%) at 16 weeks. In total, 11 (52%) intervention group participants and 6 (50%) control group participants (odds ratio = 1.3, 95% confidence interval = 0.2 to 7.8) had improved Action Research Arm Test level by 8 weeks; at 16 weeks, this was 8 (61%) intervention and 6 (75.0%) control participants (odds ratio = 1.1, 95% confidence interval = 0.1 to 13.1). Change on other measures favoured control participants. Acceptability was influenced by 26 adverse reactions.

Conclusion:

Recruitment and retention were low, and adverse reactions were problematic. There were no indications of clinically relevant effects, but the small sample means definitive conclusions cannot be made. A definitive trial is not warranted without orthoses adaptation.

Involuntary hamstring muscle activity reduces passive hip range of motion during the straight leg raise test: a stimulation study in healthy people

Background

Involuntary hamstring muscle activity is present in some people during the straight leg raise test, but it is not known to what extent involuntary muscle activity limits passive joint range of motion. This study aimed to determine whether small amounts of involuntary hamstring activity limit passive hip range of motion during the straight leg raise test in healthy people.

Methods

Thirty healthy subjects were recruited from The University of Sydney. As the hamstring muscles were continuously stimulated to generate 0, 2.5, 5, 7.5 and 10% of knee flexion maximal voluntary contraction force, an investigator blinded to the amount of stimulation performed a straight leg raise test by passively raising the tested leg while keeping the knee extended. The test was stopped when the knee started to flex, at which point hip range of motion was recorded.

Results

On average, passive hip range of motion decreased by 0.6° for every 1% increase in knee flexion force caused by muscle activation (95% CI 0.3 to 0.9°, p = 0.0012). Subjects were instructed to fully relax when the straight leg raise test was performed, but a small amount of involuntary muscle activity (median 2.4% of maximal activation) was present during the trial without stimulation.

Conclusions

Small amounts of involuntary hamstring muscles activity reduce passive hip range of motion during the straight leg raise test in healthy people.

Trial registration

The protocol for this study was registered with the Open Science Framework, reference: https://osf.io/fejpf/. Registered 9 March 2017.

Effects of stroke injury on the shear modulus of the lower leg muscle during passive dorsiflexion

Contractures are common complications of a stroke. The spatial location of the increased stiffness among plantar flexors and its variability among survivors remain unknown. This study assessed the mechanical properties of the lower leg muscles in stroke survivors during passive dorsiflexions. Stiffness was estimated through the measurement of the shear modulus. Two experiments were independently conducted, in which participants lay supine: with the knee extended ( experiment 1, n = 13 stroke survivors and n = 13 controls), or with the knee flexed at 90° ( experiment 2, n = 14 stroke survivors and n = 14 controls). The shear modulus of plantar flexors [gastrocnemius medialis (three locations), gastrocnemius lateralis (three locations), soleus (two locations), flexor digitorum longus, flexor hallucis longus), peroneus longus] and dorsiflexors (tibialis anterior and extensor digitorum longus) was measured using ultrasound shear wave elastography during passive dorsiflexions (2°/s). At the same ankle angle, stroke survivors displayed higher shear modulus than controls for gastrocnemius medialis and gastrocnemius lateralis (knee extended) and soleus (knee flexed). Very low shear modulus was found for the other muscles. The adjustment for muscle slack angle suggested that the increased shear modulus was arising from consequences of contractures. The stiffness distribution between muscles was consistent across participants with the highest shear modulus reported for the most distal regions of gastrocnemius medialis (knee extended) and soleus (knee flexed). These results provide a better appreciation of stiffness locations among plantar flexors of stroke survivors and can provide evidence for the implementation of clinical trials to evaluate targeted interventions applied on these specific muscle regions.

NEW & NOTEWORTHY The shear modulus of 13 muscle regions was assessed in stroke patients using elastography. When compared with controls, shear modulus was increased in the gastrocnemius muscle (GM) when the knee was extended and in the soleus (SOL) when the knee was flexed. The distal regions of GM and SOL were the most affected. These changes were consistent in all the stroke patients, suggesting that the regions are a potential source of the increase in joint stiffness.

Use Of Ankle Immobilization In Evaluating Treatments To Promote Longitudinal Muscle Growth In Mice

INTRODUCTION

Difficulty in modeling congenital contractures (deformities of muscle-tendon unit development that include shortened muscles and lengthened tendons) has limited research of new treatments.

METHODS

Early immobilization of the ankle in prepuberal mice was used to produce deformities similar to congenital contractures. Stretch treatment, electrostimulation, and local intramuscular injection of a follistatin analog (FST-288) were assessed as therapeutic interventions for these deformities.

RESULTS

Ankle immobilization at full plantarflexion and 90 ° created tendon lengthening and muscle shortening in the tibialis anterior and soleus. Stretch treatment produced minimal evidence for longitudinal muscle growth and electrostimulation provided no additional benefit. Stretch treatment with FST-288 produced greater longitudinal muscle growth and less tendon lengthening, constituting the best treatment response.

DISCUSSION

Ankle immobilization recapitulates key morphologic features of congenital contracture, and these features can be mitigated by a combination of stretch and pharmacological approaches that may be useful in patients. Muscle Nerve 58: 718-725, 2018.

Outcomes indicators and a risk classification system for spinal manipulation under anesthesia: a narrative review and proposal

Over a period of decades chiropractors have utilized spinal manipulation under anesthesia (SMUA) to treat chronic back and neck pain. As an advanced form of manual therapy, SMUA is reserved for the patient whose condition has proven refractory to office-based manipulation and other modes of conservative care. Historically, the protocols and guidelines put forth by chiropractic MUA proponents have served as the clinical compass for directing MUA practice. With many authors and MUA advocates having focused primarily on anticipated benefit, the published literature contains no resource dedicated to treatment precautions and contraindications. Also absent from current relevant literature is acknowledgement or guidance on the preliminary evidence that may predict poor clinical outcomes with SMUA. This review considers risk and unfavorable outcomes indicators in therapeutic decision making for spinal manipulation under anesthesia. A new risk classification system is proposed that identifies patient safety and quality of care interests for a procedure that remains without higher-level research evidence. A scale which categorizes risk and outcome potential for SMUA is offered for the chiropractic clinician, which aims to elevate the standard of care and improve patient selection through the incorporation of specific indices from existing medical literature.

Intra-articular collagenase injection increases range of motion in a rat knee flexion contracture model

Objectives

A knee joint contracture, a loss in passive range of motion (ROM), can be caused by prolonged immobility. In a rat knee immobilization flexion contracture model, the posterior capsule was shown to contribute to an irreversible limitation in ROM, and collagen pathways were identified as differentially expressed over the development of a contracture. Collagenases purified from Clostridium histolyticum are currently prescribed to treat Dupuytren’s and Peyronie’s contractures due to their ability to degrade collagen. The potential application of collagenases to target collagen in the posterior capsule was tested in this model.

Materials and methods

Rats had one hind leg immobilized, developing a knee flexion contracture. After 4 weeks, the immobilization device was removed, and the rats received one 50 µL intra-articular injection of 0.6 mg/mL purified collagenase. Control rats were injected with only the buffer. After 2 weeks of spontaneous remobilization following the injections, ROM was measured with a rat knee arthrometer, and histological sections were immunostained with antibodies against rat collagen types I and III.

Results/conclusion

Compared with buffer-injected control knees, collagenase-treated knees showed increased ROM in extension by 8.0°±3.8° (p-value <0.05). Immunohistochemical analysis revealed an increase in collagen type III staining (p<0.01) in the posterior capsule of collagenase-treated knees indicating an effect on the extracellular matrix due to the collagenase. Collagen I staining was unchanged (p>0.05). The current study provides experimental evidence for the pharmacological treatment of knee flexion contractures with intra-articular collagenase injection, improving the knee ROM.

Stretch for the treatment and prevention of contracture: an abridged republication of a Cochrane Systematic Review

QUESTION

Is stretch effective for the treatment and prevention of contractures in people with neurological and non-neurological conditions?

DESIGN

A Cochrane Systematic Review with meta-analyses of randomised trials.

PARTICIPANTS

People with or at risk of contractures.

INTERVENTION

Trials were considered for inclusion if they compared stretch to no stretch, or stretch plus co-intervention to co-intervention only. The stretch could be administered in any way.

OUTCOME MEASURES

The outcome of interest was joint mobility. Two sets of meta-analyses were conducted with a random-effects model: one for people with neurological conditions and the other for people with non-neurological conditions. The quality of evidence supporting the results of the two sets of meta-analyses was assessed using GRADE.

RESULTS

Eighteen studies involving 549 participants examined the effectiveness of stretch in people with neurological conditions, and provided useable data. The pooled mean difference was 2 deg (95% CI 0 to 3) favouring stretch. This was equivalent to a relative change of 2% (95% CI 0 to 3). Eighteen studies involving 865 participants examined the effectiveness of stretch in people with non-neurological conditions, and provided useable data. The pooled standardised mean difference was 0.2 SD (95% CI 0 to 0.3) favouring stretch. This translated to an absolute mean increase of 1 deg (95% CI 0 to 2) and a relative change of 1% (95% CI 0 to 2). The GRADE level of evidence was high for both sets of meta-analyses.

CONCLUSION

Stretch does not have clinically important effects on joint mobility. [Harvey LA, Katalinic OM, Herbert RD, Moseley AM, Lannin NA, Schurr K (2017) Stretch for the treatment and prevention of contracture: an abridged republication of a Cochrane Systematic Review. Journal of Physiotherapy 63: 67-75].

Specialist health visitor-led weight management intervention in primary care: exploratory evaluation

AIM

This paper is a report of an exploratory study to evaluate the effectiveness and acceptability of a specialist health visitor-led weight management clinic in primary care.

BACKGROUND

Tackling obesity is a global health priority. Whilst there is evidence to support a role for primary healthcare professionals in its management, provision in England varies widely. Using designated 'obesity specialists' is an approach warranting further investigation.

METHOD

In 2003-2004, patients with a body mass index of 30 or more received a specialist health visitor-led intervention based on the Jan Felgens 'I2E2' model. Clinical outcome data and self-reported dietary consumption data were collected at weeks 1, 13, 27 and 52. Quantitative and qualitative data on patient acceptability of the clinic were collected at week 26.

FINDINGS

Eighty-nine patients attended the clinic. Mean body weight and body mass index and systolic and diastolic blood pressure decreased over time by statistically significant amounts. There was a non-significant decrease in fasting blood sugar over time, but approximately one in 10 patients with undiagnosed diabetes were identified. No statistically significant change was evident for cholesterol levels. Mean self-reported weekly consumption of cakes, desserts and snacks decreased and that of fruit and vegetables increased, each by statistically significant amounts. Participants found the clinic highly acceptable and identified the specialist health visitor as fundamental to its success.

CONCLUSION

A partnership approach to weight management through which patients are empowered to make sustainable lifestyle changes now needs to be tested in a multi-centre randomized controlled trial.