Hippocampal neurometabolic and structural changes from pre-to post-COVID-19: A case-series study

BACKGROUND

Neurological complications of the COVID-19 infection may be caused in part by local neurochemical and structural abnormalities that could not be detected during routine medical examinations. We examined within subject neurometabolic and structural brain alterations from pre-to post-COVID-19 in the hippocampal region of three elderly individuals (aged 63-68 years) who had a COVID-19 infection with mild symptoms. Patients were participating in an interventional study in which they were closely monitored at the time they were diagnosed with COVID-19. Patients 1 and 2 just completed 18-20 resistance training sessions prior to their diagnosis. Patient 3 was assigned to a non-training condition in the same study.

METHODS

Whole brain magnetic resonance imaging (MRI) images and proton magnetic resonance spectroscopy (1H-MRS) of the left hippocampus were collected before and after infection. Structural and spectroscopic imaging measures post-COVID-19 were contrasted to the pre-COVID-19 measures and were compared with values for Minimal Detectable Change at 95% (MDC95) and 90% (MDC90) confidence from a group of six elderly (aged 60-79 years) without COVID-19 that participated in the same study.

RESULTS

After SARS-COV-2 infection, we observed a reduction of glutamate-glutamine (Glx) in Patients 1 and 2 (≥ 42.0%) and elevation of myo-inositol (mIns) and N-acetyl-aspartate (NAA) in Patient 3 (≥ 36.4%); all > MDC90. MRI findings showed increased (Patients 1 and 2) or unchanged (Patient 3) hippocampal volume.

CONCLUSIONS

Overall, findings from this exploratory study suggest that mild COVID-19 infection could be associated with development of local neuroinflammation and reduced glutamate levels in the hippocampus. Our 1H-MRS findings may have clinical value for explaining chronic neurological and psychological complaints in COVID-19 long-haulers.

Caregiver burden and impact on COVID-19 patient participation and quality of life one year after ICU discharge - A prospective cohort study

OBJECTIVES

to investigate changes in caregiver strain, mental health complaints and QoL in caregivers of COVID-19 ICU survivors in the first year after discharge, and their associations with patients' participation and quality of life.

METHODS

Post-ICU COVID-19 survivors, needing inpatient rehabilitation and their informal caregivers were included. Caregiver self-administered questionnaires included quality of life, self-rated health, caregiver strain, anxiety and depression symptoms, post-traumatic stress and coping style. Patients' participation in society was assessed and quality of life.

RESULTS

67 patients (78% male) and 57 caregivers (23.6% male) were included. Three months post-ICU, caregivers experienced caregiver strain (32%), anxiety (41%), depressive symptoms (16%) and PTSD (24%). One year post-ICU, rates decreased, still being 11%, 26%, 10% and 5%, respectively. Caregiver anxiety symptoms and self-rated health at three months were associated with worse patient levels of participation and quality of life one year after ICU discharge (p < 0.05).

CONCLUSIONS

COVID-19 caregivers experience high levels of mental health complaints one year after a patient's ICU discharge. Furthermore, our results indicate that patient participation levels and quality of life one year after ICU discharge may be negatively associated by caregiver complaints.

PRACTICAL IMPLICATIONS

Counselling and routine assessment of emotional complaints and unmet needs of the informal caregiver should be incorporated and addressed in the rehabilitation treatment of (COVID-19) post-ICU patients.

Greater male variability in daily energy expenditure develops through puberty

There is considerably greater variation in metabolic rates between men than between women, in terms of basal, activity and total (daily) energy expenditure (EE). One possible explanation is that EE is associated with male sexual characteristics (which are known to vary more than other traits) such as musculature and athletic capacity. Such traits might be predicted to be most prominent during periods of adolescence and young adulthood, when sexual behaviour develops and peaks. We tested this hypothesis on a large dataset by comparing the amount of male variation and female variation in total EE, activity EE and basal EE, at different life stages, along with several morphological traits: height, fat free mass and fat mass. Total EE, and to some degree also activity EE, exhibit considerable greater male variation (GMV) in young adults, and then a decreasing GMV in progressively older individuals. Arguably, basal EE, and also morphometrics, do not exhibit this pattern. These findings suggest that single male sexual characteristics may not exhibit peak GMV in young adulthood, however total and perhaps also activity EE, associated with many morphological and physiological traits combined, do exhibit GMV most prominently during the reproductive life stages.

Task-oriented arm training for stroke patients based on remote handling technology concepts: A feasibility study

BACKGROUND

Improving arm-hand skill performance is a major therapeutic target in stroke rehabilitation. Arm-hand rehabilitation may be enriched in content and variation by using technology-assisted training. Especially for people with a severely affected arm, technology-assisted training offers more challenging training possibilities.

OBJECTIVE

The aim of this study was to explore the feasibility of ReHab-TOAT, a "Remote Handling Based Task-Oriented Arm Training" approach featuring enriched haptic feedback aimed at improving daily activities and participation.

METHODS

Five subacute or chronic stroke patients suffering moderate to severe arm-hand impairments and five rehabilitation therapists participated. All participants received 2 ReHab-TOAT sessions. Outcome measure was a bespoke feasibility questionnaire on user experiences and satisfaction regarding 'motivation', 'individualization of training', 'potential training effects', and 'implementation in rehabilitation' of patients and therapists.

RESULTS

Both patients and therapists experienced ReHab-TOAT as being feasible. They found ReHab-TOAT very motivating and challenging. All patients perceived an added value of ReHab-TOAT and would continue the training. Small improvements regarding exercise variability were suggested.

CONCLUSION

ReHab-TOAT seems to be a feasible and very promising training approach for arm-hand rehabilitation of stroke patients with a moderately or severely affected arm. Further research is necessary to investigate potential training effects of ReHab-TOAT.

Life after COVID-19: the road from intensive care back to living - a prospective cohort study

OBJECTIVES

The aim of the study was to evaluate recovery of participation in post-COVID-19 patients during the first year after intensive care unit (ICU) discharge. The secondary aim was to identify the early determinants associated with recovery of participation.

DESIGN

Prospective cohort study.

SETTING

COVID-19 post-ICU inpatient rehabilitation in the Netherlands, during the first epidemic wave between April and July 2020, with 1-year follow-up.

PARTICIPANTS

COVID-19 ICU survivors ≥18 years of age needing inpatient rehabilitation.

MAIN OUTCOME MEASURES

Participation in society was assessed by the 'Utrecht Scale for Evaluation of Rehabilitation-Participation' (USER-P) restrictions scale. Secondary measures of body function impairments (muscle force, pulmonary function, fatigue (Multidimensional Fatigue Inventory), breathlessness (Medical Research Council (MRC) breathlessness scale), pain (Numerical Rating Scale)), activity limitations (6-minute walking test, Patient reported outcomes measurement information system (PROMIS) 8b), personal factors (coping (Utrecht Proactive Coping Scale), anxiety and depression (Hospital Anxiety and Depression Scale), post-traumatic stress (Global Psychotrauma Screen-Post Traumatic Stress Disorder), cognitive functioning (Checklist for Cognitive Consequences after an ICU-admission)) and social factors were used.

STATISTICAL ANALYSES

linear mixed-effects model, with recovery of participation levels as dependent variable. Patient characteristics in domains of body function, activity limitations, personal and social factors were added as independent variables.

RESULTS

This study included 67 COVID-19 ICU survivors (mean age 62 years, 78% male). Mean USER-P restrictions scores increased over time; mean participation levels increasing from 62.0, 76.5 to 86.1 at 1, 3 and 12 months, respectively. After 1 year, 50% had not fully resumed work and restrictions were reported in physical exercise (51%), household duties (46%) and leisure activities (29%). Self-reported complaints of breathlessness and fatigue, more perceived limitations in daily life, as well as personal factors (less proactive coping style and anxiety/depression complaints) were associated with delayed recovery of participation (all p value <0.05).

CONCLUSIONS

This study supports the view that an integral vision of health is important when looking at the long-term consequence of post-ICU COVID-19. Personal factors such as having a less proactive coping style or mental impairments early on contribute to delayed recovery.

Corticolimbic Circuitry in Chronic Pain Tracks Pain Intensity Relief Following Exposure In Vivo

Background

A subset of patients with chronic pain who receive exposure in vivo (EXP) treatment experience clinically relevant relief of pain intensity. Although pain relief is not an explicit therapeutic target, it is important to understand how and why this concomitant effect occurs in some patients but not others. This longitudinal study therefore aimed to characterize brain plasticity as well as to explore pretreatment factors related to pain relief.

Methods

Resting-state functional magnetic resonance imaging data were acquired in 30 patients with chronic pain. Twenty-three patients completed EXP, and 6-month follow-up data were available in 20 patients (magnetic resonance imaging data in 17 patients). Pain-free control data were acquired at two time points (n = 29, n = 21). Seed-based resting-state functional connectivity (rsFC) analyses were performed, with seeds in the amygdala, hippocampus, and nucleus accumbens.

Results

Pain relief after EXP was highly variable, with 60% of patients reporting a clinically relevant improvement. Amygdala rsFC with the middle frontal gyrus decreased significantly over time in patients but was not associated with pain relief. In contrast, greater pain relief was associated with greater decreases over time in hippocampus rsFC with the precuneus, which was related to reductions in catastrophizing (EXP therapeutic target) as well. Greater pain relief was also associated with lower pretreatment rsFC between nucleus accumbens and postcentral gyrus.

Conclusions

While changes in hippocampus rsFC were associated with pain relief after EXP, pretreatment nucleus accumbens rsFC showed potential prognostic value. Our findings further support the importance of corticolimbic circuitry in chronic pain, emphasizing its relation to pain relief and identifying potential underlying mechanisms and prognostic factors, warranting further testing in independent samples.

Are chronic musculoskeletal pain and generalized joint hypermobility: disabling contributors to physical functioning?

BACKGROUND

Chronic musculoskeletal pain (CMP), Generalized Joint Hypermobility (GJH) and pain-related fear have influence on physical functioning in adolescents.

AIM

To evaluate differences in physical functioning between adolescents with CMP, GJH or the combination of both, and in addition evaluate the potential contribution of pain-related fear.

DESIGN

Observational, cross-sectional design.

SETTING

The adolescents with CMP were recruited by a physician in rehabilitation medicine and measured in the university outpatient rehabilitation clinic (Adelante/Maastricht University Medical Center+, the Netherlands). The adolescents without CMP were recruited in the Southern area of the Netherlands and measured in the university outpatient rehabilitation clinic (Adelante/Maastricht University Medical Center+, the Netherlands).

POPULATION

Four subgroups of adolescents were included; 21 adolescents with CMP without GJH, 9 adolescents with CMP and GJH, 51 adolescents without CMP without GJH, and 11 adolescents without CMP with GJH.

METHODS

Outcome measures were muscle strength and endurance, motor performance, physical activity level, and pain-related fear were measured. Hierarchical regression analyses were used to study differences in physical functioning and the contribution of pain-related fear in adolescents with/without CMP as well as with/without GJH.

RESULTS

Adolescents with CMP had decreased muscle strength (p=0.01), endurance (p=0.02) and lower motor performance (p<0.01) compared to adolescents without CMP. Higher levels of pain-related fear were related to decreased muscle strength (p=0.01), endurance (p<0.01) and motor performance (p<0.01). No differences in physical functioning and pain-related fear between hypermobile and non-hypermobile adolescents with CMP were found.

CONCLUSIONS

Adolescents with CMP had decreased muscle strength and motor performance associated with increased levels of pain-related fear compared to adolescents without CMP. The association of being hypermobile with physical functioning is not more pronounced in adolescents with CMP.

CLINICAL REHABILITATION IMPACT

No differences were found in physical functioning and pain-related fear between hypermobile adolescents with CMP compared to nonhypermobile adolescents with CMP. Future rehabilitation treatment in hypermobile adolescents with CMP should also focus on psychological components, such as pain-related fear.

Effectiveness of an integrated multidisciplinary geriatric rehabilitation programme for older persons with stroke: a multicentre randomised controlled trial

Background

Almost half of the stroke patients admitted to geriatric rehabilitation has persisting problems after discharge. Currently, there is no evidence based geriatric rehabilitation programme available for older stroke patients, combining inpatient rehabilitation with adequate ambulatory aftercare in the community. Therefore, we developed an integrated multidisciplinary rehabilitation programme that includes aftercare for older persons with stroke. We evaluated the effectiveness of this newly developed rehabilitation programme in comparison to usual care.

Methods

A multicentre randomised controlled trial was conducted in eight geriatric rehabilitation stroke units and their collaborating partners in primary care. The study population involved stroke patients and their informal caregivers who were aged 65 or over, living in the community before admission to geriatric rehabilitation, and expected to be able to return home after discharge. The programme consisted of three modules: inpatient neurorehabilitation, home-based self-management training, and stroke education. For patients, daily activity (FAI) was assessed as primary outcome and functional dependence (Katz-15), perceived quality of life (SSQoL) and social participation (IPA) as secondary outcomes. Additionally, among informal caregivers perceived care burden (self-rated burden VAS), objective care burden (Erasmus iBMG), and quality of life (CarerQol), were assessed as secondary outcomes.

Results

In total 190 patients and 172 informal caregivers were included. Mean age of the patients in the intervention group was 78.9 years (SD = 7.0) and in the usual care group 79.0 years (SD = 6.5). Significant favourable effects for the programme were observed for the subscale autonomy outdoors of the IPA (− 2.15, P = .047, and for the informal caregivers perceived care burden (1.23, P = .048. For the primary outcome daily activity and the other secondary outcomes, no significant effects were observed.

Conclusion

The integrated multidisciplinary programme had no effect on daily activity of older stroke patients. However, patients participating in the programme had a higher level of perceived autonomy of outdoor activities and their informal caregivers perceived a lower care burden. The programme might be promising in providing adequate (after) care, although adaptation of the programme is recommended to increase its feasibility and improve its effects.

Trial registration

Current Controlled Trials ISRCTN62286281. Registered 19-3-2010.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-021-02082-4.

Effectiveness of Exposure in Vivo for Patients with Painful Diabetic Neuropathy: a Pilot Study of Effects on Physical Activity and Quality of Life

OBJECTIVE

To evaluate the effects of personalized exposure in vivo on level of physical activity and quality of life in patients with painful diabetic neuropathy.

DESIGN

Randomized, single-case, ABC design.

SUBJECTS

Twelve patients with painful diabetic neuropathy, age > 18 years, diabetes mellitus type II, Clinical Neurological Examination score > 5, Diabetic Neuropathy Symptom Score ≥ 1 and Douleur Neuropathique 4 Questions score ≥ 3.

METHODS

The treatment consists of an Intensive screening, followed by an 8-week exposure in vivo intervention specifically adapted to the needs/risks of patients with painful diabetic neuropathy, and 6-months follow-up. Outcome measures included daily and non-daily measures of physical activity, quality of life, metabolic parameters, disability, depression, general and painful diabetic neuropathy-related anxiety, pain intensity and pain catastrophizing.

RESULTS

Due to high drop-out rates (n = 6 during screening, n = 2 during treatment, n = 1 after treatment), only 3 participants completed the study. Slight, but non-significant, changes in physical activity and disability were observed. In quality of life, no changes were observed.

CONCLUSION

Analysis of the reasons for the high drop-out rate indicate that exposure in vivo may have added value in patients with painful diabetic neuropathy only for those patients: (i) whose daily life functioning is impaired mainly by the painful diabetic neuropathy; (ii) in whom painful diabetic neuropathy-related fears are exaggerated and irrational; (iii) in whom specific activities evoke the painful diabetic neuropathy-related fears; (iv) whose spouse and healthcare providers are involved in the treatment; and (v) who are willing to change their daily behaviour. Further research is needed into this subject.

COVID-19: Patient Characteristics in the First Phase of Postintensive Care Rehabilitation

Objective

To describe clinical characteristics of patients after intensive care unit (ICU) treatment for coronavirus disease 2019 (COVID-19) who were admitted for inpatient rehabilitation.

Design

A cross-sectional design.

Setting

Inpatient rehabilitation care in the Netherlands.

Participants

All post-ICU patients with COVID-19 admitted to the rehabilitation center between April 2 and May 13, 2020, were invited to participate in the study. Included were patients older than 18 years needing inpatient rehabilitation after ICU treatment for COVID-19 (N=60; mean age, 59.9y; 75% male).

Interventions

Not applicable.

Main Outcome Measures

The following information was collected in the first week of inpatient rehabilitation care: (1) demographics; (2) ICU stay parameters; (3) medical, physical, and functional characteristics; and (4) self-reported symptoms.

Results

The most important findings for rehabilitation were the following: in the first week after discharge to the rehabilitation center, 38.3% of all patients experienced exercise-induced oxygen desaturation, in 72.7% muscle weakness was present in all major muscle groups, and 21.7% had a reduced mobility in 1 or both shoulders. Furthermore 40% had dysphagia, and 39.2% reported symptoms of anxiety.

Conclusion

Post-ICU patients with COVID-19 display physical and anxiety symptoms as reported in other post-ICU patient groups. However, this study showed some remarkable clinical characteristics of post-ICU patients with COVID-19. Rehabilitation programs need to anticipate on this. Long-term follow-up studies are necessary.

Subgrouping patients with chronic low back pain: What are the differences in actual daily life behavior between patients classified as avoider or persister?

BACKGROUND AND OBJECTIVE

The purpose of this study is to determine whether patients, classified by their treating consultant in rehabilitation medicine as avoider or persister, show differences in a large set of detailed outcomes of actual, objectively measured daily physical behaviour.

METHODS

In this explorative cross-sectional study, 16 patients were included; 9 patients were categorized as avoider and 7 patients as persister. Subjects wore the VitaMove activity monitor, a high-end accelerometry-based device that allowed automatic detection of a large set of body postures and motions. Physical behaviour was assessed in detail by total duration of body postures and motions as percentages of 24 hours, as well as by the number of sit-to-stand transfers, overall activity level, walking speed, and the distribution of bouts of physical activity and sedentary behaviour. Differences between groups were tested with the Mann Whitney U test.

RESULTS

There were no significant differences between groups in any of the physical behaviour outcomes.

CONCLUSIONS

Our study showed that activity-related behavioural style categorization by consultants in rehabilitation medicine is not expressed in objectively measured detailed outcomes of daily physical behaviour.

Exploring the underlying mechanism of pain-related disability in hypermobile adolescents with chronic musculoskeletal pain

OBJECTIVES

A significant proportion of adolescents with chronic musculoskeletal pain (CMP) experience difficulties in physical functioning, mood and social functioning, contributing to diminished quality of life. Generalized joint hypermobility (GJH) is a risk factor for developing CMP with a striking 35-48% of patients with CMP reporting GJH. In case GJH occurs with one or more musculoskeletal manifestations such as chronic pain, trauma, disturbed proprioception and joint instability, it is referred to as generalized hypermobility spectrum disorder (G-HSD). Similar characteristics have been reported in children and adolescents with the hypermobile Ehlers-Danlos Syndrome (hEDS). In the management of CMP, a biopsychosocial approach is recommended as several studies have confirmed the impact of psychosocial factors in the development and maintenance of CMP. The fear-avoidance model (FAM) is a cognitive-behavioural framework that describes the role of pain-related fear as a determinant of CMP-related disability.

CONTENT

Pubmed was used to identify existing relevant literature focussing on chronic musculoskeletal pain, generalized joint hypermobility, pain-related fear and disability. Relevant articles were cross-referenced to identify articles possibly missed during the primary screening. In this paper the current state of scientific evidence is presented for each individual component of the FAM in hypermobile adolescents with and without CMP. Based on this overview, the FAM is proposed explaining a possible underlying mechanism in the relations between GJH, pain-related fear and disability.

SUMMARY AND OUTLOOK

It is assumed that GJH seems to make you more vulnerable for injury and experiencing more frequent musculoskeletal pain. But in addition, a vulnerability for heightened pain-related fear is proposed as an underlying mechanism explaining the relationship between GJH and disability. Further scientific confirmation of this applied FAM is warranted to further unravel the underlying mechanism.In explaining disability in individuals with G-HSD/hEDS, it is important to focus on both the physical components related to joint hypermobility, in tandem with the psychological components such as pain-related fear, catastrophizing thoughts and generalized anxiety.

Clinicians' Initial Experiences of Transition to Online Interdisciplinary Pain Rehabilitation During the Covid-19 Pandemic

Objective

Public health legislation during the CO-VID-19 pandemic has resulted in forced transitioning to the use of remote care in order to continue the provision of pain rehabilitation worldwide. The objective of this study was to gain insight into clinicians’ initial experiences with the provision of interdisciplinary pain rehabilitation via videoconferencing.

Design

Observational, cross-sectional design.

Participants

Twelve team members (specialists in rehabilitation medicine -MD-, psychologists, physiotherapists and occupational therapists) from a tertiary expertise centre in pain rehabilitation.

Methods

Quantitative and qualitative data were collected via a digital survey. Theme-based content analysis was performed for qualitative data.

Results

The themes that emerged were: the compulsory context; prerequisites for proper use of videoconferencing methods, which are strongly associated with the clinicians’ experiences; changes experienced in specific components of pain rehabilitation; and overarching changes experienced, including opportunities and limitations (sub-themes: therapeutic relationship, system involvement, efficiency, hands-on possibilities, interdisciplinary teamwork, and formalities). Overall, clinicians expressed moderate agreement with the statements that the quality of the pain rehabilitation programme can be maintained using videoconferencing, and that the COVID-19 pandemic offers opportunities for growth and innovation in telehealth.

Conclusion

It is feasible to provide valid and satisfactory pain rehabilitation via videoconferencing. This study identified facilitators and barriers to the use of videoconferencing, and great potential for integrating aspects of telehealth into standard care after the pandemic.

Feasibility of an integrated multidisciplinary geriatric rehabilitation programme for older stroke patients: a process evaluation

Background

Almost half of the stroke patients admitted to geriatric rehabilitation has persisting problems after discharge. Currently, there is no evidence based geriatric rehabilitation programme available for older stroke patients, combining inpatient rehabilitation with adequate aftercare aimed at reducing the impact of persisting problems after discharge from a geriatric rehabilitation unit. Therefore, we developed an integrated multidisciplinary rehabilitation programme consisting of inpatient neurorehabilitation treatment using goal attainment scaling, home based self-management training, and group based stroke education for patients and informal caregivers. We performed a process evaluation to assess to what extent this programme was performed according to protocol. Furthermore, we assessed the participation of the patients in the programme, and the opinion of patients, informal caregivers and care professionals on the programme.

Methods

In this multimethod study, process data were collected by means of interviews, questionnaires, and registration forms among 97 older stroke patients, 89 informal caregivers, and 103 care professionals involved in the programme.

Results

A part of patients and informal caregivers did not receive all key elements of the programme. Almost all patients formulated rehabilitation goals, but among two thirds of the patients the goal attainment scaling method was used. Furthermore, the self-management training was considered rather complex and difficult to apply for frail elderly persons with stroke, and the percentage of therapy sessions performed in the patients’ home environment was lower than planned. In addition, about a quarter of the patients and informal caregivers attended the education sessions. However, a majority of patients, informal caregivers and care professionals indicated the beneficial aspects of the programme.

Conclusion

This study revealed that although the programme in general is perceived to be beneficial by patients, and informal and formal caregivers, the feasibility of the programme needs further attention. Because of persisting cognitive deficits and specific care needs in our frail and multimorbid target population, some widely used methods such as goal attainment scaling, and self-management training seemed not feasible in their current form. To optimize feasibility of the programme, it is recommended to tailor these elements more optimally to the population of frail older patients.

Multidisciplinary Treatment for Hypermobile Adolescents with Chronic Musculoskeletal Pain

BACKGROUND

To determine whether adolescents with generalized hypermobility spectrum disorder/ hypermobile Ehlers-Danlos syndrome (G-HSD/ hEDS) show changes in the level of disability, physical functioning, perceived harmfulness and pain intensity after completing multidisciplinary rehabilitation treatment.

METHODS

Pre-test post-test design. Fourteen adolescents with G-HSD/hEDS participated. The multidisciplinary rehabilitation treatment consisted of a combination of physical training and exposure in vivo. Physical training aims to improve aerobic capacity, muscle strength and propriocepsis for compensating hypermobility. Exposure in vivo aims to decrease disability and pain-related fear. Pre- and post-treatment assessments were conducted to assess the level of disability, physical functioning (motor performance, muscle strength and physical activity level), perceived harmfulness and pain intensity.

RESULTS

After completing multidisciplinary rehabilitation treatment, the adolescents showed a significant and clinically relevant improvement (improvement of 67%, p<0.01) in functional disability. Furthermore, significant improvements were found in motor performance (p < 0.01), muscle strength (p < 0.05), perceived harmfulness (p < 0.01) and pain intensity (p <0.01) after completing multidisciplinary rehabilitation treatment.

CONCLUSION

Multidisciplinary rehabilitation treatment leads to a significantly and clinically relevant improvement in the level of disability for adolescents with G-HSD/hEDS. Positive effects were also found in physical functioning, perceived harmfulness and pain intensity. Although the results of this multidisciplinary rehabilitation treatment for adolescents with G-HSD/hEDS are promising, further study is needed to confirm these findings in a randomized design.

Factors associated with successful home discharge after inpatient rehabilitation in frail older stroke patients

Background

Stroke is a highly prevalent disease among older people and can have a major impact on daily functioning and quality of life. When community-dwelling older people are hospitalized due to stroke, discharge to an intermediate care facility for geriatric rehabilitation is indicated when return to the previous living situation is expected but not yet possible. However, a substantial proportion is still unable to return home after discharge and has to be admitted to a residential care setting. This study aims to identify which factors are associated with home discharge after inpatient rehabilitation among frail and multimorbid older stroke patients.

Methods

This study is a longitudinal cohort study among 92 community-dwelling stroke patients aged 65 years or over. All patients were admitted to one of eight participating intermediate care facilities for geriatric rehabilitation, under the expectation to return home after rehabilitation. We examined whether 16 potentially relevant factors (age; sex; household situation before admission; stroke history; cardiovascular disorders; diabetes mellitus; multimorbidity; cognitive disability; neglect; apraxia; dysphagia; urinary and bowel incontinence; emotional problems; sitting balance; daily activity level; and independence in activities of daily living) measured at admission were associated with discharge to the former living situation. Logistic regression analysis was used for statistical analysis.

Results

Mean age of the patients was 79.0 years (SD 6.4) and 51.1% was female. A total of 71 patients (77.1%) were discharged to the former living situation within 6 months after the start of geriatric rehabilitation. Of the 16 factors analysed, only a higher level of independence in activities of daily living at admission was significantly associated with home discharge.

Conclusions

Our study shows that the vast majority of previously identified factors predicting home discharge among stroke patients, could not predict home discharge among a group of frail and multimorbid older persons admitted to geriatric rehabilitation. Only a higher level of independence in activities of daily living at admission was significantly related to home discharge. Additional insight in other factors that might predict home discharge after geriatric rehabilitation among this specific group of frail older stroke patients, is needed. Trial registration: ISRCTN ISRCTN62286281. Registered 19-3-2010.

Exposure in vivo Induced Changes in Neural Circuitry for Pain-Related Fear: A Longitudinal fMRI Study in Chronic Low Back Pain

Exposure in vivo (EXP) is a cognitive-behavioral treatment aimed at reducing pain-related fear in chronic pain, and has proven successful in reducing pain-related disability in patients with chronic low back pain (cLBP). The current longitudinal study aimed to reveal the neural correlates of changes in pain-related fear as a result of EXP. Twenty-three patients with cLBP were included in this study. Patients with cLBP underwent MRI scanning pre-treatment (pre-EXP), post-treatment (post-EXP), and 6 months after end of treatment (FU-EXP). Pain-free controls were scanned at two time points. In the scanner, participants were presented with pictures involving back-related movements, evoking pain-related fear in patients. Pre-treatment, functional MRI revealed increased activation in right posterior insula and increased deactivation in medial prefrontal cortex (mPFC) in patients compared to controls. Post-treatment, patients reported reduced fear and pre-EXP group differences were no longer present. Contrasting pre- to post- and FU-EXP in patients revealed that stimulus-evoked neural responses changed in sensorimotor as well as cognitive/affective brain regions. Lastly, exploratory analyses revealed a tendency toward an association between changes in neural activation and changes in fear ratings, including the hippocampus and temporal lobe (pre- to post-EXP changes), and mPFC and posterior cingulate cortex (pre- to FU-EXP changes). Taken together, we show evidence that neural circuitry for pain-related fear is modulated by EXP, and that changes are associated with self-reported decreases in pain-related fear.

Biopsychosocial Rehabilitation Treatment "Exposure In Vivo" for Patients with Painful Diabetic Neuropathy: Development of a Treatment Protocol

Objective

Painful diabetic neuropathy is associated with low quality of life, depression and anxiety. Patients are limited in their performance of activities of daily living due to fears related to their condition. Treatment modalities are needed to help patients cope with their pain and pain-related disability. Exposure in vivo is an effective treatment in other chronic pain syndromes, increasing patients’ functional ability and quality of life. This paper presents an Exposure in vivo treatment protocol for patients with painful diabetic neuropathy.

Protocol

An 8-week Exposure in vivo treatment protocol was specifically adapted to the needs and risks of patients with painful diabetic neuropathy. New screening tools were developed for patients with PDN; the Painful Diabetic Neuropathy Anxiety Rasch-Transformed Questionnaire (PART-Q30) identifies specific fears related to painful diabetic neuropathy (e.g. fear of hypoglycaemia); and a customized version of the Photograph-series Of Daily Activities (PHODA-PDN) detects fear-eliciting activities related to the condition in individual patients. During Exposure in vivo, catastrophic interpretations regarding painful stimuli are challenged and corrected, thereby diminishing pain-related fear and enabling the patient to re-engage in activities of daily living. An interdisciplinary team provides Exposure in vivo in 1-h sessions twice a week.

Discussion

To the best of our knowledge, this treatment protocol is the first intervention using Exposure in vivo specifically adapted to the needs and risks of patients with painful diabetic neuropathy.

Living with painful diabetic neuropathy: insights from focus groups into fears and coping strategies

OBJECTIVE

Painful diabetic neuropathy (PDN) is known to negatively affect quality of life. Being physically active is a crucial part of successful diabetes self-management, but regimen adherence is often low. Coping strategies and fears have shown to be related to less physical activity (PA). The aim of the present study was to obtain more in-depth information on psychological risk factors leading to less PA in persons with PDN.

DESIGN

Three semi-structured focus group interviews were conducted with a representative sample of persons with PDN (N = 12). Data were transcribed verbatim and analysed using a hybrid method of thematic analyses and a grounded theory approach.

MAIN OUTCOME MEASURES

Fears and coping strategies related to PA in persons with PDN.

RESULTS

Several specific fears were identified; fear of hypoglycaemia, fear of pain increase, fear of total exhaustion, fear of physical injury, fear of falling, fear of loss of identity, and fear of negative evaluation by others. To cope with these fears, avoidance, remaining active, cognitive distraction, and acceptance strategies were described.

CONCLUSION

In persons with PDN, diabetes-related fears and pain-related fears play a role in less engagement in PA, indicating the need for new methods for improving self-management in persons with PDN.

Treatment Fidelity of a Nurse-Led Motivational Interviewing-Based Pre-Treatment in Pain Rehabilitation

Treatment fidelity and proficiency of a nurse-led motivational interviewing (MI)-based pre-treatment and control condition was evaluated. A random sample was scored by means of the Motivational Interviewing Treatment Integrity (MITI) scale, and a second rater was in charge. MI fidelity was satisfactory for three out of five ratings. Most mean ratings were higher in the MI-based intervention, but differences were not statistically significant. The threshold for beginning MI proficiency was only exceeded for one score and one additional measure. In general, higher levels of fidelity in the intervention condition confirmed that MI was partially applied there. Although the quality of MI delivery as well as mixed inter-rater reliabilities of the fidelity scores leaves room for improvement, robust findings between the two raters were found. These results suggest the need for rigor selection of MI counselors on beforehand, and continuous supervision. Furthermore, fidelity check in studies using MI is needed.

Long-term Outcome After Survival of a Cardiac Arrest: A Prospective Longitudinal Cohort Study

Background. A cardiac arrest can lead to hypoxic brain injury, which can affect all levels of functioning. Objective. To investigate 1-year outcome and the pattern of recovery after surviving a cardiac arrest. Methods. This was a multicenter, prospective longitudinal cohort study with 1 year of follow-up (measurements 2 weeks, 3 months, 1 year). On function level, physical/cardiac function (New York Heart Association Classification), cognition (Cognitive Log [Cog-log], Cognitive Failures Questionnaire), emotional functioning (Hospital Anxiety and Depression Scale, Impact of Event Scale), and fatigue (Fatigue Severity Scale) were assessed. In addition, level of activities (Frenchay Activities Index, FAI), participation (Community Integration Questionnaire [CIQ] and return to work), and quality of life (EuroQol 5D, EuroQol Visual Analogue Scale, SF-36, Quality of Life after Brain Injury) were measured. Results. In this cohort, 141 cardiac arrest survivors were included. At 1 year, 14 (13%) survivors scored below cutoff on the Cog-log. Both anxiety and depression were present in 16 (15%) survivors, 29 (28%) experienced posttraumatic stress symptoms and 55 (52%), severe fatigue. Scores on the FAI and the CIQ were, on average, respectively 96% and 92% of the prearrest scores. Of those previously working, 41 (72%) had returned to work. Most recovery of cognitive function and quality of life occurred within the first 3 months, with further improvement on some domains of quality of life up to 12 months. Conclusions. Overall, long-term outcome in terms of activities, participation, and quality of life after cardiac arrest is reassuring. Nevertheless, fatigue is common; problems with cognition and emotions occur; and return to work can be at risk.

The impact of cardiac arrest on the long-term wellbeing and caregiver burden of family caregivers: a prospective cohort study

Objective:

The purpose was to gain insight in the functioning of caregivers of cardiac arrest survivors at 12 months after a cardiac arrest. Secondly, the course of the wellbeing of the caregivers during the first year was studied. Finally, factors that are associated with a higher care burden at 12 months after the cardiac arrest were investigated.

Subjects:

A total of 195 family caregivers of cardiac arrest survivors were included.

Main measures:

Quality of life (SF-36, EuroQol-VAS), caregiver strain (CSI) and emotional functioning (HADS, IES) were measured at two weeks, three months and one year after the cardiac arrest. Thereby, the caregiver was asked to fill out the cognitive failure questionnaire (CFQ) to evaluate their view on the cognitive status of the patient.

Results:

Caregiver strain was high in 16 (15%) of the caregivers at 12 months. Anxiety was present in 33 (25%) caregivers and depression in 18 (14%) caregivers at 12 months. The repeated measures MANOVA showed that during the first year the following variables improved significantly: SF-36 domains social and mental health, role physical, role emotional and vitality, caregiver strain, HADS and IES ( P<0.001). At 12 months caregiver strain correlated significantly (explained variance 63%, P=0.03) with caregiver HADS ( P=0.01), EuroQol-VAS ( P=0.02), and the CFQ ( P<0.001), all measured at 12 months after the cardiac arrest.

Conclusions:

Overall wellbeing of the caregivers improves during the first year up to normal levels, but caregivers with emotional problems or perceived cognitive problems at 12 months are at risk for developing a higher care burden.

Early neurologically focused follow-up after cardiac arrest is cost-effective: A trial-based economic evaluation

OBJECTIVE

To evaluate the cost-effectiveness of an early intervention service for cardiac arrest survivors called 'Stand still …, and move on' from a societal perspective.

INTERVENTION

This concise nursing intervention consists of screening for cognitive and emotional problems, information provision and support, self-management promotion, and further referral if necessary. Earlier research confirmed the feasibility of the intervention and its effectiveness in improving emotional functioning and quality of life.

METHODS

In this multicentre randomized controlled trial with one year follow-up 185 patients were included between April 2007 and December 2010. The experimental group received the intervention, the control group received care-as-usual. Intervention costs, other direct healthcare costs (e.g. hospital care, rehabilitation, medication, home care) and indirect costs (productivity loss) were measured during ten months using monthly cost-diaries. The economic evaluation comprised a cost-utility analysis (SF-36) and a cost-effectiveness analysis (QOLIBRI) using bootstrapping (5000 replications) to quantify uncertainty concerning the incremental cost effectiveness ratio (ICER), and the probability of the intervention being cost-effective was estimated. To check the robustness of the findings, two sensitivity analyses were performed using the EQ-5D and the complete cases respectively.

RESULTS

Of 136 (74%) participants sufficient data concerning costs were collected to be included in this economic evaluation. Intervention costs were on average €127 (SD 85). No significant differences between groups were found with regard to overall costs. The ICERs of the cost-utility and the cost-effectiveness analyses supported the cost-effectiveness of the intervention. The probability of the intervention being cost-effective was 54-76% for the SF-36 and 94% for the QOLIBRI. Findings were robust.

CONCLUSION

The intervention 'Stand still …, and move on' has positive societal economic effects and has a high probability to be cost-effective. Implementation in regular healthcare is recommended.

TRIAL REGISTRATION

ISRCTN74835019.

Perceived Physical Activity Decline as a Mediator in the Relationship Between Pain Catastrophizing, Disability, and Quality of Life in Patients with Painful Diabetic Neuropathy

BACKGROUND

To fully understand the burden of painful diabetic neuropathy (PDN), we investigated the relationship of pain catastrophizing with disability and quality of life in patients with PDN. Furthermore, we studied the mediating roles of physical activity and/or decline in physical activity.

METHODS

This questionnaire-based cross-sectional study included 154 patients with PDN. Linear regression analyses, adjusted for age, gender, pain intensity, and insulin treatment, were performed to assess the association of pain catastrophizing (Pain Catastrophizing Scale [PCS]) with the outcome variables disability (Pain Disability Index [PDI]) and quality of life (Norfolk Quality of Life Questionnaire Diabetic Neuropathy Version [QOL-DN]). The mediating roles of actual physical activity (Physical Activity Rating Scale [PARS]) and perceived Physical Activity Decline (PAD) were assessed using mediation analyses according to Baron and Kenny.

RESULTS

This study included 154 patients (62% male). Mean age was 65.7 years (SD = 6.6). PCS (M = 20.3, SD = 13.1) was significantly associated with PDI (M = 32.4, SD = 17.0; R² = 0.356, P < 0.001), QOL-DN (M = 52.6, SD = 26.1; R² = 0.437, P < 0.001), and PAD (M = 7.4, SD = 5.7; R² = 0.087, P = 0.045). PAD acted as a partial mediator in the associations of PCS with PDI and QOL-DN, respectively. There was no association of PCS with PARS.

CONCLUSIONS

Pain catastrophizing was associated with increased disability and decreased quality of life in patients with PDN. Also, it was associated with a perceived decline in physical activity, which had a mediating role in the association between catastrophizing and disability and quality of life, respectively. This study emphasizes the role of catastrophic thinking about pain and the experienced loss in daily activities due to PDN.

Measuring outcome after cardiac arrest: construct validity of Cerebral Performance Category

INTRODUCTION

Approximately half of the survivors of cardiac arrest have cognitive impairments due to hypoxic brain injury. To describe the outcome after a cardiac arrest, the Cerebral Performance Category (CPC) is frequently used. Although widely used, its validity is still debatable.

OBJECTIVE

To investigate the construct validity of the Cerebral Performance Category in survivors of a cardiac arrest. Participants were 18 years and older that survived a cardiac arrest more than six months.

METHODS

Cross-sectional design. A method to administer the CPC in a structured and reproducible manner was developed. This 'Structured CPC' was administered by a structured interview. Construct variables were Cognitive Failure Questionnaire (CFQ), Barthel Index (BI), Frenchay Activity Index (FAI), Community Integration Questionnaire (CIQ) and Quality of Life after Brain Injury (Qolibri). Associations were tested based on Spearman correlation coefficients.

RESULTS

A total of 62 participants responded. In 58 (94%) patients the CPC was determined, resulting in CPC 1 (48%), CPC 2 (23%) and CPC 3 (23%). The CPC-scoring correlated significantly with the CFQ (r=-0.40); BI (r=-0.57); FAI (r=-0.65), CIQ (r=-0.53) and Qolibri (r=-0.67).

DISCUSSION AND CONCLUSIONS

In this study we developed the 'Structured CPC' to improve the transparency and reproducibility of the original CPC. A moderate correlation between the 'Structured CPC' and the constructs 'activities', 'participation' and 'quality of life' confirmed the validity of the 'Structured CPC'.

CLINICAL MESSAGE

The 'Structured CPC' can be used as an instrument to measure the level of functioning after cardiac arrest.

A biopsychosocial primary care intervention (Back on Track) versus primary care as usual in a subgroup of people with chronic low back pain: protocol for a randomised, controlled trial

INTRODUCTION

Multidisciplinary biopsychosocial interventions are effective at improving functional disability in people with chronic low back pain. However, these interventions are often expensive and have long waiting times before treatment starts. Therefore, implementing biopsychosocial interventions in primary care settings may be of interest. Because people with chronic low back pain show different biopsychosocial profiles, they might respond differently to specific interventions.

RESEARCH QUESTIONS

This study will investigate the difference in (cost) effectiveness between a biopsychosocial primary care intervention, Back on Track, and primary care physiotherapy as usual in a subgroup of adults with chronic low back pain.

DESIGN

Double-blind, multicentre (n = 8), randomised, controlled trial.

PARTICIPANTS

Eighty-six adults with chronic low back pain, aged 18 to 65 years, experiencing low to moderate levels of disability and in whom the contributing role of psychosocial factors to this disability is restricted.

INTERVENTION

The Back on Track intervention: four individual and eight group sessions, based on biopsychosocial approaches from multidisciplinary pain rehabilitation programs and provided by trained physiotherapists.

CONTROL

Primary care physiotherapy as usual.

MEASUREMENTS

The primary outcome is functional disability (Quebec Back Pain Disability Scale) at post treatment, and 3-month and 12-month follow-up. Secondary measures are: credibility and expectancy, anxiety and depression, catastrophising, pain intensity, kinesiophobia, self-efficacy, participant's global perceived effect, cost-effectiveness, and cost-utility estimated with cost diaries and quality-adjusted life years.

ANALYSIS

Linear mixed models using an intention-to-treat principle. Incremental cost-effectiveness and cost-utility ratios will be calculated and plotted on a cost-effectiveness plane.

DISCUSSION

This study will provide useful information on a biopsychosocial intervention for chronic low back pain in primary care settings.

The psychometric characteristics of an assessment instrument for perceived harmfulness in adolescents with musculoskeletal pain (PHODA-youth)

BACKGROUND

Cognitive-behavioural models of chronic pain predict that dysfunctional assumptions about harmfulness of activities may maintain pain-related fear and disability. To assess perceived harmfulness in adolescents, the Photograph Series of Daily Activities for youth (PHODA-youth) was developed. Information concerning its methodological quality is currently lacking.

OBJECTIVE

To investigate psychometric characteristics (factor structure, test-retest reliability, construct validity) and feasibility of the PHODA-youth in adolescents with chronic musculoskeletal pain.

STUDY DESIGN

Test-retest design.

STUDY POPULATION

Adolescents aged 13-21 years with chronic nonspecific musculoskeletal pain.

METHODS

Participants filled in an electronic version of the PHODA-youth including 89 items twice with a 4-week interval. The instrument's factor structure was determined by a factor analysis. Construct validity was studied with criterion variables: catastrophizing (Pain Catastrophizing Scale for Children), pain intensity (visual analogue scale), depression (Children's Depression Inventory) and pain-related disability (Functional Disability Inventory) using regression analysis. Test-retest reliability was evaluated based on the Pearson correlation coefficient. Feasibility was studied with self-constructed questions.

RESULTS

Seventy-one adolescents participated. Results show a three-factor structure for the PHODA-youth including 51 items with subscales labelled as: 'activities of daily life', 'intensive physical activities' and 'social activities'. Total and subscale scores showed a high internal consistency. Its test-retest reliability was good (r = 0.94) and its construct validity is supported by the finding that both catastrophizing (β = 0.25; p = 0.02) and disability (β = 0.71; p < 0.001) were uniquely related to the PHODA-youth. In addition, feasibility appeared adequate.

CONCLUSION

The findings support the PHODA-youth as a valid and reliable measure of the perceived harmfulness of activities in adolescents with musculoskeletal pain.

'Stand still …, and move on' , an early neurologically-focused follow-up for cardiac arrest survivors and their caregivers: a process evaluation

Background

A cardiac arrest can lead to hypoxic-ischaemic brain injury which can result in cognitive and emotional impairments and may negatively affect daily functioning, participation in society and quality of life. Furthermore, the impact on the family of the patient can be high. We designed an intervention called ‘Stand still …, and move on’, which is a concise, individualised, semi-structured intervention for survivors of cardiac arrest and their caregivers, consisting of between one and six face-to-face consultations provided by a trained nurse. The intervention is directed at early detection of cognitive and emotional problems, provision of information, promotion of self-management and referral to specialised care if necessary. The effectiveness of the intervention is being examined in a randomised controlled trial [ISRCTN74835019]. Alongside this trial we performed a process evaluation which aims to investigate the feasibility of the intervention by assessing: 1) the attendance and dose delivered; 2) performance according to protocol; and 3) the opinion of patients, caregivers and nurses on the intervention.

Methods

Participants of this process evaluation were 97 patients allocated to the intervention group of the RCT, their 91 caregivers, and six nurses who conducted the intervention. Measurement instruments used were evaluation forms for patients and caregivers, registration and evaluation forms for nurses, and semi-structured interviews with nurses.

Results

Seventy-nine of the patients (81%) allocated to the intervention group and 65 caregivers (71%) participated in the intervention. The mean (SD) number of consultations per patient was 1.8 (1.0), and most consultations were conducted at the patients’ home. The intervention was performed largely according to protocol, except that the intervention usually started later than intended, consultations were longer than expected, and the topic of self-management was not regularly addressed. Patients marked the quality of the intervention with a mean score of 7.5 and the performance of the nurse with an 8.0 out of ten. Overall, the intervention was positively evaluated by patients, caregivers and nurses.

Conclusions

The intervention ‘Stand still …, and move on’ is a promising intervention which was performed largely according to protocol and seems feasible for implementation after some adaptations, if it is found to be effective.

Responsiveness of the Child Health Questionnaire-Parent Form in adolescents with non-specific chronic pain or fatigue

BACKGROUND

The Child Health Questionnaire (CHQ) is a widely used instrument for measuring health-related quality of life covering both the physical and psychosocial domain. This study examined the responsiveness of the Dutch CHQ 50-item Parent Form (PF50) in a sample of adolescents with chronic non-specific pain and/or fatigue.

METHOD

Five different methods were used to calculate the responsiveness for the physical (PhS) and psychosocial (PsS) subscale of the CHQ-50: standardized response mean (SRM), pooled effect sizes (ESs), standard error of measurement of agreement (SEMagreement ), minimal detectable change (MDC) and the area under the receiver operating characteristics (ROC) curve. For data analysis, the population was divided into two groups based on the parent's global perceived effect of treatment: a changed group (A) and an unchanged group (B).

RESULTS

The responsiveness analyses were performed including 92 adolescents (88.0% girls; mean age 16.4 years). The SRMs are 2.89 and 1.01 for the PhS and PsS, respectively. Large ESs are found for group A (PhS = 3.30; PsS = 1.16). The method used for calculating SEMagreement results in a score of PhS = 18.92 and PsS = 11.39. The MDCs of PhS and PsS are 52.45 and 31.57, respectively. The area under the ROC curve (AUC) for PhS = 0.79 and for PsS = 0.64, and the corresponding optimal cut-off points are 21.1 and 7.0.

CONCLUSION

Using the methods SRM, ES and AUC, the responsiveness of the CHQ-PF50 in adolescents with non-specific chronic pain or fatigue treated in a rehabilitation clinic is adequate for the physical scale and moderate for the psychosocial scale.

Multidisciplinary care for stroke patients living in the community: a systematic review

OBJECTIVE

A systematic review of randomized controlled trials was performed to evaluate the effectiveness of multidisciplinary care for stroke patients living in the community.

DATA SOURCES

Databases PubMed, EMBASE, CINAHL and the Cochrane Library from January 1980 until July 2012.

STUDY SELECTION

Randomized controlled trials focused on multidisciplinary interventions for stroke patients living at home after hospitalization or inpatient rehabilitation were selected. The outcome domains were activities of daily living, social participation and quality of life. A total of 14 studies were included.

DATA EXTRACTION

Two authors independently extracted the data and independently assessed the quality of reporting of the included studies using the Consolidated Standards of Reporting Trials (CONSORT) statement 2010.

DATA SYNTHESIS

None of the studies showed favourable effects of the intervention on activities of daily living and none assessed social participation. Furthermore, two studies reported favourable effects of the intervention in terms of quality of life. These concerned an intervention combining assessment with follow-up care and a rehabilitation intervention.

CONCLUSION

There is little evidence for the effectiveness of multidisciplinary care for stroke patients being discharged home. Additional research should provide more insight into potentially effective multidisciplinary care for community-living stroke patients.

Effects of nurse-led motivational interviewing of patients with chronic musculoskeletal pain in preparation of rehabilitation treatment (PREPARE) on societal participation, attendance level, and cost-effectiveness: study protocol for a randomized controlled trial

Background

Non-adherence and drop-out are major problems in pain rehabilitation. For patients with various health problems, motivational interviewing (MI) has shown promising effects to tackle these problems. In chronic pain patients, the effectiveness of MI is however unknown. Therefore, a MI-based pre-pain rehabilitation intervention (MIP) addressing motivation, expectations, and beliefs has been developed to prepare eligible patients for rehabilitation treatment.

Methods/design

Study design: A parallel randomized controlled trial including two interventions: a motivational interviewing pre-pain rehabilitation intervention (MIP) and a usual care (UC) control arm. Follow-up will be 6 months after completion of rehabilitation treatment.

Study population: One hundred and sixty (n = 80 per arm) patients with chronic non-specific musculoskeletal pain visiting an outpatient rehabilitation department, who are eligible to participate in an outpatient cognitive behavioral pain rehabilitation program.

Intervention: MIP consists of two sessions to prepare and motivate the patient for pain rehabilitation treatment and its bio psychosocial approach. UC consists of information and education about the etiology and the general rehabilitation approach of chronic pain. Both the MIP and UC contain two sessions of 45 to 60 minutes each.

Objective: The aim of the current study is to evaluate the effectiveness of MIP compared to UC in terms of an increase in the long-term level of societal participation and decrease of drop-out during rehabilitation treatment.

Main study endpoints: Primary outcome is the change in level of participation (according to the ICF-definition: ‘involvement in a life situation’) 6 months after completion of rehabilitation treatment. Secondary outcomes are adherence and treatment drop-out, disability, pain intensity, self-reported main complaints, (pain-specific) self-efficacy, motivation, and quality of life. Costs are calculated including the costs of the pre-treatment intervention, productivity losses, and healthcare utilization. Potential moderators and active ingredients of MI are explored. For the process evaluation, parameters such as MI fidelity, feasibility, and experiences are explored.

Discussion

The results of this study will provide evidence on the effectiveness of this MI-based pre-treatment in pain rehabilitation. Furthermore, a cost-effectiveness analysis and exploration of moderating and working mechanisms of MI and an extensive process evaluation takes place.

Trial registration

Nederlands trial register NTR3065

Multidisciplinary transmural rehabilitation for older persons with a stroke: the design of a randomised controlled trial

Background

Stroke is one of the major causes of loss of independence, decreased quality of life and mortality among elderly people. About half of the elderly stroke patients discharged after rehabilitation in a nursing home still experience serious impairments in daily functioning one year post stroke, which can lead to difficulties in picking up and managing their social life. The aim of this study is to evaluate the effectiveness and feasibility of a new multidisciplinary transmural rehabilitation programme for older stroke patients.

Methods

A two group multicentre randomised controlled trial is used to evaluate the effects of the rehabilitation programme. The programme consists of three care modules: 1) neurorehabilitation treatment for elderly stroke patients; 2) empowerment training for patient and informal caregiver; and 3) stroke education for patient and informal caregiver. The total programme has a duration of between two and six months, depending on the individual problems of the patient and informal caregiver. The control group receives usual care in the nursing home and after discharge.

Patients aged 65 years and over are eligible for study participation when they are admitted to a geriatric rehabilitation unit in a nursing home due to a recent stroke and are expected to be able to return to their original home environment after discharge. Data are gathered by face-to-face interviews, self-administered questionnaires, focus groups and registration forms. Primary outcomes for patients are activity level after stroke, functional dependence, perceived quality of life and social participation. Outcomes for informal caregivers are perceived care burden, objective care burden, quality of life and perceived health. Outcome measures of the process evaluation are implementation fidelity, programme deliverance and the opinion of the stroke professionals, patients and informal caregivers about the programme. Outcome measures of the economic evaluation are the healthcare utilisation and associated costs. Data are collected at baseline, and after six and 12 months. The first results of the study will be expected in 2014.

Trial registration

International Standard Randomised Controlled Trial Register Number ISRCTN62286281, The Dutch Trial Register NTR2412

Effect of mental practice on the improvement of function and daily activity performance of the upper extremity in patients with subacute stroke: a randomized clinical trial

OBJECTIVES

More than 50% of patients with upper limb paresis after stroke face long-term impaired arm function and ensuing disability in daily life. This study aims to evaluate the effectiveness of a task-oriented mental practice (MP) approach as an addition to regular arm-hand therapy in patients with subacute stroke.

METHODS

A multicenter, prospective, single-blind, randomized clinical trial was performed. Patients trained for 6 weeks, at least 3 times per day. In the experimental group, patients performed video-instructed MP. In the control group, patients performed neurodevelopmental therapy-based exercise therapy. The primary outcome measures are Fugl-Meyer test, Frenchay arm test, Wolf motor function test, and accelerometry.

RESULTS

The patients did improve over time on Fugl-Meyer test and Wolf motor function test in both the control and the experimental group. A significant improvement on the Frenchay arm test was found after training (which was maintained at 12-month follow-up) only in the experimental group. However, no difference in training effects between groups was demonstrated.

CONCLUSIONS

Training effects were demonstrated after MP training in patients with subacute stroke. However, the results of this study do not corroborate the hypothesis that the use of MP in addition to therapy as usual in patients with subacute stroke has an additional effect over neurodevelopmental therapy in addition to therapy as usual.

Investigating the Dutch Movement-Specific Reinvestment Scale in people with stroke

Objective:

Reinvestment is a phenomenon in which conscious control of movements that are best controlled automatically disrupts performance. The propensity for reinvestment may therefore play an important role in the movement rehabilitation process. The Movement-Specific Reinvestment Scale measures an individual’s propensity for reinvestment. The aim of this study was to translate the scale for use with Dutch participants with stroke and to assess its reliability.

Design:

A test–retest design.

Setting:

In community after discharge from rehabilitation centre.

Subjects:

Forty-five people with stroke.

Measures:

Reliability of the translated scale was assessed using intraclass correlation coefficients (ICC) and Bland–Altman plot.

Results:

The ICC was 0.85 (95% confidence interval (CI) 0.74–0.91). Limits of agreement ranged from −2.38 to 3.10.

Conclusion:

The Dutch Movement-Specific Reinvestment Scale appears to be a reliable tool with which to assess the propensity for movement-specific reinvestment by people with stroke.

Decline in physical activity, disability and pain-related fear in sub-acute low back pain

AIM OF INVESTIGATION

To evaluate whether a perceived decline in the level of physical activity after the onset of pain (PAD) is more appropriate in the explanation of disability as compared to the actual level of physical activity (PAL) in patients with sub-acute back pain.

METHODS

Patients with 4-7 weeks of non-specific low back pain (LBP) participated in this study. Their habitual physical activity level before the back pain started (H-PAL), their actual level of physical activity (PAL) and their perceived decline in the level of physical activity after the onset of pain (PAD) were assessed. The association between these physical activity related variables and perceived disability (QBPDS), fear of movement/(re)injury (TSK), pain catastrophizing (PCS) and pain intensity (VAS) was examined. The role of PAD as a mediator in the association between fear of movement/(re)injury and disability was examined by three linear regression analyses.

RESULTS

123 patients (66 male and 57 female) with a mean age of 44.1 years (SD=10.3) participated in this study. PAD was significantly correlated with disability, fear of movement/(re)injury, pain catastrophizing and pain intensity. PAD and PAL appeared more important in the explanation of disability in the subgroup of patients who were physically active before their back pain started. Generally, PAD indeed mediated the association between fear of movement/(re)injury and disability.

CONCLUSIONS

The perceived decline in physical activity, rather than the current physical activity itself is important in the evaluation of the impact of activity related changes on disability in low back pain.

Assessment of arm activity using triaxial accelerometry in patients with a stroke

OBJECTIVE

To study the validity of accelerometry in the assessment of arm activity of patients with impaired arm function after stroke.

DESIGN

Cross-sectional concurrent validity study.

SETTING

Rehabilitation center.

PARTICIPANTS

Patients (N=45) at different stages after stroke.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

All patients wore 2 triaxial accelerometers around their wrists during 3 consecutive days. Arm activity was assessed, based on unilateral (activity of the affected arm) and bilateral accelerometry (ratio between the activity of the affected and nonaffected arm). The Motor Activity Log-26 (MAL-26) Amount of Use (AOU) scale was used as the main external criterion to test the concurrent validity of arm accelerometry. In addition, the MAL-26 Quality of Movement (QOM) scale and the Stroke Impact Scale (SIS) subscale Hand Function were used. To test the divergent validity, the SIS subscale Mobility was used. Spearman correlation coefficients were calculated. In an additional regression analysis, the hypothesized confounding influence of spasm, therapy intensity, and interobserver differences was studied.

RESULTS

Both unilateral (ρ=.58, P<.001) and bilateral (ρ=.60, P<.001) accelerometry were significantly related to the MAL-AOU scale. Associations of both unilateral and bilateral accelerometry with the MAL-QOM and SIS subscale Hand Function corroborated these findings. The SIS subscale Mobility was not significantly associated with unilateral accelerometry (ρ=.41, P=.01) or bilateral accelerometry (ρ=.23, P=.11). None of the hypothesized confounders influenced these associations significantly.

CONCLUSIONS

Based on the results, both the concurrent and divergent validity of unilateral and bilateral arm accelerometry for measuring arm activity after stroke are good.