A Systematic Review of Outcomes Measured Following New Wheelchair and Seating-Prescription Interventions in Adults

Objectives

To determine the outcomes and outcome-measurement tools currently used during the prescription of new wheelchairs and/or seating systems. A systematic review of studies was performed to identify outcome-measurement tools.

Data Sources

MEDLINE, CINAHL, EMBASE, and PsycINFO were searched from earliest available to March 2022.

Study Selection

Studies were included if they focused on a new wheelchair or seating-system prescription with adults.

Data Extraction

Data extraction and quality assessments were conducted by 2 reviewers; disagreements were resolved by consensus. Risk of bias was assessed using the PEDro scale (for randomized controlled trials) and the Newcastle-Ottawa Quality Assessment Scale (for non-randomized studies).

Data Synthesis

48 articles were included which identified 37 standardized outcome-measurement tools. Use of study-specific outcome-measurement tools was common. Wheelchair use, user satisfaction, activity, and participation were the most studied outcome domains. Commonly used standardized assessments included the QUEST 2.0, functional independence measure, WHODAS II, IPPA, and PIADS.

Conclusion

Outcome measures to evaluate wheelchair and seating-system prescription vary, and the use of study-specific outcome-measurement tools is high. There is a need to choose consistent outcome measures that are reliable and valid, and deal with this complex area through ensuring carefully constructed study designs.

Effects of the CarFreeMe Traumatic Injuries, a Community Mobility Group Intervention, to Increase Community Participation for People With Traumatic Injuries: A Randomized Controlled Trial With Crossover

Introduction

After traumatic injuries community participation is a common goal, promoting wellbeing and independence. Community mobility and transportation influence an individual's independence in community participation. With the ability to drive safely often compromised after traumatic injuries, the adverse consequences of driving cessation include a loss of identity and reduced participation in chosen activities. In rehabilitation, individualized community mobility intervention is not routinely provided. The primary aim of this trial was to evaluate whether a group-based intervention, the CarFreeMe TI program was more effective than standard intervention, an information sheet of alternative transport, in improving community mobility for people following traumatic injuries. The secondary aim of this study was to evaluate the effect: types of transport used, transport satisfaction, community mobility self-efficacy, quality of life, goal satisfaction and performance, for people following traumatic injuries; and to undertake a preliminary assessment of the potential resource use associated with the intervention, and lessons for implementation.

Design

Prospective, pilot, randomized, blind observer, controlled trial with crossover.

Participants

Twenty individuals with traumatic injuries.

Intervention

Six-week group-based support and education program, the CarFreeMe TI delivered in community settings (intervention) and standard information related to transport options available (control).

Primary Outcome Measures

Community participation using a Global Positioning System device to record the location and number of outings from home.

Secondary Outcome Measures

CarFreeMe TI Transport Questionnaire, Community Mobility Self-efficacy Scale, quality of life measures, Modified Canadian Occupational Performance Measure for goals (importance and satisfaction), participant satisfaction survey results and researcher logs.

Results

Those who received the intervention were more likely to use public transport and transport services and had an improved quality of life, when compared to the control group. The intervention group also reported high levels of improvement in goal performance and satisfaction. Global Positioning System data collection was incomplete, with geolocation data unusable. There was no significant change in number/type of visits away from home.

Conclusions

A group-based community mobility education program promoted modes of active independent transport but did not impact on outings from home. Future research could include passive collection methods using a smartphone to record community participation.

Clinical Trial Registration

https://www.anzctr.org.au/, identifier: ACTRN12616001254482.

Chair design for older immobile people: Comparison of pressure mapping and manual handling outcomes

The number of older adults unable to transfer or ambulate independently is increasing. High support chairs enable people experiencing loss of mobility to be mobile, but current chair designs are associated with global functional loss and pressure ulcers. This pilot study compared the functionality of a traditional design high support chair to a new design of motorised high support chair: 1) a motion laboratory study compared joint angles and pressure at the hip, knee, ankle, elbow and spine when pushing each chair, and 2) a pressure mapping study compared the interface pressure when older people with limited mobility used the chairs. Significant reduction in joint angles for the person pushing the chair (degree difference range -3.6 to 14.2) and decreased seated pressure (w/kg difference range -0.2 to 2.1) for the seated user were identified for the motorised chair. Longitudinal investigations are required to determine if the significant differences identified in this pilot study result in less manual handling injuries and pressure areas.

Ultrasound Probe Pose Classification for Task Recognition in Central Venous Catheterization

Central Line Tutor is a system that facilitates real-time feedback during training for central venous catheterization. One limitation of Central Line Tutor is its reliance on expensive, cumbersome electromagnetic tracking to facilitate various training aids, including ultrasound task identification and segmentation of neck vasculature. The purpose of this study is to validate deep learning methods for vessel segmentation and ultrasound pose classification in order to mitigate the system's reliance on electromagnetic tracking. A large dataset of segmented and classified ultrasound images was generated from participant data captured using Central Line Tutor. A U-Net architecture was used to perform vessel segmentation, while a shallow Convolutional Neural Network (CNN) architecture was designed to classify the pose of the ultrasound probe. A second classifier architecture was also tested that used the U-Net output as the CNN input. The mean testing set Intersect over Union score for U-Net cross-validation was 0.746 ± 0.052. The mean test set classification accuracy for the CNN was 92.0% ± 3.0, while the U-Net + CNN achieved 92.7% ± 2.1%. This study highlights the potential for deep learning on ultrasound images to replace the current electromagnetic tracking-based methods for vessel segmentation and ultrasound pose classification, and represents an important step towards removing the electromagnetic tracker altogether. Removing the need for an external tracking system would significantly reduce the cost of Central Line Tutor and make it far more accessible to the medical trainees that would benefit from it most.

Towards a Clinical Decision-Making Algorithm Guiding Locomotor Therapy Modality in Subacute Stroke: An Exploratory Study

OBJECTIVES

To propose a clinical decision-making algorithm guiding modality choice and transition from the Lokomat® robotic to body-weight supported treadmill training in subacute stroke, due to current evidence being limited, making clinical decisions difficult.

MATERIALS AND METHODS

For 10 adult patients with subacute stroke completing Lokomat® therapy, physiotherapist clinical judgement regarding body-weight supported treadmill training readiness and the following objective measurements were collected; Functional Ambulation Category; sit to stand/standing ability; Lokomat® settings; maximal active hip and knee flexion in standing; and gait biomechanics during body-weight supported treadmill training. Based on observed patterns a proposed clinical decision-making algorithm was developed.

RESULTS

Clinical judgement deemed four of 10 participants ready to transition to body-weight supported treadmill training. Unlike participants judged not ready, these participants had: a) a Functional Ambulation Category of 1; b) independence with sit to stand and standing with even weight bearing; c) Lokomat®: Body-Weight Support <30%, Guidance Force <30-35%, speed >2.0kph; d) >45° standing active hip and knee flexion; e) no significant issues with physiological stepping in treadmill training or only requiring assistance from one therapist to achieve this.

CONCLUSION

Participants judged ready for transition from the Lokomat® to body-weight supported treadmill training presented with increased independent functional ability, more challenging Lokomat® settings, greater active volitional lower-limb control, and less issues with physiological stepping in treadmill training, than those participants judged not ready. Results were translated into a proposed clinical decision-making algorithm guiding transition from the Lokomat® to body-weight supported treadmill training, to be further tested in clinical trials.

Management and cleanup of legacy radium-contaminated sites in the United States

The hazards associated with radium-containing materials were largely unknown when they were first introduced into household and other products over a century ago. Radium was also originally thought to have beneficial health properties, leading to confusion amongst the public about the safety of radium in household products and food items. When the adverse health effects associated with radium were discovered and became well known, radium products became unpopular and were prohibited in some countries. In the United States, after the hazards associated with radium became known, radium was first regulated by individual states in the late 1920s and early 1930s. Later, the US Nuclear Regulatory Commission (NRC) was given a role in the regulation of discrete sources of radium with the passage of the Energy Policy Act of 2005. After passage of the Act, the NRC began to systematically identify sites around the country where radium was used and reached out to site owners to determine whether existing radium contamination could pose a risk to public health and safety and the environment. The NRC devised a graded approach in response to its new regulatory responsibilities to address potential public health and safety issues at legacy radium sites. By September 2019, the NRC had dispositioned all the sites that were identified as having potential contamination from historical radium within its regulatory purview in non-Agreement States. The staff worked with site owners and federal, state and local officials, as needed, to properly disposition the sites to ensure that each site either meets the applicable criteria for unrestricted use or has controls in place to limit access during remediation so that no site poses an unacceptable risk to public health and safety and the environment.

Percolation of Ion-Irradiation-Induced Disorder in Complex Oxide Interfaces

Mastery of order-disorder processes in highly nonequilibrium nanostructured oxides has significant implications for the development of emerging energy technologies. However, we are presently limited in our ability to quantify and harness these processes at high spatial, chemical, and temporal resolution, particularly in extreme environments. Here, we describe the percolation of disorder at the model oxide interface LaMnO₃/SrTiO₃, which we visualize during in situ ion irradiation in the transmission electron microscope. We observe the formation of a network of disorder during the initial stages of ion irradiation and track the global progression of the system to full disorder. We couple these measurements with detailed structural and chemical probes, examining possible underlying defect mechanisms responsible for this unique percolative behavior.

Integrating community participation in the transition of older adults from hospital to home: a scoping review

INTRODUCTION

Benefits of community participation and physical activity for the health and wellbeing of older adults are well documented. This review aims to answer the question; "How is community participation considered for older adults in the transition from hospital to home?"

MATERIALS AND METHODS

This scoping review searched key databases using subject headings and keywords. Two independent reviewers selected studies based on a systematic procedure. Inclusion criteria were adults aged ≥60 years, transitioning from hospital to home, reporting on community participation, inclusive of leisure activities, social activities, and physical activity.

RESULTS

Of 2206 initial unique articles, 19 met inclusion criteria. Articles covered a range of diagnoses, most frequently stroke, hip replacement, or fracture. Numerous measures of community participation were reported, identifying "low" and "reduced" community participation in ten studies. Measures of physical activity, health-related quality of life, sleep quality, and loneliness were variable. Five studies reported interventions and four reported improved components of community participation. Numerous barriers to community participation were identified, with recommendations for future transition care services considered.

CONCLUSION

There are considerable barriers to promoting community participation in transition care services for older people. Older adults need information to prepare for returning home from hospital and to regain valued leisure and social activities for health-related quality of life.IMPLICATIONS FOR REHABILITATIONCommunity participation is an important component of healthy ageing which health professionals should consider beyond discharge.Levels of mobility and endurance should be considered in terms of facilitating community participation for older adults.Transition care services should provide adequate information to prepare individuals expectations of returning home following hospital stay, whilst attempting to maintain valued leisure and social activities.

Morphological Errors in Spanish-Speaking Bilingual Children With and Without Developmental Language Disorders

Purpose The purpose of this study was to find morphological markers with good diagnostic accuracy to identify developmental language disorders (DLD) in Spanish-English bilingual children. Method The participants in this study included 66 Spanish-English bilingual children between the ages of 4;0 and 6;11 (years;months) with (n = 33) and without DLD (n = 33). We employed a comprehensive production task in Spanish to elicit morphological structures that have been previously found to be problematic for Spanish-speaking children with DLD. These structures included elements of nominal morphology (articles, direct object pronouns, adjectives, and plurals) and verbal morphology (verbs and the subjunctive mood). Logistic regression was used in this study to find a set of grammatical structures that most accurately predicted group membership. Results Spanish-English bilingual children with and without DLD significantly differed from each other in their accurate production of articles, clitics, adjectives, verbs, and the subjunctive mood. Clitics, verbs, and the subjunctive mood in isolation had adequate diagnostic accuracy. A combination of verb and subjective mood accuracy best predicted group membership in this study (sensitivity of 85% and specificity of 91%). Conclusion In addition to clitics, verbs, and the subjunctive mood, both elements of verbal morphology should be considered grammatical markers of DLD in Spanish-English bilingual children. Supplemental Material https://doi.org/10.23641/asha.13641320.

Community participation of community dwelling older adults: a cross-sectional study

BACKGROUND

With the advancing age of the population, and increasing demands on healthcare services, community participation has become an important consideration for healthy ageing. Low levels of community participation have been linked to increased mortality and social isolation. The extent to which community participation has been measured objectively in older adults remains scarce. This study aims to describe where and how older adults participate in the community and determine the feasibility of measurement methods for community participation.

METHODS

This observational cross-sectional study obtained data from 46 community dwelling older adults. A combination of Global Positioning Systems (GPS), accelerometry, and self-reported diaries were used over a 7-day monitoring period. Feasibility of methods were determined by calculating the loss of GPS data, questionnaires, and comparison of self-reported locations with GPS co-ordinates. Relationships between community participation, physical activity, social interactions, health related quality of life, sleep quality and loneliness were explored.

RESULTS

Older adults took a median (IQR) of 15 (9.25-18.75) trips out of home over the 7-day monitoring period, most frequently visiting commercial and recreational locations. In-home activities were mainly sedentary in nature, with out of home activities dependent on location type. Self-reported and GPS measures of trips out of home and the locations visited were significantly correlated (self-report 15.7 (5.6) GPS 14.4 (5.8) (r = 0.94)). Significant correlations between both the number of trips taken from home, with social interactions (r = 0.62) and the minutes of moderate to vigorous physical activity (MVPA) (r = 0.43) were observed. Daily MVPA was higher in participants who visited local walk/greenspaces (r = 0.48).

CONCLUSION

Participants performed more activities with social interactions out of home and visited commercial locations most frequently. The combination of GPS, accelerometry and self-report methods provided a detailed picture of community participation for older adults. Further research is required with older adults of varying health status to generalise the relationships between community participation, location and physical activity.

TRIAL REGISTRATION

Ethical approval was gained from the Flinders University Social and Behavioural Research Ethics Committee (protocol no. 8176).

The Autism Impact Measure (AIM): Examination of Sensitivity to Change

The Autism Impact Measure (AIM) was designed specifically for treatment-outcome assessment in children with ASD, focusing on treatment-relevant aspects of symptom presentation and efficient detection of short-term improvement. The AIM demonstrated strong reliability and validity in initial psychometric studies. The current study evaluated the AIM's sensitivity to change across well-established treatments. The sample included 471 children with ASD (ages 2-14) participating in one of six treatments. The AIM was administered at baseline and 6-week intervals and a battery of domain-specific concurrent measures was also administered. A longitudinal repeated measures design examined the degree to which: (a) AIM domain scores changed over time in response to treatment and (b) change in AIM domains was associated with change in measures of similar constructs. Results across growth curve models indicated that AIM domains are sensitive to change in symptoms across treatment. Across all models, symptoms decreased over time, with some deceleration in rate of improvement. For all AIM domains except Repetitive Behavior, symptoms improved as a function of treatment group. Correlations of change between AIM and other measures varied across domains (from 0.01-0.43 across measures). This was the first large-scale study to systematically evaluate sensitivity to change in a measure of core ASD symptoms. The results provide support for the AIM's ability to detect short-term improvement across symptom domains and indicate that AIM domains are sensitive to change overall and as a function of different treatment conditions. The brief repeated assessment window also highlights the AIM's utility for detecting improvements across short-term treatments. Autism Res 2020, 13: 1867-1879. © 2020 International Society for Autism Research and Wiley Periodicals LLC LAY SUMMARY: Good measures are important for assessing outcomes in children with autism. However, there are few tools for tracking short-term changes in autism symptoms. This study tested a new measure, the Autism Impact Measure (AIM), in a large group of children with autism. The results showed that the AIM appears to be a valid and accurate tool for measuring autism symptoms. The AIM may be a helpful tool for researchers and clinicians interested in tracking short-term improvements in autism symptoms.

How Commercially Available Virtual Reality-Based Interventions Are Delivered and Reported in Gait, Posture, and Balance Rehabilitation: A Systematic Review

OBJECTIVE

Virtual reality (VR) technologies are increasingly used in physical rehabilitation; however, it is unclear how VR interventions are being delivered, and, in particular, the role of the therapist remains unknown. The purpose of this study was to systematically evaluate how commercially available VR technologies are being implemented in gait, posture, and balance rehabilitation, including justification, content, procedures, and dosage of the intervention and details of the therapist role.

METHODS

Five databases were searched between 2008 and 2018. Supervised interventional trials with >10 adult participants using commercially available VR technologies to address mobility limitations were independently selected by 2 authors. One author extracted reported intervention characteristics into a predesigned table and assessed methodological quality, which was independently verified by a second author. A total of 29 studies were included.

RESULTS

Generally, minimal clinical reasoning was provided to justify technology or activity selection, with recreational systems and games used most commonly (n = 25). All but 1 study used a single interventional technology. When explicitly described, the intervention was delivered by a physical therapist (n = 14), a therapist assistant (n = 2), both (n = 1), or an occupational therapist (n = 1). Most studies reported supervision (n = 12) and safeguarding (n = 8) as key therapist roles, with detail of therapist feedback less frequently reported (n = 4). Therapist involvement in program selection, tailoring, and progression was poorly described.

CONCLUSION

Intervention protocols of VR rehabilitation studies are incompletely described and generally lack detail on clinical rationale for technology and activity selection and on the therapist role in intervention design and delivery, hindering replication and translation of research into clinical practice. Future studies utilizing commercially available VR technologies should report all aspects of intervention design and delivery and consider protocols that allow therapists to exercise clinical autonomy in intervention delivery.

IMPACT STATEMENT

The findings of this systematic review have highlighted that VR rehabilitation interventions targeting gait, posture, and balance are primarily delivered by physical therapists, whose most reported role was supervision and safeguarding. There was an absence of detail regarding complex clinical skills, such as tailoring of the intervention and reasoning for the choice of technology and activity. This uncertainty around the role of the therapist as an active ingredient in VR-based rehabilitation hinders the development of implementation guidelines. To inform the optimal involvement of therapists in VR rehabilitation, it is essential that future studies report on all aspects of VR intervention design and delivery.

Vulnerability of Clitics and Articles to Bilingual Effects in Typically Developing Spanish-English Bilingual Children

This study examines bilingual effects in Spanish-English bilingual children with good maintenance of the minority language. The present study compares the performance of a group of Spanish-monolingual children (MON; n=30) with two groups of Spanish-speaking bilingual children (Low English proficiency group: LEP; n=36; High English proficiency group, HEP; n=36) on the elicited productions of Spanish articles and object clitics. Our results suggest that children with LEP performed significantly lower than MON children of the same age on both articles and clitics in Spanish. However, children with HEP, who were a year older on average, performed similarly to the MON group. Both groups of bilingual children produced errors of clitic omission and substitution, but these errors were minimal in the MON group. The results suggest that Spanish clitics and articles are vulnerable to bilingual effects for English/Spanish speaking children with good Spanish maintenance.

Morphological Errors in Monolingual Spanish-Speaking Children With and Without Developmental Language Disorders

Purpose The purpose of this study was to identify which morphological markers have the best diagnostic accuracy to identify developmental language disorders (DLD) in monolingual Spanish-speaking children. Method The participants in this study included 50 Spanish-speaking monolingual children with (n = 25) and without (n = 25) DLD. Data collection took place in Mexico. Children were administered a comprehensive elicitation task that set up felicitous contexts to produce morphological structures previously identified as problematic for Spanish-speaking children with DLD: articles, direct object pronouns, adjectives, plurals, verb conjugations, and the subjunctive in Spanish. Results Statistically significant group differences between children with and without DLD were found for all morphological structures examined but plurals. Logistic regression analyses suggested that a model that included clitic and verbs was the best model to uniquely predict group membership. This model showed sensitivity of 96% and specificity of 80%. Conclusion Clitics and verbs should be considered morphological markers of DLD in monolingual Spanish-speaking children.

Augmented Performance Feedback during Robotic Gait Therapy Results in Moderate Intensity Cardiovascular Exercise in Subacute Stroke

BACKGROUND

Low cardiovascular fitness is common poststroke. Conventional subacute stroke rehabilitation does not meet Australian National Stroke Guidelines for cardiovascular exercise, particularly in mobility-dependent patients. Walking robotics can potentially achieve recommended cardiovascular exercise with these patients.

AIM

The primary aim was to determine whether sustained moderate intensity cardiovascular exercise can be achieved using 3 Lokomat Augmented Performance Feedback activities in mobility-dependent adults with subacute stroke. Secondary aims were to assess if cardiovascular workload was influenced by the activity completed, participants motivation or enjoyment, or changes in Lokomat settings.

METHODS

Ten patients with subacute stroke (mean (SD) age: 63.4 (13) years) participated in 6x20-minute Lokomat study sessions. Each study session involved a warm-up and 3x5-minute APF activities presented in a random order. Metabolic data were collected using the COSMED-K5. Participants rated their perceived exertion on the BORG CR10 scale and Lokomat settings of body-weight support, guidance force, and speed were recorded.

RESULTS

Moderate intensity cardiovascular exercise was achieved and maintained over the 15 minutes of exercise, objectively demonstrated by a mean (SD) Metabolic Equivalent Task of 3.1 (1.3), and mean (SD) oxygen consumption of 8.0 (3.8) ml/kg/min, estimated as 52% VO₂max. This was subjectively confirmed by exertion scores between 3 and 5. The cardiovascular workload was not affected by which activity was completed, participant motivation or enjoyment, or significant progression of Lokomat settings between study sessions.

CONCLUSIONS

Mobility-dependent patients with subacute stroke can achieve sustained moderate intensity cardiovascular exercise on the Lokomat when using APF activities.

Screening Nitrate in Forages with a Test Strip: Collaborative Study

A collaborative study was conducted for screening nitrate in forages with a commercially available test strip. The method involves extracting a finely ground sample with deionized water. The test strip is dipped in the sample extract. The color of the reaction zone on the test strip changes from white to pink or purple depending on the nitrate concentration in sample extract. The nitrate present in the extract is determined by comparing the color of the test strip to the color scale on the test strip container. Six blind quintuplicates of forage samples were analyzed by 20 collaborators. Nitrate concentrations in forage samples tested ranged from &lt;1000 ppm nitrate to &gt;10 000 ppm nitrate on dry matter basis. Each collaborator was asked to assign each sample to one of the 4 following nitrate concentration ranges: (1) &lt;1000 ppm, (2) 1000 to 5000 ppm, (3)&gt;5000 ppm to 10 000 ppm, and (4) &gt;10 000 ppm. Nineteen of 20 collaborators reported results. Results from 2 laboratories were rejected as outliers by inspection and χ2 test. Sensitivity rates (p+) ranged from 0.965 to 0.998, with standard errors of 0.006 to 0.16. Specificity rates (p−) ranged from 0.991 to 0.997 for the 4 ranges, with standard errors of 0.003 to 0.006. False-positive rates (pf+) ranged from 0.006 to 0.046, with standard errors of 0.006 to 0.025. False-negative rates (pf−) ranged from 0.003 to 0.007, with standard errors of 0.003 to 0.006. Screening nitrate in forages with a test strip has been adopted first action by AOAC INTERNATIONAL.

Pedometers alone do not increase mobility in inpatient rehabilitation: a randomized controlled trial

OBJECTIVE

To test if pedometers, as a motivational tool, could affect mobility outcomes in inpatient rehabilitation.

DESIGN

Randomized controlled clinical trial.

SETTING

Subacute hospital rehabilitation unit in Australia.

PARTICIPANTS

A total of 78 participants with reduced mobility and clinician-determined capacity to improve.

INTERVENTIONS

Both groups received usual care. For the intervention group, a pedometer was worn on the hip with the step count visible to participant and recorded daily on an exercise log. For the control group, a pedometer fixed shut was worn on the hip and they recorded estimated distances walked on an exercise log.

MAIN MEASURES

Primary outcome was functional mobility - De Morton Mobility Index. Secondary outcome measures were walking velocity, functional independence measure, time spent upright and daily step count.

RESULTS

Significant improvements over time (P < 0.001) in functional mobility, comfortable walking velocity and functional independence measure were not influenced by the intervention. The daily average upright time (hours) in the first week of intervention was different (P = 0.004) between the intervention group (median, interquartile range (IQR): 1.67, 1.77) compared to the control group (median, IQR: 1.12, 0.82).

CONCLUSION

Pedometers as a motivational tool without targets do not improve functional mobility in this population. Pedometers may improve daily upright time in this setting.

Clinician Perspectives of an Avatar-Directed Scheduling and Memory App

BACKGROUND AND AIMS

Effective strategies are needed to address the need for scheduling support in the unique setting of a home rehabilitation service, providing home based therapy, as well as telerehabilitation. One approach is an electronic avatar-directed scheduling and memory aid in the form of an app. The aim of this study is to investigate clinician perspectives on the use of this type of technology.

METHODS

In this mixed method study a total of sixteen clinicians from various disciplines based at a metropolitan hospital in Adelaide (SA, Australia) participated in 2 semi-structured focus groups aimed to explore experiences and attitudes towards scheduling support in the form of an avatar-directed app, perceptions on the usefulness of the app, as well as acceptability. Thematic analysis was undertaken on focus groups' transcripts. Self-reported technology proficiency, perceived usefulness (PU), and perceived ease of use (PEOU) were assessed quantitatively. Summary statistics were used to analyse the quantitative data and Spearman's correlation was used to explore the relationship between participant characteristics and individual and mean scores for PU and PEOU.

RESULTS

Four themes emerged from the focus groups: effectiveness versus efficiency, patient empowerment, practicality and ease of use, and likability of the avatar. Clinicians experienced time constraints, and welcomed technology that could assist with reliable scheduling of appointments and therapy sessions. They liked the concept of the avatar and found the app interesting, novel and fun. However, although the app was reasonably easy to use, the setting up was problematic and time consuming. Clinicians did not see the app as beneficial to their patients, and felt that the technology did not add value to the delivery of care. The older, more experienced, clinicians found the app more difficult to use, but neither the level of technological competency, nor gender, was found to be associated with PU or PEOU.

DISCUSSION

Although clinicians appreciated the concept of an avatar-directed scheduling and memory app, they did not see it as a useful tool in the provision of scheduling assistance in this particular setting providing short-term rehabilitation services. Clinicians felt time-poor and emphasized the importance of a time-efficient solution. Perceived lack of usefulness in this context and poor likeability of the avatar highlight the need for clinician involvement in the design process before an app can be successfully implemented in a clinical setting.

Impairments of balance, stepping reactions and gait in people with cervical dystonia

BACKGROUND

Impaired balance is common in neurological disorders. Cervical dystonia is a neurological movement disorder affecting the neck. The effect of this aberrant head posture on physical function is unknown.

OBJECTIVES

To compare balance, mobility, gait and stepping reactions between ten people with cervical dystonia and ten control adults.

METHODS

Spatiotemporal gait parameters and walking speed were assessed using a computerised walkway. Step length and time, time in double support and gait variability were calculated, then normalised to gait speed. Centre of pressure path length was assessed with eyes open and eyes closed to calculate a Romberg Quotient. Simple and choice reaction times were measured using customised apparatus while mobility was assessed by the timed up and go. Cervical spine range of motion was measured using a head mounted goniometer. Self-reported scales included Falls Self Efficacy Scale and Dystonia Discomfort Scale.

RESULTS

There was a difference between groups for most outcome measures. The timed up-and-go and walking speed was slower (both P<0.005) and the Romberg Quotient lower (P=0.046) in cervical dystonia. People with cervical dystonia had lower falls self-efficacy (P=0.0002). Reduced cervical range of motion was correlated with balance, stepping reaction time and mobility (all P<0.05). Timed up and go was positively associated with stepping reaction time (P<0.01). Dystonia discomfort did not impact function.

CONCLUSIONS

People with cervical dystonia displayed deficits in balance, gait and stepping reactions, and expressed higher fear of falling. Studies to further elucidate functional limitations and their impact on activity and participation in daily life are required.

The relationship between knowledge of pain neurophysiology and fear avoidance in people with chronic pain: A point in time, observational study

Chronic pain is prevalent in the western world; however fear of pain often has a greater impact than the degree of initial injury. The aim of this study was to explore the relationship between knowledge of the neurophysiology of pain and fear avoidance in individuals diagnosed with chronic pain. Twenty-nine people with chronic musculoskeletal pain were recruited and completed questionnaires to determine their understanding of pain neurophysiology and the degree of their fear avoidance beliefs. There was an inverse relationship between knowledge of pain neurophysiology and the level of fear avoidance. Patients with higher pain knowledge reported less fear avoidance and lower perceived disability due to pain. There was no relationship with the educational level or compensable status for either variable. The findings suggest that fear avoidance is positively influenced by neurophysiology of pain education, so that a higher level of pain knowledge is associated with less activity-related fear. The clinical implication is that reducing fear avoidance/kinesiophobia using neurophysiology of pain education in people with chronic pain may provide an effective strategy to help manage fear avoidance and related disability in the chronic pain population in order to improve treatment outcomes.

Minimizing right ventricular pacing in pacemaker patients with intact and compromised atrioventricular conduction : Results from the EVITA Trial

INTRODUCTION

Unnecessary ventricular pacing is associated with increased morbidity and mortality. Over the years different algorithms have been developed to reduce right ventricular pacing.

OBJECTIVES

Goal of the present study was to test the efficacy of the ventricular intrinsic preference (VIP) algorithm in patients with atrioventricular intact (AVi) and atrioventricular compromised (AVc) AV-conduction.

METHODS

Evaluation of VIP feature in pacemaker patients (EVITA) was a multicenter, prospective, randomized trial (Trials.gov Identifier: NCT00366158). In total, 389 patients were randomized to AVc group: n = 140/132 VIP OFF/VIP On, AVi group: n = 54/63 VIP OFF/VIP ON). One-month post-implantation AV conduction testing (AVc: PR/AR interval > 210 ms) was performed. Follow-up visits occurred 6 and 12 months after DDD-pacemaker implantation.

RESULTS

In AVi and AVc-patients initiation of the VIP feature significantly reduced incidence of ventricular pacing (AVi: 53 ± 38 vs. 9 ± 21%, p = 0.0001; AVc: 79 ± 31 vs. 28 ± 35%, p = 0.0001). DDD-pacemaker implantation per se significantly reduced incidence of AF in VIP ON (AVi 27 vs. 0%, p < 0.0001; AVc 29 vs. 3%, p < 0.0001) and VIP OFF patients (AVi 43 vs. 4%, p < 0.0001; AVc 33 vs. 3, p < 0.0001), without significant differences between VIP ON and OFF groups (p > 0.05). In the AVc group activation of VIP significantly reduced incidence of adverse events (AE). All-cause mortality was not significantly different in VIP ON (n = 5) and VIP OFF (n = 4, p > 0.05) patients.

CONCLUSION

AV search hysteresis (VIP) markedly reduces ventricular pacing both in patients with normal AV conduction and in patients with prolonged PR interval or intermittent AV block.

Association of Postural Sway with Disability Status and Cerebellar Dysfunction in People with Multiple Sclerosis: A Preliminary Study

BACKGROUND

The aims of this study were 1) to examine postural sway in the eyes open (EO) and eyes closed (EC) conditions in people with multiple sclerosis (MS) with moderate levels of disability compared with controls and 2) to examine relationships between postural sway and total Expanded Disability Status Scale (EDSS) scores, functional system subscores, and clinical measures of strength and spasticity in the MS group.

METHODS

Thirty-four people with moderate MS and ten matched controls completed measures of postural sway with EO and EC, knee extension and ankle dorsiflexion isometric strength, EDSS total score and subscores, and spasticity levels.

RESULTS

Participants with MS swayed significantly more with EO and EC and had reduced knee extension and ankle dorsiflexion strength compared with controls (P < .001). In the MS group, increased sway was associated with higher total EDSS scores and cerebellar function subscores, whereas increased sway ratio (EC/EO) was associated with reduced sensory function subscores. Postural sway was not significantly associated with strength or spasticity.

CONCLUSIONS

Participants with MS swayed more and were significantly weaker than controls. Cerebellar dysfunction was identified as the EDSS domain most strongly associated with increased sway, and sensory loss was associated with a relatively greater dependence on vision for balance control. These findings suggest that exercise interventions targeting sensory integration and cerebellar ataxia may be beneficial for enhancing balance control in people with MS.

Intracortical inhibition is modulated by phase of prosthetic rehabilitation in transtibial amputees

Reorganization of primary motor cortex (M1) is well-described in long-term lower limb amputees. In contrast cortical reorganization during the rehabilitation period after amputation is poorly understood. Thirteen transtibial amputees and 13 gender matched control participants of similar age were recruited. Transcranial magnetic stimulation was used to assess corticomotor and intracortical excitability of M1 bilaterally. Neurophysiological assessments were conducted at admission, prosthetic casting, first walk and discharge. Gait variability at discharge was assessed as a functional measure. Compared to controls, amputees had reduced short-latency intracortical inhibition (SICI) for the ipsilateral M1 at admission (p = 0.01). Analysis across rehabilitation revealed SICI was reduced for the contralateral M1 at first walk compared to discharge (p = 0.003). For the ipsilateral M1 both short and long-latency intracortical inhibition were reduced at admission (p < 0.05) and prosthetic casting (p < 0.02). Analysis of the neurophysiology and gait function revealed several interesting relationships. For the contralateral M1, reduced inhibition at admission (p = 0.04) and first walk (p = 0.05) was associated with better gait function. For the ipsilateral M1, reduced inhibition at discharge (p = 0.05) was associated with poor gait function. This study characterized intracortical excitability in rehabilitating amputees. A dichotomous relationship between reduced intracortical inhibition for each M1 and gait function was observed at different times. Intracortical inhibition may be an appropriate cortical biomarker of gait function in lower limb amputees during rehabilitation, but requires further investigation. Understanding M1 intracortical excitability of amputees undertaking prosthetic rehabilitation provides insight into brain reorganization in the sub-acute post-amputation period and may guide future studies seeking to improve rehabilitation outcomes.

Over ground walking and body weight supported walking improve mobility equally in cerebral palsy: a randomised controlled trial

Objective:

To assess partial body weight supported treadmill training versus over ground training for walking ability in children with mild to moderate cerebral palsy.

Design:

Randomised controlled trial.

Setting:

A Special Needs school in Singapore.

Subjects:

Thirty children with cerebral palsy, aged 6-18, with a Gross Motor Function Classification System score of II-III.

Interventions:

Two times 30 minute sessions of walking training per week for 8 weeks, progressed as tolerated, either over ground (control) or using partial body weight supported treadmill training (intervention).

Main measures:

The 10 metre walk test, and the 6 minute walk test. Secondary measures were sub-sections D and E on the Gross Motor Function Measure. Outcomes were assessed at baseline, and after 4 and 8 weeks of training.

Results:

There was no effect of group allocation on any outcome measure, while time was a significant factor for all outcomes. Walking speed improved significantly more in the intervention group by week 4 (0.109 (0.067)m/s vs 0.048 (0.071)m/s, P=0.024) however by week 8 the change from baseline was similar (intervention 0.0160 (0.069)m/s vs control 0.173 (0.109)m/s, P=0.697). All gains made by week 4 were significantly improved on by week 8 for the 10 metre walk test, 6 minute walk test, and the gross motor function measure.

Conclusions:

Partial body weight supported treadmill training is no more effective than over ground walking at improving aspects of walking and function in children with mild to moderate cerebral palsy. Gains seen in 4 weeks can be furthered by 8 weeks.

Does fluoroscopy improve acetabular component placement in total hip arthroplasty?

BACKGROUND

The success of THA largely depends on correct placement of the individual components. Traditionally, these have been placed freehand using anatomic landmarks, but studies have shown poor accuracy with this method.

QUESTIONS/PURPOSES

Specifically, we asked (1) does using fluoroscopy lead to more accurate and greater likelihood of cup placement with the Lewinnek safe zone than does freehand cup placement; (2) is there a learning curve associated with the use of fluoroscopy for cup placement; (3) does the use of fluoroscopy increase operative time; and (4) is there a difference in leg length discrepancy between freehand and fluoroscopic techniques?

METHODS

This series consisted of 109 consecutive patients undergoing primary THA, conversion of a previous hip surgery to THA, and revision THA during a 24-month period. No patients were excluded from analysis during this time. The first 52 patients had cups placed freehand, and then the next 57 patients had acetabular components placed using fluoroscopy; the analysis began with the first patient treated using fluoroscopy, to include our initial experience with the technique. The abduction, version, and limb length discrepancy were measured on 6-week postoperative pelvic radiographs obtained with the patient in the supine position. Operative time, sex, age, BMI, diagnosis, operative side, and femoral head size were recorded as possible confounders.

RESULTS

Cups inserted freehand were placed in the ideal range of abduction (30°-45°) and anteversion (5°-25°) 44% of the time. With fluoroscopy, placement in the Lewinnek safe zone for both measures significantly increased to 65%. The odds of placing the cup in the Lewinnek safe zone for abduction and version were 2.3 times greater with the use of fluoroscopy (95% CI, 1.2-5.0; p = 0.03). Patients undergoing primary THAs (32 freehand, 35 C-arm) had cup placement in the safe zone for abduction and version 44% of the time freehand and 57% of the time with fluoroscopy, which failed to reach statistical significance. There was no difference in operative time, patient age, sex, operative side, diagnosis, limb length discrepancy, or femoral head size between the two groups.

CONCLUSIONS

The use of fluoroscopy to directly observe pelvic position and acetabular component placement increased the success of placement in the Lewinnek safe zone in this cohort of patients having complex and primary THAs. This is a simple, low-cost, and quick method for increasing successful acetabular component alignment. The study population included a large proportion of patients having complex THAs, and further validation of this technique in patients undergoing straightforward, primary THAs needs to be done to understand if similar gains in accuracy for component placement can be expected in that group.

LEVEL OF EVIDENCE

Level III, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence.

Ipsilateral corticomotor excitability is associated with increased gait variability in unilateral transtibial amputees

Ipsilateral primary motor cortex (M1) reorganisation after unilateral lower-limb amputation may degrade function of the amputated limb. We hypothesised unilateral lower-limb amputees would have a bilateral increase in corticomotor excitability, and increased excitability of ipsilateral M1 would be associated with increased step-time variability during gait. Twenty transtibial amputees (16 male) aged 60.1 years (range 45-80 years), and 20 age- and gender-matched healthy adult controls were recruited. Single-pulse transcranial magnetic stimulation assessed corticomotor excitability. Two indices of corticomotor excitability were calculated. An index of corticospinal excitability (ICE) determined relative excitability of ipsilateral and contralateral corticomotor projections to alpha-motoneurons innervating the quadriceps muscle (QM) of the amputated limb. A laterality index (LI) assessed relative excitability of contralateral projections from each hemisphere. Spatial-temporal gait analysis was performed to calculate step-time variability. Amputees had lower ICE values, indicating relatively greater excitability of ipsilateral corticomotor projections than controls (P = 0.04). A lower ICE value was associated with increased step-time variability for amputated (P = 0.04) and non-amputated limbs (P = 0.02). This association suggests corticomotor projections from ipsilateral M1 to alpha-motoneurons innervating the amputated limb QM may interfere with gait. Cortical excitability in amputees was not increased bilaterally, contrary to our hypothesis. There was no difference in excitability of contralateral M1 between amputees and controls (P = 0.10), and no difference in LI (P = 0.71). It appears both hemispheres control one QM, with predominance of contralateral corticomotor excitability in healthy adults. Following lower-limb amputation, putative ipsilateral corticomotor excitability is relatively increased in some amputees and may negatively impact on function.

Use of an activity monitor and GPS device to assess community activity and participation in transtibial amputees

This study characterized measures of community activity and participation of transtibial amputees based on combined data from separate accelerometer and GPS devices. The relationship between community activity and participation and standard clinical measures was assessed. Forty-seven participants were recruited (78% male, mean age 60.5 years). Participants wore the accelerometer and GPS devices for seven consecutive days. Data were linked to assess community activity (community based step counts) and community participation (number of community visits). Community activity and participation were compared across amputee K-level groups. Forty-six participants completed the study. On average each participant completed 16,645 (standard deviation (SD) 13,274) community steps and 16 (SD 10.9) community visits over seven days. There were differences between K-level groups for measures of community activity (F(2,45) = 9.4, p < 0.001) and participation (F(2,45) = 6.9, p = 0.002) with lower functioning K1/2 amputees demonstrating lower levels of community activity and participation than K3 and K4 amputees. There was no significant difference between K3 and K4 for community activity (p = 0.28) or participation (p = 0.43). This study demonstrated methodology to link accelerometer and GPS data to assess community activity and participation in a group of transtibial amputees. Differences in K-levels do not appear to accurately reflect actual community activity or participation in higher functioning transtibial amputees.

Long-term fracture rates seen with continued ibandronate treatment: pooled analysis of DIVA and MOBILE long-term extension studies

Ibandronate reduces the risk of vertebral and non-vertebral fractures versus placebo in postmenopausal women with osteoporosis. This analysis, in which fractures were reported as safety events, showed that long-term use of ibandronate was associated with low fracture rates over 5 years of treatment.

INTRODUCTION

A previous post-hoc meta-analysis of 2-3 year studies found that ibandronate regimens with annual cumulative exposure (ACE) of ≥10.8 mg reduced the risk of vertebral and nonvertebral fractures (NVFs) versus placebo in postmenopausal women. This post-hoc analysis used individual patient data from the 2-year monthly oral ibandronate in ladies (MOBILE) and dosing intravenous administration (DIVA) studies, including the 3-year long-term extensions (LTEs), to assess fracture risk in patients treated with ibandronate for 5 years.

METHODS

Patients treated for 2 years in MOBILE with monthly oral ibandronate 150 mg (n = 176) and in DIVA with IV ibandronate every 2 months 2 mg (n = 253) or quarterly 3 mg (n = 263) who continued on the same regimens for 3 additional years in the LTEs were included. Three-year placebo data (n = 1,924) were obtained from the ibandronate osteoporosis vertebral fracture trial in North America and Europe (BONE) and IV Fracture Prevention trials. The primary endpoint was clinical fracture rate; clinical fracture data were collected as adverse events. Time to fracture was analyzed using Kaplan-Meier and statistical analysis was conducted using the log-rank test. All clinical fractures included all NVFs and symptomatic vertebral fractures.

RESULTS

For ibandronate regimens with ACE ≥10.8 mg, time to fracture was significantly longer for all clinical fractures, NVFs, and clinical vertebral fractures versus placebo (P = 0.005). For all fracture types, the rate of fracture appeared stable during the 5-year treatment period.

CONCLUSION

In women with postmenopausal osteoporosis, continuous treatment with ibandronate over 5 years results in low sustained clinical fracture rate.

Acetabular cup positioning in revision total hip arthroplasty with Paprosky type III acetabular defects: Martell radiographic analysis

PURPOSE

This study evaluates acetabular cup position in the setting of revision total hip arthroplasty (THA) with severe acetabular bone defects.

METHODS

With a definition of safe zone of abduction (30-50°) and anteversion (5-25°), acetabular cup position was measured by a digital image analysis program for 34 patients with Paprosky type III acetabular bone defects.

RESULTS

There were 24 cups (71%) for abduction and 26 cups (76%) for anteversion located in the safe zone. Nineteen cups (56%) were within the safe zone for both abduction and anteversion. There was no dislocation, however one cup out of the safe zone resulted in early cup failure due to aseptic loosening.

CONCLUSIONS

The acetabular cup positioning in patients with Paprosky type III defects was 'optimal' in half of the cases. The prevalence of optimal acetabular cup position was similar to those reported in primary THA, suggesting that the presence of a large acetabular bone defect may not be a significant risk factor for suboptimal acetabular cup positioning in the setting of revision THA.

Comparison of iPad applications with traditional activities using person-centred care approach: Impact on well-being for persons with dementia

Professionals working with people with dementia need to develop new activities that occupy patients and increase positive emotions. Dementia care mapping is a reliable method of measuring well-being during activities with people with dementia. The iPad has many applications that may be suitable as a group activity for persons with dementia. Six people with dementia took part in two traditional and two iPad activities over two days. Well-being was recorded using dementia care mapping. Subjects displayed similar or better levels of well-being during iPad activities than traditional activities. A larger variation of behaviors was seen during iPad activities than traditional activities. With detailed planning using a person-centred care approach, iPad group activity has the potential to be as effective and engaging as other conventional activities in achieving well-being.

Dipolar addition to cyclic vinyl sulfones leading to dual conformation tricycles

Dipolar addition of cyclic azomethine imines with cyclic vinyl sulfones gave rise to functionalized tricycles that exhibited fluxional behavior in solution at room temperature. The scope of the synthetic methodology was explored, and the origin of the fluxional behavior was probed by NMR methods together with DFT calculations. This behavior was ultimately attributed to stereochemical inversion at one of two nitrogen centers embedded in the tricyclic framework. Two tetracycles were also synthesized, and the degree of signal-broadening in the NMR spectra was found to depend on the presence of substitution next to the inverting nitrogen center.