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1.
Ian D. Coulter Patricia M. Herman Gery W. Ryan Ronald D. Hays Lara G. Hilton Margaret D. Whitley 《Journal of manipulative and physiological therapeutics》2018,41(9):800-806
Objectives
The purpose of this article is to report on the Center of Excellence for Research on Complementary and Alternative Medicine at RAND Corporation. The overall project examined the appropriateness of chiropractic spinal manipulation and mobilization for chronic low back pain and chronic cervical pain using the RAND and University of California Los Angeles Appropriateness Method, including patient preferences and costs, to acknowledge the importance of patient-centered care in clinical decision-making.Methods
This article is a narrative summary of the overall project and its inter-related components (ie, 4 Research Project Grants and 2 centers), including the Data Collection Core, whose activities and learning will be the subject of a following series of methods articles.Results
The project team faced many challenges in accomplishing data collection goals. The processes we developed to overcome barriers may be of use to other researchers and for practitioners who may want to participate in such studies in complementary and integrative health, which previously was known as complementary and alternative medicine.Conclusion
For this large, complex, successful project, we gathered online survey data, collected charts, and abstracted chart data from thousands of chiropractic patients. The present article delineates the challenges and lessons that were learned during this project so that others may gain from the authors’ experience. This information may be of use to future research that collects data from independent practitioners and their patients because it provides what is needed to be successful in such studies and may encourage participation. 相似文献2.
Trent Peng Baojiang Chen Kelley Pettee Gabriel 《Journal of manipulative and physiological therapeutics》2018,41(9):725-733
Objective
The purpose of this study was to describe the prevalence of chiropractic utilization and examine sociodemographic characteristics associated with utilization in a representative sample of US children and adolescents aged 4 to 17 years.Methods
Data are from 9734 respondents to the 2012 National Health Interview Survey. Age, sex, race/ethnicity, geography, family income, parental educational attainment, and other health care providers served as exposure variables. Chiropractic utilization in the past 12 months (yes/no) was the targeted outcome. Weighted crude and adjusted logistic regression models, controlling for relevant covariates, were performed.Results
The 12-month prevalence of chiropractic utilization in US children was 3.0% (95% confidence interval: 2.6%-3.6%). The adjusted odds (95% confidence interval) of chiropractic utilization were higher among 11- to 17-year-olds (2.02 [1.41-2.90]) (vs 4- to10-year-olds), Midwest residents (2.45 [1.36-4.44]) (vs Northeast), families with incomes ≥$100 000 (3.25 [1.87-5.66]) (vs <$35 000), and those that visited other Complementary and Integrative Health (also known as Complementary and Alternative Medicine) practitioners (11.26 [7.19-17.64]). Blacks and Asians had lower adjusted odds of chiropractic utilization compared with whites (0.17 [0.06-0.47] and 0.17 [0.07-0.43], respectively). Sex, parental education, and having an orthodox medical personal physician were not associated with utilization.Conclusion
Although overall prevalence was low, sociodemographic characteristics of child and adolescent users of chiropractic care were identified. Age, race/ethnicity, region of residence, family income, and utilization of other Complementary and Integrative Health services were associated with chiropractic utilization, after adjusting for sociodemographic covariates. 相似文献3.
Anupama Kizhakkeveettil Kevin A. Rose Gena E. Kadar Eric L. Hurwitz 《Journal of manipulative and physiological therapeutics》2017,40(3):201-213
Objectives
The objective of this study was to assess the feasibility of conducting a large-scale randomized controlled trial (RCT) examining whether an integrative care model combining spinal manipulative therapy (SMT) and acupuncture can lead to better outcomes for low back pain (LBP) than either therapy alone.Methods
This study was conducted at a complementary and alternative medicine university health center. Participants with acute or chronic LBP were randomized to (1) acupuncture, (2) SMT, or (3) integrative acupuncture and SMT groups. Treatments were provided over 60 days by licensed doctors of chiropractic and acupuncturists. Acupuncture treatments consisted of needling of acupoints combined with electrotherapy, moxibustion, cupping, and Tui Na. SMT used specific contact points on vertebral processes, along with soft tissue therapy and physiotherapy. Primary outcome measures were the Roland-Morris LBP Disability Questionnaire and 0 to 10 Numeric Rating Scale for LBP.Results
Participants in all 3 groups experienced clinically meaningful improvements in the primary outcome measures; however, no between-group differences in outcomes were apparent.Conclusions
This study indicated that it is feasible to conduct an RCT to compare the effectiveness of integrative acupuncture and SMT for LBP to either therapy alone. Future studies should include a larger sample to increase the power for detecting clinically meaningful differences between groups. 相似文献4.
Cheryl Hawk Michael J. Schneider Mitchell Haas Paul Katz Paul Dougherty Brian Gleberzon Lisa Z. Killinger John Weeks 《Journal of manipulative and physiological therapeutics》2017,40(4):217-229
Objective
The purpose of this study was to update evidence-based recommendations on the best practices for chiropractic care of older adults.Methods
The project consisted of a systematic literature review and a consensus process. The following were searched from October 2009 through January 2016: MEDLINE, Index to Chiropractic Literature, CINAHL (Cumulative Index to Nursing and Allied Health Literature), AMED (Allied and Complementary Medicine Database), Alt HealthWatch, Cochrane Database of Systematic Reviews, and Cochrane Registry of Controlled Trials. Search terms were: (manipulation, spinal OR manipulation, chiropractic OR chiropract*) AND (geriatric OR “older adult*”). Two reviewers independently screened articles and abstracts using inclusion and exclusion criteria. The systematic review informed the project steering committee, which revised the previous recommendations. A multidisciplinary panel of experts representing expertise in practice, research, and teaching in a variety of health professions serving older adults rated the revised recommendations. The RAND Corporation/University of California, Los Angeles methodology for a modified Delphi consensus process was used.Results
A total of 199 articles were found; after exclusion criteria were applied, 6 articles about effectiveness or efficacy and 6 on safety were added. The Delphi process was conducted from April to June 2016. Of the 37 Delphi panelists, 31 were DCs and 6 were other health care professionals. Three Delphi rounds were conducted to reach consensus on all 45 statements. As a result, statements regarding the safety of manipulation were strengthened and additional statements were added recommending that DCs advise patients on exercise and that manipulation and mobilization contribute to general positive outcomes beyond pain reduction only.Conclusions
This document provides a summary of evidence-informed best practices for doctors of chiropractic for the evaluation, management, and manual treatment of older adult patients. 相似文献5.
Kelvin J. Murray Tom Molyneux Michael R. Le Grande Aurora Castro Mendez Franz K. Fuss Michael F. Azari 《Journal of manipulative and physiological therapeutics》2017,40(5):320-329
Objective
The purpose of this study was to evaluate the correlation between mild leg length discrepancy (LLD) and degenerative joint disease (DJD) or osteoarthritis.Methods
We evaluated standard postural lumbopelvic radiographs from 255 adults (121 women and 134 men) who had presented with spinal pain for chiropractic care. Symmetry of femoral head diameters was used to exclude magnification errors. Pearson’s partial correlation was used to control for age and derive effect sizes for LLD on DJD in the hip and lower lumbar motion segments. Krippendorff’s α was used for intraobserver and interobserver reliability.Results
A strong correlation was found between LLD and hip DJD in men (r = 0.532) and women (r = 0.246). We also found a strong correlation between LLD and DJD at the L5-S1 motion segment in men (r = 0.395) and women (r = 0.246). At the L4-5 spinal level this correlation was much attenuated in men (r = 0.229) and women (r = 0.166).Conclusions
These findings suggest an association between LLD and hip and lumbar DJD. Cause–effect relationships between mild LLD and DJD deserve to be properly evaluated in future longitudinal cohort studies. 相似文献6.
Megan Sutter Laiene Olabarrieta Landa Amilkar Calderón Chagualá Helmer Chacón Peralta Gina Vergara Torres Paul B. Perrin Juan Carlos Arango-Lasprilla 《PM & R》2017,9(1):8-14
Background
Stroke is a primary cause of death and disability in upper-middle–income countries such as Colombia. Given the lack of comprehensive rehabilitation for stroke patients in Colombia, there is a need to assess longitudinal mental health problems poststroke in this region.Objective
To compare the course of mental health in stroke patients to healthy controls over the first year poststroke in Ibague, Colombia.Design
Cross-sectional study.Setting
The Psychological Attention Center of Antonio Nariño University in Ibague, Colombia.Participants
Stroke patients (n = 50) and age- and gender-matched healthy controls (n = 50).Methods
Patients and controls completed self-report Spanish versions of demographic information, injury-related characteristics, and mental health questionnairesMain Outcome Measurements
Outcomes assessed included mental health (depression, anxiety, and stress) at 3, 6, and 12 months poststroke.Results
Hierarchical linear models suggested that stroke patients had worse depression and anxiety over time than controls (P < .001). Among patients, depression and anxiety decreased over time (P < .001), whereas stress increased over time (P < .01). The findings suggest that although anxiety and depression improved over time in stroke patients, their mental health remained significantly lower than that of controls.Conclusions
This is the first study to examine the course of mental health over the first year poststroke in Latin America, specifically in Ibague, Colombia. Despite the improvements in anxiety and depression over the first year poststroke, patient anxiety and depression were still worse in comparison to those in healthy controls. The current findings indicate a need for rehabilitation services in Colombia, especially targeting mental health issues.Level of Evidence
I 相似文献7.
Background
A total of 2.7 million patients present to US emergency departments annually for management of low back pain (LBP). Despite optimal medical therapy, more than 50% remain functionally impaired 3 months later. We performed a systematic review to address the following question: Among patients with nonchronic LBP, does spinal manipulation, massage, exercise, or yoga, when combined with standard medical therapy, improve pain and functional outcomes more than standard medical therapy alone?Methods
We used published searches to identify relevant studies, supplemented with our own updated search. Studies were culled from the Cochrane Register of Controlled Trials, Medline, EMBASE, CINAHL, and the Index to Chiropractic Literature. Our goal was to identify randomized studies that included patients with nonradicular LBP of <12 weeks’ duration that compared the complementary therapy to usual care, sham therapy, or interventions known not to be efficacious, while providing all patients with standard analgesics. The outcomes of interest were improvement in pain scores or measures of functionality.Results
We identified 2 randomized controlled trials in which chiropractic manipulation + medical therapy failed to show benefit vs medical therapy alone. We identified 4 randomized controlled trials in which exercise therapy + medical therapy failed to show benefit vs medical therapy alone. We did not identify any eligible studies of yoga or massage therapy.Conclusions
In conclusion, for patients with nonchronic, nonradicular LBP, available evidence does not support the use of spinal manipulation or exercise therapy in addition to standard medical therapy. There is insufficient evidence to determine if yoga or massage is beneficial. 相似文献8.
Casey S. Okamoto Andrew S. Dunn Bart N. Green Lance R. Formolo David Chicoine 《Journal of manipulative and physiological therapeutics》2017,40(5):358-364
Objective
Back pain is more prevalent in the obese, but whether back pain severity is directly correlated to obesity in veterans is unknown. We sought to determine if there was a correlation between body composition and low back pain severity in a sample of veterans. The hypothesis was that veterans with higher body mass index values would report higher low back pain severity scores.Methods
This study was a retrospective chart review of 1768 veterans presenting to a Veterans Affairs chiropractic clinic with a chief complaint of low back pain between January 1, 2009 and December 31, 2014. Spearman’s rho was used to test for correlation between body composition as measured by body mass index and low back pain severity as measured by the Back Bournemouth Questionnaire.Results
On average, the sample was predominantly male (91%), older than 50, and overweight (36.5%) or obese (48.9%). There was no correlation between body mass index and Back Bournemouth Questionnaire scores, r = .088, p < .001.Conclusions
The majority of veterans with low back pain in this sample were either overweight or obese. There was no correlation between body composition and low back pain severity in this sample of veterans. 相似文献9.
Background
Ideally, high-stakes examinations assess 1 dimension of medical knowledge to produce precise estimates of a candidate’s performance. It has not been reported whether the American Board of Physical Medicine and Rehabilitation Part 1 Certification Examination (ABPMR-CE-1) is unidimensional or not.Objective
To examine the ABPMR-CE-1 to measure how many dimensions it assesses.Design
Retrospective observational study.Setting
We assessed examination results from the 2015 ABPMR-CE-1.Participants
A total of 489 deidentified candidates taking the 2015 ABPMR-CE-1.Methods
A 1-parameter Item Response Theory (IRT) measurement model was utilized. A Principal Components Analysis (PCA) of standardized residual correlations was used to detect multidimensionality.Main Outcome Measure
Number of primary dimensions reflected in the 325 test questions.Results
The results of the dimensionality analysis indicated that the ABPMR-CE-1 examination is highly unidimensional from a psychometric perspective. Expert content review of the substantive content of small contrasting clusters of questions provided additional assurance of the unidimensional nature of the examination.Conclusions
The ABPMR-CE-1 appears indeed to measure a single construct, which suggests a sound structure of the examination. It closely approximates the assumption of statistical unidimensionality.Level of Evidence
Not applicable. 相似文献10.
Heidi Haavik Imran Khan Niazi Kelly Holt Bernadette Murphy 《Journal of manipulative and physiological therapeutics》2017,40(3):127-138
Objective
The purpose of this preliminary study was to assess whether the dual somatosensory evoked potential (SEP) technique is sensitive enough to measure changes in cortical intrinsic inhibitory interactions in patients with chronic neck or upper extremity pain and, if so, whether changes are associated with changes in pain scores.Methods
The dual peripheral nerve stimulation SEP ratio technique was used for 6 subjects with a history of chronic neck or upper limb pain. SEPs were recorded after left or right median and ulnar nerve stimulation at the wrist. SEP ratios were calculated for the N9, N13, P14-18, N20-P25, and P22-N30 peak complexes from SEP amplitudes obtained from simultaneous median and ulnar stimulation divided by the arithmetic sum of SEPs obtained from individual stimulation of the median and ulnar nerves. Outcome measures of SEP ratios and subjects’ visual analog scale rating of pains were recorded at baseline, after a 2-week usual care control period, and after 12 weeks of multimodal chiropractic care (chiropractic spinal manipulation and 1 or more of the following: exercises, peripheral joint adjustments/manipulation, soft tissue therapy, and pain education).Results
A significant decrease in the median and ulnar to median plus ulnar ratio and the median and ulnar amplitude for the cortical P22-N30 SEP component was observed after 12 weeks of chiropractic care, with no changes after the control period. There was a significant decrease in visual analog scale scores (both for current pain and for pain last week).Conclusion
The dual SEP ratio technique appears to be sensitive enough to measure changes in cortical intrinsic inhibitory interactions in patients with chronic neck pain. The observations in 6 subjects revealed that 12 weeks of chiropractic care improved suppression of SEPs evoked by dual upper limb nerve stimulation at the level of the motor cortex, premotor areas, and/or subcortical areas such as basal ganglia and/or thalamus. It is possible that these findings explain one of the mechanisms by which chiropractic care improves function and reduces pain for chronic pain patients. 相似文献11.
Objective
To evaluate the impact of a rivaroxaban discharge initiative on the efficacy and safety of acute venous thromboembolism treatment in emergency department patients.Practice innovation
Patients discharged on rivaroxaban from the emergency department were provided extensive counseling along with a commercially-available medication dose pack by the ED pharmacist. Patients were contacted by phone until they had obtained outpatient follow-up and remained adherent to anticoagulation beyond the initial first month of treatment.Methods
In this retrospective chart review over a thirteen month period, efficacy and safety outcomes were compared between patients with intervention versus those who received usual care. Efficacy was defined by reduced 90-day readmission rates due to nonadherence or treatment failure, and improved medication adherence beyond the first month from discharge. Safety was determined by comparing 90-day readmission rates due to bleeding or adverse event.Results
41 patients received intervention with rivaroxaban, and 34 patients received usual care, with 76% prescribed rivaroxaban and remaining patients started on enoxaparin alone (6%) or enoxaparin plus warfarin (18%). Improved treatment efficacy in the intervention group was not found to be statistically significant. Safety outcomes were similar between the two groups.Conclusion
Home treatment of acute VTE, facilitated by medication dose pack, is a promising tactic to ensure both immediate and long-term treatment efficacy and safety. Further studies are warranted to demonstrate clinical superiority of this intervention. 相似文献12.
Jared Scott Benjamin Howard Philip Sinnett Michael Schiesel Jana Baker Patrick Henderson Matt Vassar 《The American journal of emergency medicine》2017,35(12):1828-1835
Background
The objective of this study was to assess the methodological quality and clarity of reporting of the systematic reviews (SRs) supporting clinical practice guideline (CPG) recommendations in the management of ST-elevation myocardial infarction (STEMI) across international CPGs.Methods
We searched 13 guideline clearinghouses including the National Guideline Clearinghouse and Guidelines International Network (GIN). To meet inclusion criteria CPGs must be pertinent to the management of STEMI, endorsed by a governing body or national organization, and written in English. We retrieved SRs from the reference sections using a combination of keywords and hand searching. Two investigators scored eligible SRs using AMSTAR and PRISMA.Results
We included four CPGs. We extracted 71 unique SRs. These SRs received AMSTAR scores ranging from 1 (low) to 9 (high) on an 11-point scale. All CPGs consistently underperformed in areas including disclosure of funding sources, risk of bias, and publication bias according to AMSTAR. PRISMA checklist completeness ranged from 44% to 96%. The PRISMA scores indicated that SRs did not provide a full search strategy, study protocol and registration, assessment of publication bias or report funding sources. Only one SR was referenced in all four CPGs. All CPGs omitted a large subset of available SRs cited by other guidelines.Conclusions
Our study demonstrates the variable quality of SRs used to establish recommendations within guidelines included in our sample. Although guideline developers have acknowledged this variability, it remains a significant finding that needs to be addressed further.Funding
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. 相似文献13.
Sean P. Wilson Taher Vohra McKenna Knych Jared Goldberg Christopher Price Sean Calo Meredith Mahan Joseph Miller 《The American journal of emergency medicine》2017,35(5):701-703
Introduction
Delay in current nucleic acid amplification testing for Neisseria gonorrhoeae and Chlamydia trachomatis has led to recommendations for presumptive treatment in patients with concern for infection and unreliable follow-up. In the urban setting, it is assumed that many patients have unreliable follow-up, therefore presumptive therapy is thought to be used frequently. We sought to measure the frequency of disease and accuracy of presumptive treatment for these infections.Methods
This was an observational cohort study performed at an urban academic Level 1 trauma center ED with an annual census of 95,000 visits per year. Testing was performed using the APTIMA Unisex swab assay (Gen-Probe Incorporated, San Diego, CA). Presumptive therapy was defined as receiving treatment for both infections during the initial encounter without confirmation of diagnosis.Results
A total of 1162 patients enrolled. Infection was present in 26% of men, 14% of all women and 11% of pregnant women. Despite high frequency of presumptive treatment, > 4% of infected patients in each category went untreated.Conclusion
Inaccuracy of presumptive treatment was common for these sexually transmitted infections. There is an opportunity to improve diagnostic accuracy for treatment. 相似文献14.
Ruth Ann LaMar 《Teaching and Learning in Nursing》2017,12(1):53-58
Objective
Registered nurses must remain current with evidence-based practice knowledge to meet job demands in an evolving health care climate. This pilot study's purpose was to investigate a virtual journal club's effect on satisfaction, knowledge, and practice.Background
On-line learning is used to convey information while meeting diverse learner needs, and journal clubs are used to disseminate and discuss evidence-based practice knowledge. Combining the 2 concepts into a virtual journal club creates an opportunity to meet learner needs while discussing information that promotes evidence-based practice knowledge and implementation.Setting/Population
Sixteen critical care nurses from one midwestern teaching hospital's intensive care unit.Methodology
Researchers used the Kirkpatrick Learning Evaluation Model in a 4-week-long, mixed methods pilot study. Researchers presented 1 article about sepsis in an on-line discussion forum. Nurses took a pretest before participation and a Likert-type satisfaction survey and posttest after participation. Two weeks following journal club participation, researchers sent participants e-mails asking if/how nurses applied knowledge to practice. Researchers analyzed pre?/posttest results using McNemar's Test.Results
Sixteen nurses actively participated. Ten nurses took satisfaction surveys, choosing mostly 4 s (agree) and 5 s (strongly agree), reflecting statistically significant satisfaction. Sixteen nurses took pre- and posttests and demonstrated improvement in knowledge; however, only answers to 2 questions demonstrated statistically significant improvement. Eight nurses responded to the evaluation surveys with comments surrounding increased confidence in caring for septic patients and increased awareness of symptomology, testing, and treatments. Two nurses noted that their practice was not impacted by participation.Practice Implications
Choose relevant articles and make hard copies of the article available for easy access. The virtual journal club discussion forum should promote ease of use and be moderated by someone well positioned to participate frequently and knowledgably. In addition, consider offering continuing education credits to encourage participation. 相似文献15.
Steve Karas Albert Pannone 《Journal of manipulative and physiological therapeutics》2017,40(2):118-125
Objective
The purpose of this scoping review was to identify any available evidence regarding T4 syndrome.Methods
Databases were searched from inception through October 2015 and included PubMed, CINAHL, PEDro, Google Scholar, Osteomed-DR; Index to Chiropractic Literature, PROSPERO, and Chiroaccess. All studies with information about T4 syndrome that were published in a peer-reviewed journal or textbook were included. The information was organized in the format of the International Classification of Functioning, Disability, and Health. Studies were ranked using Sackett’s levels of evidence.Results
Eight articles met the inclusion criteria. Studied areas included theoretical pathophysiology and symptom etiology, diagnosis, symptoms, treatment, and outcomes of T4 syndrome. The methodological quality of included studies was low.Conclusion
T4 syndrome is a diagnosis of exclusion that appears to be rare. It has been treated conservatively in the literature using mobilization and exercise. There is no high-quality evidence published about T4 syndrome, and we caution clinicians when considering it as a primary means to determine patient care. 相似文献16.
Kyu-Sun Choi Youngsuk Cho Bo-Hyoung Jang Wonhee Kim Chiwon Ahn Tae Ho Lim Hyoung-Joong Yi 《The American journal of emergency medicine》2017,35(10):1444-1450
Purpose
Copeptin, the C-terminal portion of provasopressin, has emerged as a novel prognostic marker in neurocritical care, such as in traumatic brain injury (TBI). The aim of this study was to quantitatively assess the prognostic significance of initial plasma copeptin levels in the neurological outcome and mortality after traumatic brain injury.Materials and methods
Six relevant studies with data from 552 patients were included in this meta-analysis.Results
The plasma copeptin levels were found to be significantly higher in patients who died than in the survivors (standardized mean difference [SMD], 1.80). In the four studies reporting Glasgow outcome scale (GOS) data, patients with unfavorable outcomes had significantly higher copeptin levels than those with favorable outcomes (SMD, 1.62). The plasma copeptin level predicted mortality and unfavorable outcomes (AUC, 0.873; AUC, 0.876).Conclusions
The present meta-analysis suggests that early measurement of plasma copeptin levels can provide better prognostic information about the functional outcome and mortality in patients with TBI. 相似文献17.
Rex Pui Kin Lam Wai Lam Yip Chi Keung Wan Matthew Sik Hon Tsui 《The American journal of emergency medicine》2017,35(4):665.e1-665.e4
Background
Chemical restraint is often required to control agitation induced by methamphetamine. Dexmedetomidine is an α-2 adrenergic receptor agonist with sedative, analgesic, and sympatholytic properties. Its use in the emergency department (ED) to control methamphetamine-induced agitation has not been reported.Objective
To report two cases of methamphetamine-induced agitation successfully sedated with dexmedetomidine in the ED.Case Report
The first case was a 42-year-old man with unstable emotion and violent behaviours after smoking methamphetamine. His agitation did not respond to a large cumulative dose of benzodiazepines (10 mg of diazepam and 332 mg of midazolam) administered over 48 h and sedation was achieved with dexmedetomidine. The second case was a 38-year-old methamphetamine user with unstable emotion and recurrent episodes of agitation despite repeated doses of benzodiazepines, whose agitation was controlled with dexmedetomidine infusion.Discussion
In both cases, dexmedetomidine apparently reduced the dose of benzodiazepines needed to achieve adequate sedation. Transient falls in blood pressure and slowing of the heart rate were noted, which resolved either spontaneously or after reducing the infusion rate without requiring drug treatment.Conclusion
Dexmedetomidine can be considered as an adjunct for chemical restraint when standard treatment fails to control the agitation induced by methamphetamine, but patient's hemodynamic state should be monitored closely during administration. Its efficacy and safety in the ED warrant further evaluation with prospective controlled trials. 相似文献18.
Alberto Esquenazi Abraham Alfaro Ziyad Ayyoub David Charles Khashayar Dashtipour Glenn D. Graham John R. McGuire Ib R. Odderson Atul T. Patel David M. Simpson 《PM & R》2017,9(10):960-968
Background
OnabotulinumtoxinA is approved for the treatment of upper and lower limb spasticity in adults. Guidance on common postures and onabotulinumtoxinA injection paradigms for upper limb spasticity has been developed via a Delphi Panel; however, similar guidance for lower limb spasticity has not been established.Objective
To define a clinically recommended treatment paradigm for the use of onabotulinumtoxinA for each common posture among patients with poststroke lower limb spasticity (PSLLS) and to identify the most common PSLLS aggregate postures.Design
Clinical experts provided insight regarding onabotulinumtoxinA treatment for PSLLS using an adaptation of the Delphi consensus process.Setting
Delphi panel.Participants
Ten expert clinicians in neurology and physical medicine and rehabilitation who treat PSLLS.Methods
A minimum of 2 rounds of anonymous voting occurred for each recommendation until consensus was reached (≥66% agreement). The first round was conducted via a survey; the second round was an in-person meeting.Main Outcome Measurements
Reached consensus on muscle selection for injection, overall and per-muscle dose of onabotulinumtoxinA, number of injection sites/muscle, onabotulinumtoxinA dilution, and use of localization techniques. The most common PSLLS postures were reviewed. Recommendations were tailored toward injectors with less experience.Results
Consensus was reached on targeted subsets of muscles for each posture. Doses ranged from 20 to 150 U for individual muscles and 50 to 300 U for limb postures. OnabotulinumtoxinA dilution 50 U/mL (2:1 ratio) was considered most appropriate but varied based on muscles selected (range, 2:1-4:1). Experts agreed that localization techniques for muscle identification during injection for all postures would be useful. For suboptimal response to injection, all panel members would increase the dose, and the majority (89%) would increase the number of treated muscles. The panel identified 3 common aggregating lower limb postures: (1) equinovarus foot and flexed toes; (2) extended knee and plantar flexed foot/ankle; and (3) plantar flexed foot/ankle and flexed toes. The recommended starting doses for each aggregate posture were 400 U, 400 U, and 300 U, respectively.Conclusion
The modified Delphi panel process provided consensus on common muscles and corresponding onabotulinumtoxinA treatment paradigms for postures associated with PSLLS that can be used for guidance in optimizing care delivery.Level of Evidence
V 相似文献19.
Alexander J. Bajorek Chloe Slocum Richard Goldstein Jacqueline Mix Paulette Niewczyk Colleen M. Ryan Carla Tierney Hendricks Ross Zafonte Jeffrey C. Schneider 《PM & R》2017,9(1):1-7
Background
A significant proportion of burn injury patients are admitted to inpatient rehabilitation facilities (IRFs). There is increasing interest in the use of functional variables, such as cognition, in predicting IRF outcomes. Cognitive impairment is an important cause of disability in the burn injury population, yet its relationship to IRF outcomes has not been studied.Objective
To assess how cognitive function affects rehabilitation outcomes in the burn injury population.Design
Retrospective study.Setting
Inpatient rehabilitation facilities in the United States.Participants
A total of 5347 adults admitted to an IRF with burn injury between 2002 and 2011.Methods or Interventions
Multivariable regression was used to model rehabilitation outcome measures, using the cognitive domain of the Functional Independence Measure (FIM) instrument as the independent variable and controlling for demographic, medical, and facility covariates.Main Outcome Measurements
FIM total gain, readmission to an acute care setting at any time during inpatient rehabilitation, readmission to an acute care setting in the first 3 days of IRF admission, rate of discharge to the community setting, and length of stay efficiency.Results
Cognitive FIM total at admission was a significant predictor of FIM total gain, length of stay efficiency, and acute readmission at 3 days (P < .05). Cognitive FIM total scores did not have an impact on acute care readmission rate or discharge to the community setting.Conclusions
Cognitive status may be an important predictor of rehabilitation outcomes in the burn injury population. Future work is needed to further examine the impact of specific cognitive interventions on rehabilitation outcomes in this population.Level of Evidence
II 相似文献20.
Timothy E. Brenkert Cynthia Adams Rebecca L. Vieira Rachel G. Rempell 《The American journal of emergency medicine》2017,35(10):1497-1499