Effectiveness of Physical Therapy Interventions in Reducing Fear of Falling Among Individuals With Neurologic Diseases: A Systematic Review and Meta-analysis

ObjectiveTo summarize the effectiveness of physical therapy interventions to reduce fear of falling (FOF) among individuals living with neurologic diseases.Data SourcesPubMed, Physiotherapy Evidence Database, Scopus, Web of Science, PsycINFO, Cumulative Index to Nursing and Allied Health, and SportDiscuss were searched from inception until December 2019.Study SelectionClinical trials with either the primary or secondary aim to reduce FOF among adults with neurologic diseases were selected.Data ExtractionPotential articles were screened for eligibility, and data were extracted by 2 independent researchers. Risk of bias was assessed by the Cochrane Risk of Bias tool for randomized controlled trials and the National Institutes of Health Quality Assessment Tool for pre-post studies. A meta-analysis was performed among trials presenting with similar clinical characteristics. The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) was used to rate the overall quality of evidence.ResultsSixty-one trials with 3954 participants were included in the review and 53 trials with 3524 participants in the meta-analysis. The included studies presented, in general, with a low to high risk of bias. A combination of gait and balance training was significantly more effective compared with gait training alone in reducing FOF among individuals with Parkinson disease (PD) (mean difference [MD]=11.80; 95% CI, 8.22-15.38; P<.001). Home-based exercise and leisure exercise demonstrated significant improvement in reducing FOF over usual care in multiple sclerosis (MS) (MD=15.27; 95% CI, 6.15-24.38; P=.001). No statistically significant between-groups differences were reported among individuals with stroke and spinal cord injury. The overall quality of evidence presented in this review ranges from very low to moderate according to the assessment with the GRADE approach.ConclusionsGait with lower limb training combined with balance training is effective in reducing FOF in individuals with PD. Also, home-based or leisure exercise is effective among individuals with MS. However, because of several limitations of the included studies, further research is needed to examine the effectiveness of FOF intervention among individuals with neurologic diseases.     

Non-pharmacological interventions for spasticity in adults: An overview of systematic reviews

ObjectivesSpasticity causes significant long-term disability-burden, requiring comprehensive management. This review evaluates evidence from published systematic reviews of clinical trials for effectiveness of non-pharmacological interventions for improved spasticity outcomes.MethodsData sources: a literature search was conducted using medical and health science electronic (MEDLINE, EMBASE, CINAHL, PubMed, and the Cochrane Library) databases for published systematic reviews up to 15th June 2017. Data extraction and synthesis: two reviewers applied inclusion criteria to select potential systematic reviews, independently extracted data for methodological quality using Assessment of Multiple Systematic Reviews (AMSTAR). Quality of evidence was critically appraised with Grades of Recommendation, Assessment, Development and Evaluation (GRADE).ResultsOverall 18 systematic reviews were evaluated for evidence for a range of non-pharmacological interventions currently used in managing spasticity in various neurological conditions. There is “moderate” evidence for electro-neuromuscular stimulation and acupuncture as an adjunct therapy to conventional routine care (pharmacological and rehabilitation) in persons following stroke. “Low” quality evidence for rehabilitation programs targeting spasticity (such as induced movement therapy, stretching, dynamic elbow-splinting, occupational therapy) in stroke and other neurological conditions; extracorporeal shock-wave therapy in brain injury; transcranial direct current stimulation in stroke; transcranial magnetic stimulation and transcutaneous electrical nerve stimulation for other neurological conditions; physical activity programs and repetitive magnetic stimulation in persons with MS, vibration therapy for SCI and stretching for other neurological condition. For other interventions, evidence was inconclusive.ConclusionsDespite the available range of non-pharmacological interventions for spasticity, there is lack of high-quality evidence for many modalities. Further research is needed to judge the effect with appropriate study designs, timing and intensity of modalities, and associate costs of these interventions.     

Levels of Physical Activity and Sedentary Behavior During and After Hospitalization: A Systematic Review

ObjectivesTo systematically review and synthesize the evidence on physical activity and sedentary behavior during and after hospitalization.Data SourcesElectronic databases and reference lists of relevant articles were searched from 2000 to April 2020.Study SelectionStudies which continuously monitored physical activity and/or sedentary behavior in hospitalized adults across 2 settings (ie, without a break in measurement between settings). Monitoring could occur from an acute to a subacute or rehabilitation hospital setting, an acute setting to home, or from a subacute or rehabilitation setting to home.Date ExtractionData extraction and methodological quality assessments were independently performed by 2 reviewers using standardized checklists.Data SynthesisA total of 15 of the 5579 studies identified were included. The studies were composed of heterogenous patient populations. All studies monitored patients with either an accelerometer and/or pedometer and reported a variety of measures, including steps per day, sedentary time, and activity counts. The majority of studies (12 of 15) showed that patients engaged in 1.3 to 5.9 times more physical activity and up to 67% less daily sedentary behavior at home after discharge from acute or subacute settings.ConclusionsPatients engaged in more physical activity and less sedentary behavior at home compared to both the acute and subacute hospital settings. This may reflect the natural course of recovery or the effect of setting on activity levels. Enabling early discharge home through the implementation of home-hospitalization models may result in increased patient physical activity and reduced sedentary behavior. Further experimental studies are required investigating the effect of home-based models of care on physical activity and sedentary behavior.     

Is Fatigue Associated With Aerobic Capacity and Muscle Strength in People With Multiple Sclerosis: A Systematic Review and Meta-analysis

ObjectiveTo determine the relationship between self-reported fatigue and aerobic capacity and muscle strength in people with multiple sclerosis (MS).Data SourcesFour databases (Cumulative Index to Nursing and Allied Health, MEDLINE, ProQuest, and Web of Science Core Collections) were searched up to October 2018.Study SelectionCross-sectional or longitudinal studies that reported the association between self-reported fatigue and aerobic capacity or objectively measured muscle strength in people with MS were included.Data ExtractionStudy details, participant demographics, outcome measurement protocols, and the correlation coefficient derived from the association between fatigue and aerobic capacity or muscle strength at baseline was extracted, and methodological quality of included studies was assessed using the Joanna Briggs Institute Appraisal Checklist for Analytical Cross-sectional Studies.Data SynthesisTen studies were identified, of which 5 examined the association between fatigue and aerobic capacity and 7 examined the association between fatigue and muscle strength. Meta-analysis of the extracted correlation coefficients was performed using the Hedges-Olkin method, and pooled correlation coefficients demonstrated a moderate negative association between fatigue and aerobic capacity (r=−0.471; 95% CI, −0.644 to −0.251; P<.001) and a weak negative association between fatigue and muscle strength (r=−0.224; 95% CI, −0.399 to −0.032; P=.022).ConclusionsThe results of this meta-analysis suggest that higher levels of aerobic capacity are associated with lower fatigue. Therefore, this finding highlights the potential role of aerobic exercise interventions in managing fatigue. Conversely, the relationship between fatigue and muscle strength was weak and inconsistent, and further studies are required to examine the association between these variables.     

Influence of Multiple Sclerosis on Spatiotemporal Gait Parameters: A Systematic Review and Meta-Regression

ObjectiveTo quantify the effect of multiple sclerosis (MS) on spatiotemporal gait characteristics accounting for disability severity and fall classification.Data SourcesMEDLINE (1946-August 2018), Allied and Complementary Medicine Database (1985-2018 August), and PsycINFO (1806-August 2018) were searched for terms on MS and gait.Study SelectionDual independent screening was conducted to identify observational, cross-sectional studies that compared adults with MS grouped according to Expanded Disability Status Scale (EDSS) level or fall history, reported on spatiotemporal gait characteristics, and were published in English. The search retrieved 5891 results, of which 12 studies satisfied the inclusion criteria.Data ExtractionTwo authors worked independently to extract and verify data on publication details, study methodology, participant characteristics, gait outcomes, conclusions, and limitations. Risk of bias was assessed using the QualSyst critical appraisal tool. A random-effects meta-regression and meta-analysis were conducted on pooled data.Data SynthesisAll studies received quality ratings of very good to excellent and collectively examined 1513 individuals with MS. With every 1-point increase in EDSS, significant changes (P<.05) were observed in gait speed (−0.12 m/s; 95% confidence interval (CI), 0.08-0.15), step length (−0.04 m; 95% CI, 0.03-0.05), step time (+0.04 seconds; 95% CI, 0.02-0.06), step time variability (+0.009 seconds; 95% CI, 0.003-0.016), stride time (+0.08 seconds; 95% CI, 0.03-0.12), cadence (−4.4 steps per minute; 95% CI, 2.3-6.4), stance phase duration (+0.8% gait cycle; 95% CI, 0.1-1.5), and double support time (+3.5% gait cycle; 95% CI, 1.5-5.4). Recent fallers exhibited an 18% (95% CI, 13%-23%) reduction in gait speed compared with nonfallers (P<.001).ConclusionsThis review provides the most accurate reference values to-date that can be used to assess the effectiveness of MS gait training programs and therapeutic techniques for individuals who differ on disability severity and fall classification. Some gait adaptations could be part of adopting a more cautious gait strategy and should be factored into the design of future interventions.     

An Electronic Health Record–Compatible Model to Predict Personalized Treatment Effects From the Diabetes Prevention Program: A Cross-Evidence Synthesis Approach Using Clinical Trial and Real-World Data

ObjectiveTo develop an electronic health record (EHR)-based risk tool that provides point-of-care estimates of diabetes risk to support targeting interventions to patients most likely to benefit.Patients and MethodsA risk prediction model was developed and validated in a large observational database of patients with an index visit date between January 1, 2012, and December 31, 2016, with treatment effect estimates from risk-based reanalysis of clinical trial data. The risk model development cohort included 1.1 million patients with prediabetes from the OptumLabs Data Warehouse (OLDW); the validation cohort included a distinct sample of 1.1 million patients in OLDW. The randomly assigned clinical trial cohort included 3081 people from the Diabetes Prevention Program (DPP) study.ResultsEleven variables reliably obtainable from the EHR were used to predict diabetes risk. This model validated well in the OLDW (C statistic = 0.76; observed 3-year diabetes rate was 1.8% (95% confidence interval [CI], 1.7 to 1.9) in the lowest-risk quarter and 19.6% (19.4 to 19.8) in the highest-risk quarter). In the DPP, the hazard ratio (HR) for lifestyle modification was constant across all levels of risk (HR, 0.43; 95% CI, 0.35 to 0.53), whereas the HR for metformin was highly risk dependent (HR, 1.1; 95% CI, 0.61 to 2.0 in the lowest-risk quarter vs HR, 0.45; 95% CI, 0.35 to 0.59 in the highest-risk quarter). Fifty-three percent of the benefits of population-wide dissemination of the DPP lifestyle modification and 73% of the benefits of population-wide metformin therapy can be obtained by targeting the highest-risk quarter of patients.ConclusionThe Tufts–Predictive Analytics and Comparative Effectiveness DPP Risk model is an EHR-compatible tool that might support targeted diabetes prevention to more efficiently realize the benefits of the DPP interventions.     

Focus on Risk Factors for Cardiometabolic Disease in Cerebral Palsy: Toward a Core Set of Outcome Measurement Instruments

ObjectiveTo identify existing outcome measurement instruments (OMIs) assessing risk factors for cardiometabolic disease in adolescents and adults with cerebral palsy (CP) reported on in the literature or used in the field.Data SourcesThe COnsensus-based Standards for the selection of health Measurement Instruments database of systematic reviews and 4 electronic databases (Embase, MEDLINE/Ovid, MEDLINE/Pubmed, PsychINFO) were searched up to June 19, 2017, that yielded 2594 articles. Experts in the field were consulted to identify any additional OMIs.Study SelectionTwo reviewers independently applied inclusion criteria to select eligible studies using or evaluating measurement properties of OMIs assessing 1 of 8 outcomes: cardiorespiratory endurance, body size, body composition, physical behavior, sleep, nutrition, blood pressure, and blood lipids and glucose. Studies with an experimental or observational design including ≥10 adolescents or adults with CP were included.Data ExtractionOne reviewer extracted data that were summarized for study and sample characteristics, outcomes, OMIs used, and if applicable data on measurement properties. Two reviewers rated the methodological quality and the quality of the OMIs. Feasibility for clinical practice and research was rated by experts in the field.Data SynthesisNinety OMIs were identified from 56 included articles and by the experts. Seventy OMIs pertained to cardiorespiratory endurance, body size, body composition, and physical behavior, whereas only 5 were identified for sleep and nutrition. Overall synthesis revealed that there is moderate to poor evidence for good quality of OMIs in this population. Based on feasibility for clinical practice, experts agreed on a single OMI per outcome (and 2 for cardiorespiratory endurance) to be included in a core set.ConclusionDespite the range of available OMIs to assess risk factors for cardiometabolic disease in adolescents and adults with CP, evidence of good quality is often lacking. Nonetheless, a preliminary core set of 9 OMIs was systematically developed.     

Randomized Controlled Trial of a Telephone-Delivered Physical Activity and Fatigue Self-management Interventions in Adults With Multiple Sclerosis

ObjectiveTo compare the effectiveness of telephone-delivered interventions on fatigue, physical activity, and quality of life outcomes in adults with multiple sclerosis (MS).DesignA single-blinded, randomized controlled trial. Participants were randomized to contact-control intervention (CC), physical activity–only intervention (PA-only), and physical activity plus fatigue self-management intervention (FM+). Outcomes were measured at baseline (2wk prerandomization), posttest (14wk postrandomization), and follow-up (26wk postrandomization).SettingTelephone-delivered in Midwest and Northeast regions of the United States.ParticipantsInactive adults with MS (N=208) and moderate-to-severe fatigue.InterventionsThree or 6 group teleconferences followed by 4 individually tailored phone calls delivered during 12 weeks. An occupational therapist and research assistant delivered the teleconferences and tailored phone calls, respectively.Main Outcome MeasuresPrimary outcomes were self-report fatigue and physical activity measured with the Fatigue Impact Scale and Godin Leisure-Time Exercise Questionnaire, respectively. Secondary outcomes included quality of life measured with the Multiple Sclerosis Impact Scale and moderate-to-vigorous exercise and step count measured with an accelerometer.ResultsLinear mixed effects models showed FM+ significantly improved self-reported fatigue (β=−11.08; P=.03) and physical activity (β=0.54; P=.01) compared with CC at posttest. However, FM+ had nonsignificant differences compared with PA-only on self-report fatigue (β=−1.08, P=.84) and physical activity (β=0.09; P=.68) at posttest. PA–only had significant improvements compared with CC on moderate-to-vigorous exercise (β=0.38; P=.02) at posttest and step count at posttest (β=1.30; P<.01) and follow-up (β=1.31; P=.01) measured with an accelerometer. FM+ and PA-only had nonsignificant differences compared with CC on quality of life.ConclusionsGroup teleconferences followed by tailored phone calls have a small yet statistically significant effect in promoting physical activity and reducing fatigue impact in people with MS.     

Benchmarks of Significant Change After Aphasia Rehabilitation

ObjectiveTo establish benchmarks of significant change for aphasia rehabilitation outcome measures (ie, Western Aphasia Battery-Aphasia Quotient [WAB-AQ], Communicative Effectiveness Index [CETI], Boston Naming Test [BNT]) and assess if those benchmarks significantly differ across subgroups (ie, time post onset, dose frequency, treatment type).Data SourcesA comprehensive literature search of 12 databases, reference lists of previous reviews, and evidence-based practice materials was conducted.Study SelectionRandomized controlled trials, quasi-experimental studies, single-subject design, and case studies that used a standardized outcome measure to assess change were included. Titles and full-text articles were screened using a dual review process. Seventy-eight studies met criteria for inclusion.Data ExtractionData were extracted independently, and 25% of extractions were checked for reliability. All included studies were assigned quality indicator ratings and an evidence level.Data SynthesisRandom-effects meta-analyses were conducted separately for each study design group (ie, within-/between-group comparisons). For within-group designs, the summary effect size after aphasia rehabilitation was 5.03 points (95% confidence interval, 3.95-6.10, P<.001) on the WAB-AQ, 10.37 points (6.08-14.66, P<.001) on the CETI, and 3.30 points (2.43-4.18, P<.001) on the BNT. For between-group designs, the summary effect size was 5.05 points (1.64-8.46, P=.004) on the WAB-AQ and 0.55 points (-1.33 to 2.43, P=.564) on the BNT, the latter of which was not significant. Subgroup analyses for the within-group designs showed no significant differences in the summary effect size as a function of dose frequency or treatment type.ConclusionsThis study established benchmarks of significant change on 3 standardized outcome measures used in aphasia rehabilitation.     

Clinical Determinants of Fitness to Drive in Persons With Multiple Sclerosis: Systematic Review

ObjectiveTo critically appraise the evidence for the clinical determinants of fitness to drive in adults with multiple sclerosis (MS).Data SourcesThe research librarian and lead author searched 7 databases for driving simulator and on-road studies for adults with MS published in the English language from 1991 to 2018.Study SelectionThree reviewers independently screened titles, abstracts, and full-texts for studies with: cohort, case-control, or cross-sectional designs; participants, 18 years or older, with relapsing or progressive MS; visual, cognitive, or motor clinical assessments as predictors; and driving performance through simulator or fitness to drive through on-road assessment as outcomes.Data ExtractionUsing the 2017 American Academy of Neurology guidelines, reviewers independently classified each study from class I to class IV, or highest to lowest amount of rigor. For each clinical assessment, reviewers independently rated the level of confidence for predicting driving performance or fitness to drive from level A, highly probable; B, probable; C, possible; to level U, insufficient conclusions.Data SynthesisThrough qualitative synthesis, 2 class III and 4 class IV driving simulator studies employed 24 clinical assessments with level C (n=4) or level U (n=20) confidence for predicting driving performance. Six class II and 3 class IV on-road studies employed 35 clinical assessments with level B (n=9), level C (n=22), or level U (n=4) confidence for predicting fitness to drive.ConclusionsThis systematic review identified mostly insufficient conclusions for predicting driving performance in driving simulator studies, and possible conclusions for predicting fitness to drive in on-road studies. The best available evidence suggests that the Stroke Driver Screening Assessment and Useful Field of View test probably predict fitness to drive in adults with MS (level B). Class I studies that compare predictors of fitness to drive with large prospective samples of adults with and without MS are necessary for highly probable conclusions.     

Replacing Sedentary Behavior Time With Physical Activities,Recommended Physical Activity,and Incident Coronary Heart Disease

ObjectiveTo prospectively analyze the associations with coronary heart disease (CHD) risk of reallocating time from sedentary behavior to various physical activities using the isotemporal substitution model, particularly according to whether the participants meet the recommended physical activity level.MethodsWe included 455,298 UK Biobank participants free of CHD at baseline (March 13, 2006, to October 10, 2010). Sedentary behavior time was quantified by summing up the time spent on television watching, computer (not at work), and driving. Physical activities were categorized as daily-life activities (walking for pleasure, light do-it-yourself, and heavy do-it-yourself) and structured exercise (strenuous sports and other exercise).ResultsDuring a median follow-up of 11 years, 20,162 incident CHD cases were documented. Sedentary behavior time was significantly associated with a higher risk of CHD, independent of physical activity. Replacing 30 min/d of sedentary behavior with an equal time of various physical activities was associated with a 3% to 12% risk reduction of CHD. Replacing 1 h/d of sedentary behavior with different types of physical activities was associated with a 6% to 23% risk reduction of CHD. Sedentary behavior to strenuous sports reallocations showed the largest benefit. Reallocations of sedentary behavior to various physical activities showed particularly greater benefits among those who did not meet the physical activity recommendations.ConclusionsReplacing sedentary behavior time with various daily-life activities or structured exercise is associated with significant reductions in CHD risk.     

Dosage and Effectiveness of Aerobic Training on Cardiorespiratory Fitness,Functional Capacity,Balance, and Fatigue in People With Multiple Sclerosis: A Systematic Review and Meta-Analysis

ObjectivesTo evaluate the benefits of aerobic training (AT) programs on cardiorespiratory fitness, functional capacity, balance, and fatigue in individuals with multiple sclerosis (MS) and to identify the optimal dosage of AT programs for individuals with MS via a systematic review with meta-analysis.Data sourcesTwo electronic databases were searched until March 2020 (PubMed-Medline and Web of Science).Study SelectionStudies examining the effect of AT program on cardiorespiratory fitness, functional capacity, balance, and fatigue were included.Data ExtractionAfter applying the inclusion and exclusion criteria, we included 43 studies. A total sample of 1070 individuals with MS (AT group, n=680; control group, n=390) were analyzed.Data SynthesisThe AT group demonstrated a significant increase in cardiorespiratory fitness (standardized mean difference [SMD], 0.29; P=.002), functional capacity (timed Up and Go Test: SMD, –1.14; P<.001; gait speed: SMD, –1.19; P<.001; walking endurance: SMD, 0.46; P<.001), and balance (SMD, 3.49; P<.001) after training. Fatigue perception also decreased (SMD, –0.45; P<.001). However, no significant differences were observed when compared with the control group in either cardiorespiratory fitness (SMD, 0.14; P=.19) or fatigue perception. Nevertheless, we observed significant differences between the AT and control groups in balance (P=.02), gait speed (P=.02), and walking endurance (P=.03), favoring the participants who performed AT. Regarding the subgroup analysis, no significant differences were observed between subgroups in any of the variables studied except for gait speed, for which a greater increase in posttraining was observed when the AT program applied the continuous method (χ²=7.75; P=.005) and the exercises were performed by walking (χ²=9.36; P=.002).ConclusionsAerobic training improves gait speed, walking endurance, and balance. Cardiorespiratory fitness and fatigue perception also improved after AT, but we found no differences with the control group. In addition, subgroup analysis suggested that training using continuous and walking methods could optimize gait speed.     

Ballistic Resistance Training: Feasibility,Safety, and Effectiveness for Improving Mobility in Adults With Neurologic Conditions: A Systematic Review

ObjectivesTo determine whether ballistic resistance training is feasible, safe, and effective in improving muscle strength, power generation, and mobility in adults with neurologic conditions.Data SourcesNine electronic databases were searched from inception to March 2019 in addition to the reference lists of included articles.Study SelectionArticles were independently screened by 2 authors and were included if they were full-text; English-language articles published in a peer-reviewed journal; investigated ballistic resistance training for adults with a neurologic condition; and reported on feasibility, safety, strength, power, or mobility.Data ExtractionTwo authors independently extracted data. Study quality was assessed using the McMaster critical review form and the Physiotherapy Evidence Database scale.Data SynthesisThe search identified 1540 articles, with 13 articles describing 9 studies meeting the criteria for inclusion. Five studies were randomized controlled trials and 4 were cohort studies. Ballistic resistance training was feasible and safe with only 1 intervention-related adverse event reported. Findings indicated improvements in strength for hip abduction, leg press, knee flexion, and ankle dorsiflexion, but not for hip flexion, hip extension, knee extension, or ankle plantarflexion. Muscle power generation improved for hip flexion, hip abduction, leg press, knee extension, and knee flexion, but not for ankle plantarflexion. Treatment effect was positive for self-selected walking speed, with a standardized mean difference (SMD) of 0.69 (95% confidence interval [CI], 0.01-1.38) from 3 studies. However, fastest comfortable walking speed results were inconclusive with a SMD from 4 studies of 0.45 (95% CI, –0.01 to 0.91).ConclusionsBallistic training is safe and feasible for people with a neurologic condition. The effects on muscle strength, power generation, and mobility were found to be positive but not conclusive.     

Systematic Review of Clinical Guidelines Related to Care of Individuals With Cerebral Palsy as Part of the World Health Organization Efforts to Develop a Global Package of Interventions for Rehabilitation

ObjectiveThe World Health Organization’s (WHO) Rehabilitation 2030 initiative is working to develop a set of evidence-based interventions selected from clinical practice guidelines for Universal Health Coverage. As an initial step, the WHO Rehabilitation Programme and Cochrane Rehabilitation convened global content experts to conduct systematic reviews of clinical practice guidelines for 20 chronic health conditions, including cerebral palsy.Data SourcesSix scientific databases (Pubmed, EMBASE, Scopus, Web of Science, PEDro, CINAHL), Google Scholar, guideline databases, and professional society websites were searched.Study SelectionA search strategy was implemented to identify clinical practice guidelines for cerebral palsy across the lifespan published within 10 years in English. Standardized spreadsheets were provided for process documentation, data entry, and tabulation of the Appraisal of Guidelines for Research and Evaluation (AGREE II) tool. Each step was completed by 2 or more group members, with disagreements resolved by discussion. Initially, 13 guidelines were identified. Five did not meet the AGREE II established threshold or criteria for inclusion. Further review by the WHO eliminated 3 more, resulting in 5 remaining guidelines.Data ExtractionAll 339 recommendations from the 5 final guidelines, with type (assessment, intervention, or service), strength, and quality of evidence, were extracted, and an International Classification of Functioning, Disability and Health Functioning (ICF) category was assigned to each.Data SynthesisMost guidelines addressed mobility functions, with comorbid conditions and lifespan considerations also included. However, most were at the level of body functions. No guideline focused specifically on physical or occupational therapies to improve activity and participation, despite their prevalence in rehabilitation.ConclusionsDespite the great need for high quality guidelines, this review demonstrated the limited number and range of interventions and lack of explicit use of the ICF during development of guidelines identified here. A lack of guidelines, however, does not necessarily indicate a lack of evidence. Further evidence review and development based on identified gaps and stakeholder priorities are needed.     

Continuous Passive Motion After Total Knee Arthroplasty: A Systematic Review and Meta-analysis of Associated Effects on Clinical Outcomes

ObjectiveTo evaluate the efficacy of continuous passive motion (CPM) after total knee arthroplasty (TKA) and whether the use of CPM is related to improved clinical and functional outcomes.Data SourcesA systematic MEDLINE search via Web of Science, Cochrane Library, and PubMed databases was conducted.Study SelectionEnglish-language articles published between January 2000 and May 2018 reporting the related clinical outcomes of CPM after TKA were included. A total of 3334 titles and abstracts were preliminarily reviewed, of which 16 studies were included according to the eligibility criteria.Data ExtractionTwo different reviewers were selected to perform the study extraction, independent of each other. If there were any disagreements regarding the final list of studies, the third reviewer reviewed the list as an arbitrator for completeness.Data SynthesisA total of 16 trials with 1224 patients were included. The pooled results revealed that use of CPM did not show a statistically significant improvement of postoperative knee range of motion (ROM) except for middle-term passive knee extension and long-term active knee flexion ROM. Also, CPM therapy did not show a significant positive effect on the functional outcomes. No significant reduction in length of stay (LOS) and incidence of adverse events (AEs) was identified.ConclusionAmong patients undergoing TKA, neither the ROM nor the functional outcomes could be improved by CPM therapy. Moreover, the risk of AEs and LOS could not be reduced by application of CPM. The current available evidence suggested that this intervention was insufficient to be used routinely in clinical practice.     

Effects of Robotic Exoskeleton-Aided Gait Training in the Strength,Body Balance,and Walking Speed in Individuals With Multiple Sclerosis: A Single-Group Preliminary Study

ObjectiveTo assess effects of 15 exoskeleton-assisted gait training sessions, reflected by the muscle strength of the lower limbs and by walking speed immediately after the training sessions and at the 6-week follow-up.DesignSingle-group longitudinal preliminary study.SettingIndividuals with multiple sclerosis (MS) at a hospital neurology ward.ParticipantsParticipants (N=14) included women and men aged from 36-61 years, with Expanded Disability Status Scale scores from 5.0-6.5.InterventionsExoskeleton-assisted walk training.Main Outcome MeasuresPrimary outcomes included dynamometric knee extensor and flexor strength (Biodex Pro4), postural balance, and center of pressure displacements (Zebris FMD-S). Secondary outcomes included walking speed measured with the timed 25-foot walk test and fatigue (Fatigue Severity Scale). Assessments were performed 4 times, that is, prior to the start of the program (T0), at the end of the physiotherapy without an exoskeleton (T1), at the end of the exoskeleton-assisted training (T2), and at 6-week follow-up (T3).ResultsAt the end of exoskeleton-assisted gait training there was a statistically significant improvement in peak torque of knee extensor muscles compared with the period of exercise without an exoskeleton. No statistically significant change was identified in the value of peak torque of knee flexors at T1. Likewise, the assessment at T2 showed the change in peak torque of knee flexors was not significant. The participants presented significantly faster walking speed after exoskeleton-assisted gait training compared with T0 and T1. No improvement was found in body balance. The subjects reported lower fatigue after exoskeleton-assisted gait training; however, the differences between the assessments at T1 and T0 as well as at T2 and T1 were statistically insignificant.ConclusionsIndividuals with MS and severe gait impairment participating in exoskeleton-assisted gait training achieved significant improvement in lower-limb muscle strength and increase in walking speed, yet the effect was not long-lasting.     

Noninvasive Brain Stimulation for Rehabilitation of Pediatric Motor Disorders Following Brain Injury: Systematic Review of Randomized Controlled Trials

ObjectiveTo assess the evidence of the effectiveness of noninvasive brain stimulation (NIBS) for rehabilitation of pediatric motor disorders after brain injury.Data SourcesOvid, Cochrane, Science Direct, Web of Science, EBSCOhost, PubMed, and Google Scholar databases were searched up to August 2017 by 2 independent reviewers.Study SelectionRandomized controlled trials (RCTs) published in English were included if they met the following criteria. Population: Pediatric patients with motor disorders following brain injury. Intervention: NIBS, including transcranial direct current stimulation (tDCS) or repetitive transcranial magnetic stimulation (rTMS). Outcomes: Measures related to motor disorders (upper limb functional abilities, gait, balance, and spasticity). Fourteen RCTs were included (10 studies used tDCS, while 4 studies used rTMS).Data ExtractionPredefined data were tabulated by 1 reviewer and verified by another reviewer. Methodological quality was assessed using the Physiotherapy Evidence Database (PEDro) scale; also levels of evidence adapted from Sackett were used.Data SynthesisA grouped meta-analysis was performed on balance, gait parameters, and upper limb function. Data were pooled using a random-effects model to assess the immediate effect and 1-month follow-up of NIBS. According to the PEDro scale, 3 studies were excellent, 8 studies were good, and 3 studies were fair. The level of evidence of all of the included studies was 1b, except for 3 studies with grade 2a. There were significant improvements in all upper limb functions (standardized mean differences [SMDs] ranging from 0.94 to 1.83 [P values=.0001]), balance (SMDs ranging between -0.48 to 0.83 [P values<.05]) and some gait variables.ConclusionPediatric patients with brain injury can be safely stimulated by NIBS, and there is evidence for the efficacy of rTMS in improving upper limb function, and tDCS in improving balance and majority of gait variables with persisted effects for 1 month. The efficacy of spasticity is uncertain.