REHABILITATION SETTINGS DURING AND AFTER COVID-19: AN OVERVIEW OF RECOMMENDATIONS

ObjectiveThe aim of this review is to identify the best evidence to define rehabilitative approaches to acute and post-acute phases of coronavirus 2019 (COVID-19) disease.MethodsA literature search (of PubMed, Google Scholar, PEDro and Cochrane databases) was performed for relevant publications from January to April 2020.ResultsA total of 2,835 articles were retrieved, and the search resulted in a final total 31 published articles. A narrative synthesis of the selected articles was then performed. Some studies examine the effect of the pandemic on rehabilitation services and provide suggestions for a new reorganization of these services. Other studies focus on COVID-19 sequelae, formulating recommendations for rehabilitative interventions.ConclusionFor COVID-19 patients, an integrated rehabilitative process is recommended, involving a multidisciplinary and multi-professional team providing neuromuscular, cardiac, respiratory, and swallowing interventions, and psychological support, in order to improve patients’ quality of life. The intervention of a physician expert in rehabilitation should assess the patient, and a dedicated intervention set up after thorough assessment of the patient’s clinical condition, in collaboration with all rehabilitation team professionals.LAY ABSTRACTRehabilitation, in a multidisciplinary and multi-professional setting, plays a pivotal role in the management of Covid-19 patients, focusing on respiratory and motor functions and it is therefore crucial to establish treatment strategies to guarantee an optimal recovery of these patients. We performed a review of the scientific literature. All the studies concerning respiratory rehabilitation treatments for Covid-19 patients were included. Respiratory rehabilitation has the goal of improve respiratory symptoms, preserve function and reduce complications and disability; it also has positive effects on the psychological sphere, reducing anxiety and depression that can frequently develop in this context.Key words: rehabilitation, COVID-19, recommendation

In late December 2019, coronavirus 2019 (COVID-19) emerged in Wuhan, the capital city of Hubei province, China, and spread rapidly throughout the world, causing a large global outbreak and becoming a major health concern (1). In March 2020, the World Health Organization (WHO) declared COVID-19 a global pandemic and public health emergency (2).The causative agent is the newly identified severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), initially named 2019 novel coronavirus (2019-nCoV) (3). It is a non-segmented, enveloped, positive-sense single-strand RNA β-coronavirus (4), which may have been transmitted to humans from a potential reservoir in bats, through as-yet unknown intermediate hosts (5). Human-to-human transmission of COVID-19 occurs mainly through the respiratory tract, by inhalation of infected droplets (from symptomatic, but also asymptomatic people) and through direct contact (6, 7). The estimated incubation period is 1–14 days, mainly in the range 3–7 days (8).COVID-19 infection displays a prevalence of respiratory involvement, being responsible for interstitial pneumonia, the major manifestation of the disease, which first led to identification of the pathogen (3, 9). It causes various degrees of illness, with a clinical picture ranging from asymptomatic cases to acute respiratory distress syndrome (ARDS) and multi-organ failure (10).Symptoms include fever and dry cough (dominant manifestations), anosmia, sore throat, upper airway congestion, fatigue, headache, muscle ache, shortness of breath, and other signs of upper respiratory tract infection. Progression to pneumonia (mainly occurring in the second or third week of a symptomatic infection) (10, 11) is associated with a reduction in oxygen saturation, reduction in arterial blood gas exchange, extreme increase in inflammatory markers, and lymphopaenia (10). The clinical picture also correlates with bilateral ground glass opacities and patchy consolidations, seen on chest computed tomography (CT) (12, 13).Diagnosis of COVID-19 infection can be made only through nucleic acid detection by real-time polymerase chain reaction (RT-PCR) in respiratory tract samples.Since there is currently no approved treatment for COVID-19, management of the disease is based on symptomatic and supportive treatments, mainly targeted at preserving hydration and nutrition and controlling fever and respiratory symptoms. Oxygen or non-invasive ventilation are necessary for hypoxic patients. In most severe cases mechanical ventilation is required, and even extra-corporeal membrane oxygen (ECMO), which is recommended by the WHO for patients with refractory hypoxaemia (14). Elderly people and patients with underlying comorbidities are more susceptible to developing complications, including ARDS, acute kidney injury, arrhythmias, cardiac injury, and liver dysfunction (15, 16).Patients may undergo prolonged bed rest, leading to immobilization syndrome (17) associated with respiratory dysfunction, both of which might require rehabilitation interventions. Prolonged immobilization leads to muscle weakness, motor deconditioning, balance and postural impairment, and joint stiffness, pain and limitation, which have a strong impact on patients’ general condition (17, 18).Post-intensive care syndrome (PICS) refers to a new or worsening impairment of patient’s physical, cognitive, or mental health status arising during stay in the intensive care unit (ICU) and persisting beyond ICU discharge or hospital discharge. These patients undergo various degrees of respiratory, physical and psychological distress (19, 20). It is essential that any rehabilitative intervention is customized to the specific condition of each patient, and that this should take into account, as already observed in SARS-CoV and MERS-CoV, that SARS-CoV-2 may also have a neurotropic effect, leading to neurological involvement, which may be partially responsible for acute respiratory failure in COVID-19 patients (21).Indeed, it has recently been observed that SARSCoV-2 is involved in neurological manifestations (22) in COVID-19 patients, including in the central nervous system (CNS) (e.g. dizziness, headache, impaired consciousness, acute cerebrovascular disease, ataxia, and seizure), peripheral nervous system (PNS) (e.g. impairments of taste, smell and vision, and nerve pain), and skeletal muscle injury (23). Cases of viral encephalitis and infectious toxic encephalopathy have been reported (24). Patients who had cerebrovascular disease were older, developed severe COVID-19 and underlying disorders, an increased inflammatory response, and a hypercoagulable state (25, 26). Neurological manifestations, apart from cerebrovascular disease and impairment of consciousness, have been reported early in the illness prior to the onset of COVID-19-related symptoms (23). Hence it is important to evaluate patients who present with neurological symptoms, to assess risk factors (25) and underlying disorders that indicate an early diagnosis of COVID-19 (23), enabling the recognition and management of complications and improving the prognosis (24).The ongoing COVID-19 pandemic is placing great stress on healthcare systems, especially acute care departments, and is already having an impact on the rehabilitation community (17, 18, 27). In a multidisciplinary and multi-professional setting, rehabilitation plays a pivotal role in the management of patients with COVID-19, focusing on respiratory and motor functions. It is therefore crucial to establish rehabilitation treatment strategies that enable optimal recovery of these patients.The aim of this study was to review the literature on COVID-19, in order to identify best evidence to define rehabilitative approaches to acute and post-acute phases of the disease.     

ADAPTATIONS TO REHABILITATION SERVICES DURING THE COVID-19 PANDEMIC PROPOSED BY SCIENTIFIC AND PROFESSIONAL REHABILITATION ORGANIZATIONS

ObjectiveTo describe adaptations in the provision of rehabilitation services proposed by scientific and professional rehabilitation organizations to avoid interruptions to patients’ rehabilitation process and delays in starting rehabilitation in patients with COVID-19.MethodsA narrative review approach was used to identify the recommendations of scientific and professional organizations in the area of rehabilitation. A systematic search was performed in the main data bases in 78 international and regional web portals of rehabilitation organizations. A total of 21 publications from these organizations were identified and selected.ResultsThe results are presented in 4 categories: adequacy of inpatient services, including acute care services and intensive care unit for patients with and without COVID-19; adequacy of outpatient services, including home-based rehabilitation and tele- rehabilitation; recommendations to prevent the spread of COVID-19; and regulatory standards and positions during the COVID-19 pandemic expressed by organizations for protecting the rights of health workers and patients.ConclusionHealth systems around the world are rapidly learning from actions aimed at the reorganization of rehabilitation services for patients who are in the process of recovery from acute or chronic conditions, and the rapid response to the rehabilitation of survivors of COVID-19, as well as from efforts in the prevention of contagion of those providing the services.LAY ABSTRACTIn response to the coronavirus disease 2019 (COVID-19) pandemic, which developed very rapidly worldwide, rehabilitation services were forced to modify and adapt the way they provide and deliver services. These measures were proposed and adopted across a wide range of countries, the changes proposed included the following measures: critical patients with SARS-CoV-2 infection should be cared for by a multidisciplinary team providing early mobilization, respiratory, outpatient, and long-term care rehabilitation interventions. Home- based and community rehabilitation can be delivered through different strategies, such as telerehabilitation or direct care. The use of measures to prevent and protect against transmission of COVID-19 are necessary for all patients in rehabilitation care.Key words: rehabilitation service, COVID-19, disability, health professional, rehabilitation organization, health system

The coronavirus disease 2019 (COVID-19) pandemic expanded very rapidly worldwide. Because of its rapid spread, morbidity, and mortality, COVID-19 has had a significant impact on the delivery of healthcare, including rehabilitation services. Globally, rehabilitation services have been forced to modify and adapt the way they provide and deliver services in response to the pandemic, aiming to reduce physical contact between professionals and patients without affecting communication in the rehabilitation process (1). Furthermore, restrictions to contain the spread of COVID-19 have limited patients’ access to many rehabilitation services, causing collateral damage and negative consequences to people with disabilities, increasing functional limitations in chronic conditions, and hampering recovery after acute events (2).The World Health Organization (WHO) called for action to strengthen rehabilitation planning and implementation, including sanitary emergency preparedness and response to the current COVID-19 pandemic (3).However, the rehabilitation processes of people experiencing disability as well as of people with disability have been affected by the lack of continuity of care in rehabilitation services. It is estimated that, due to the pandemic at March 31^st 2020, an estimate range of 1,3–2,2 million people in Europe have had to interrupt their rehabilitation treatments in all phases of their conditions: acute, post-acute and long-term (4).Demographic and epidemiological trends suggest that the key indicators of the health of populations will be affected by the pandemic; not only mortality and morbidity, but also functioning. This, in turn, means that the primary focus of healthcare will need to include the scaling up and strengthening of rehabilitation (5).Furthermore, rehabilitation might benefit any person with rehabilitation needs, patients with any specific health condition(s), persons with any specific impairment, activity limitations and/or participation restrictions, from any cause, at any stage of illness or age. Rehabilitation might be delivered in any location (e.g. rural area, urban area, community, centralized, decentralized); in any mode of service delivery (e.g. inpatient or outpatient settings, day hospital, day services, home and community rehabilitation, telerehabilitation); and there is also consensus that rehabilitation must include habilitation, pre-habilitation, acute, sub-acute postacute and long-term chronic rehabilitation care (6).The objectives that a rehabilitation service plans and aims to achieve include: recovery; improvement of health status; optimizing functioning, such as improving self-care; returning to normal life; returning home; returning to work; improving quality of life services; increasing hospital discharge rates; and decreasing complications and hospital readmissions (6). As a consequence of the current pandemic, there is a need to identify barriers and facilitators to providing rehabilitation services, and to develop new sets of skills to meet the varied needs in these different settings (7).Even during a pandemic, rehabilitation is one of the 5 key health strategies (5). Rehabilitation is an essential part of the continuum of care, prevention, promotion, treatment, and palliation, and should therefore be considered an essential component of integrated health services (8). Rehabilitation is part of universal health coverage, which ensures all people in need, including people with disabilities, reach and maintain an optimal functioning level in interaction with the environment (9).The main aim of this study is to describe the adaptations to rehabilitation services proposed by scientific and professional rehabilitation organizations for the rehabilitation care of patients with and without COVID-19 in both inpatient and outpatient settings. The secondary objectives are to describe preventive measures to reduce the spread of COVID-19, and regulatory measures for protecting health workers and patients’ rights.     

SELF-SCORED IMPAIRMENTS IN FUNCTIONING AND DISABILITY IN POST-COVID SYNDROME FOLLOWING MILD COVID-19 INFECTION

ObjectivesTo investigate functioning, activity and disability in people with post-COVID syndrome.DesignCross-sectional.Subjects/patientsParticipants were recruited online via Facebook and a stakeholders’ organization for post-COVID syndrome in Sweden.MethodsSociodemographic data and International Classification of Functioning, Disability and Health (ICF)-based questionnaire were collected via an online platform and analysed.ResultsA total of 100 participants were included (mean age 44.5 years, 82% women, 61% with higher education, and 56% working full- or part-time). For the ICF component Body Functions, the most impaired functions were: fatigability and energy drive (98–99%); higher cognitive functions (74–94%); sleep functions (98%); muscle functions (93%); respiratory functions (92%); heart functions (82%); emotional functions (80%); sexual functions (77%); pain problems (56–90%); and thermoregulatory functions (68%). For the component Activity, the most frequent limitations were: handling stressful situations (98%); remunerative employment (95%); recreation and leisure (94%); climbing the stairs (94%); doing housework (84%); and informal socializing (64%). The most frequent degrees of impairment/limitations were light and moderate, except for severe-complete for fatigue, higher cognitive functions, multitasking, handling stressful situations; and recreation and leisure activities.ConclusionPost-COVID syndrome following a mild COVID-19 infection can result in impaired body functions and activities. These results support the importance of a multidisciplinary rehabilitation approach for these patients.LAY ABSTRACTThe SARS-CoV-2 (COVID-19) pandemic has infected several hundred million people worldwide to date. A proportion of people with COVID-19 who develop a mild initial illness, mainly staying at home or requesting few days of hospitalization, do not subsequently recover fully. Some of them develop new persistent symptoms and an increased level of disability, affecting their functioning. This study describes functioning and disability in people with post-COVID syndrome after a mild initial infection, using a self-scored questionnaire based on the International Classification of Functioning and Disability. A total of 100 participants were included in the study. Participants were relatively young and healthy prior to the infection. The majority were female, with a high level of education, and mostly working full- or part-time. Many disabling symptoms were found to persist, indicating the need for further research into post-COVID syndrome, and supporting the use of a multidisciplinary rehabilitation approach for these patients.Key words: post-COVID syndrome, International Classification of Functioning, Disability and Health, fatigue, functioning, activity, quality of life

Since the start of the COVID-19 pandemic in December 2019, several hundred million people have been infected, resulting in several million deaths worldwide and overloaded healthcare systems in many countries. The SARS-CoV-2 virus is known to affect the host in different ways: from asymptomatic infection to lethal course, probably depending on the host’s immune response (1). A neurological impact of the SARS-CoV-2 virus has been speculated, both in the pathways of respiratory failure (2) and in other neurological symptoms (3). The acute symptomatology of COVID-19 is now well-characterized, as acute respiratory failure, thrombosis, kidney failure, etc. (4, 5), and long-term symptoms are now affecting patients during the subacute (3–6 months after infection) and chronic periods (longer than 6 months after infection). Long-COVID or post-COVID syndrome appears in both hospitalized (6) and un-hospitalized patients (7). Follow-up of patients hospitalized during the acute period has identified ongoing symptoms, such as fatigue, breathing difficulties, cognitive symptoms, persistent musculoskeletal pain, sleeping difficulties, etc. (8, 9). Regardless of the severity of the initial infection, persistent fatigue appears to be the most bothersome symptom in patients with post-COVID syndrome (10). The World Health Organization (WHO) appealed to healthcare providers regarding post-COVID syndrome and estimates that approximately 10% of all infected people may develop post-COVID syndrome (11). However, knowledge about post-COVID syndrome is scare, and future levels of healthcare needs for these patients might be extremely high. There is an urgent need for scientific data about post-COVID syndrome, and the role of rehabilitation interventions to prevent disability in these patients.Although the clinical picture of post-COVID syndrome is broad, one way to analyse it is to assess functioning, activity and disability according to the International Classification of Functioning, Disability and Health (ICF). The ICF is a classification of health and health-related domains describing functioning, activity and disability, which was officially endorsed by all 191 WHO Member States in the Fifty-fourth World Health Assembly on 22 May 2001 (resolution WHA 54.21) (12). ICF is the WHO’s framework in categorizing health and disability at both individual and population levels and is recommended for use in clinical and research practise. The ICF Core Sets were developed for several (chronic) health conditions (13–18), but, until now, not for post-COVID syndrome.The aim of the current study was therefore to assess functioning, activity, and disability, using an adapted list of ICF categories for patients with post-COVID syndrome.     

FACTORS ASSOCIATED WITH MET AND UNMET REHABILITATION NEEDS AFTER STROKE: A MULTICENTRE COHORT STUDY IN DENMARK AND NORWAY

ObjectivesTo examine patient-reported needs for care and rehabilitation in a cohort following different subacute pathways of rehabilitation, and to explore factors underpinning met and unmet needs.DesignObservational multicentre cohort study.Patients and methodsA total of 318 Norwegian and 155 Danish patients with first-ever stroke were included. Participants answered questions from the Norwegian Stroke Registry about perceived met, unmet or lack of need for help and training during the first 3 months post stroke. The term “training” in this context was used for all rehabilitative therapy offered by physiotherapists, occupational or speech therapists. The term “help” was used for care and support in daily activities provided by nurses or health assistants.ResultsNeed for training: 15% reported unmet need, 52% reported met need, and 33% reported no need. Need for help: 10% reported unmet need, 58% reported met, and 31% reported no need. Participants from both Norway and Denmark had similar patterns of unmet/met need for help or training. Unmet need for training was associated with lower functioning, (odds ratio (OR) = 0.32, p < 0.05) and more anxiety (OR = 0.36, p < 0.05). Patients reporting unmet needs for help more often lived alone (OR = 0.40, p < 0.05) and were more often depressed (OR = 0.31, p < 0.05).ConclusionSimilar levels of met and unmet needs for training and help at 3 months after stroke were reported despite differences in the organization of the rehabilitation services. Functioning and psychological factors were associated with unmet rehabilitation needs.LAY ABSTRACTThe aim of this study was to examine patient-reported needs for care and rehabilitation among selected patients with stroke in Norway and Denmark. A total of 318 Norwegian and 155 Danish patients with first-ever stroke were included. Participants answered the following 2 questions from the Norwegian Stroke Registry: Have you received enough help after the stroke? Have you received as much training as you wanted after the stroke? The term “training” in this context was used for all rehabilitative therapy offered by physio-, occupational or speech therapists. The term «help» was used for care and support in daily activities provided by nurses or health assistants. Levels of anxiety and depression were investigated. With regard to training needs, 15% of all participants reported unmet needs, 52% reported that their needs had been met, and 33% reported that they had no need for training. Regarding the need for help, 10%, 58% and 31% reported unmet needs, that needs had been met, and that they had no need for care, respectively. Participants in the 2 countries had similar patterns of unmet/met needs for help or training. Unmet need for training was associated with low function and anxiety. Patients reporting an unmet need for help more often lived alone and were more often depressed. There was no difference in met or unmet needs between Norwegian and Danish participants.Different rehabilitative follow-up after stroke did not affect levels of met and unmet rehabilitation needs. Health services should pay special attention to patients at risk, including those who are anxious or depressed, live alone or have functional deficits after stroke.Key words: stroke, rehabilitation, unmet needs, rehabilitation pathways

Stroke is a major cause of death, with an increasing number of patients affected worldwide (1). Stroke survivors often have varying degrees of physical, psychosocial and cognitive disabilities, which may substantially affect their functional ability in daily and working life (2). Treatment offered by specialized stroke units (3), inpatient multidisciplinary rehabilitation teams (4) and community-based rehabilitation services adapted to patients’ home environment (5) are key elements to successful rehabilitation. At all intervention levels, the identification of patients’ individual needs is crucial for the optimization of rehabilitation outcomes. The definition of a need is, however, not unambiguous (6). A pragmatic approach is to adopt the most commonly used definition of healthcare needs and define rehabilitation needs as the needs that can be fulfilled by rehabilitation interventions and services (7). From the patient’s perspective, a need represents the perception of a situation in which help or support is desired. If adequate help is not offered, the provision of services does not fit the needs, gaps occur and needs become unmet (8).A perceived need for therapy, comprehensive care, pscyhological support or information are examples of commonly reported unmet needs post-stroke (9).Unmet rehabilitation needs may persist for years after stroke (10). According to a UK study, they are more often reported by people with disabilities, those belonging to ethnic minorities, and those living in the most deprived areas (10). According to a recent systematic review of 19 studies, mostly cross-sectional in design, 74% of stroke survivors experienced at least one unmet need. The studies revealed heterogeneous levels of unmet needs, ranging between 5% and 40% for care and between 2% and 36% for therapy (9). In most studies, unmet needs were assessed by using different multi-item questionnaires, such as the Longer-term Unmet Need after Stroke (11) and the Greater Manchester Stroke Assessment Tool (12), or by the self-report of long-term needs after stroke (10).In a Swedish registry study evaluating perceived unmet or partly met rehabilitation needs with a single question, 21.5% of patients reported unmet needs one year after stroke. Important underpinning factors were older age, dependency on others, pain and depressive/ affective symptoms (13).Rehabilitation practices are formulated and enacted in a cultural and historical context aligned to the development of healthcare services (14). Specialized stroke rehabilitation is integrated in the public healthcare systems in Nordic countries (15), but, whereas the Norwegian study region mainly emphasizes inpatient rehabilitation, the Danish region has developed an additional and more specialized, community-based rehabilitation programme (16). Although some studies have reported different rehabilitation pathways in the early subacute phase of stroke (17), no previous studies have, to our knowledge, compared unmet needs post stroke in participants with different subacute rehabilitation pathways.The primary aim of this study was to examine patient-reported needs for healthcare and rehabilitation services in a cohort with different rehabilitation pathways recruited from 2 Nordic country-regions. Secondary aims were to assess to what extent these needs were met or unmet 3 months post stroke and to explore factors associated with met and unmet needs.     

REHABILITATION IN PATIENTS WITH LYMPHOMA: AN OVERVIEW OF SYSTEMATIC REVIEWS

ObjectiveTo evaluate existing evidence from published systematic reviews for the effectiveness of rehabilitation interventions in patients with lymphoma.Data sourcesA comprehensive literature search was conducted using medical/health science databases up to 1 October 2020. Bibliographies of pertinent articles, journals and grey literature were searched.Data extraction and synthesisTwo reviewers independently selected and reviewed potential reviews for methodological quality and graded the quality of evidence for outcomes using validated tools. Any discrepancies were resolved by final group consensus.ResultsTwelve systematic reviews (n = 101 studies, 87,132 patients with lymphoma) evaluated 3 broad categories of rehabilitation interventions (physical modalities, nutrition and complementary medicine). Most reviews were of moderate-to-low methodological quality. The findings suggest: moderate-quality evidence for exercise programmes for improved fatigue and sleep disturbance; low-quality evidence for exercise therapy alone and qigong/tai chi for improved symptoms and overall quality of life, and an inverse association between sunlight/ultraviolet radiation exposure and incidence of non-Hodgkin’s lymphoma; and very low-quality evidence for beneficial effects of yoga for sleep disturbances. Association between physical activity and lymphoma risk is indistinct.ConclusionDespite a range of rehabilitation modalities used for patients with lymphoma, high-quality evidence for many is sparse. Beneficial effects of exercise programmes were noted for fatigue, psychological symptoms and quality of life. More research with robust study design is required to determine the effective rehabilitation approaches.LAY ABSTRACTLymphoma and its treatment cause significant disability and morbidity, often requiring comprehensive rehabilitation. Currently, a range of rehabilitation interventions are applied in patients with lymphoma. This review systematically evaluated evidence from published systematic reviews of clinical trials to determine the effectiveness of rehabilitation interventions in patients with lymphoma. The findings suggest that there is moderate-quality evidence for exercise programmes in improving fatigue and sleep disturbance. There was low-quality evidence for exercise therapy alone and qigong/tai chi for improved symptoms and overall quality of life, and very low-quality evidence for beneficial effects of yoga for sleep disturbances. The evidence for association of vitamin D or physical activity and lymphoma risk is limited.Key words: lymphoma, rehabilitation, systematic review, critical appraisal

Lymphomas are a heterogeneous group of malignant neoplasms of the haematopoietic system, characterized by the aberrant proliferation of mature lymphoid cells or their precursors (1). Traditionally lymphoma is classified broadly into 2 major groups: non-Hodgkin’s lymphoma (NHL, 90%) and Hodgkin’s lymphoma (HL) (1); however, lymphomas can also be stratified by cell of origin, as in the World Health Organization (WHO) classification (B-cell, T-cell/natural killer-cell (T/NK) and HL), or clinical behaviour (aggressive or indolent) (2, 3). An estimated 590,000 new cases of lymphoma (3.2% of all cancers) were diagnosed worldwide in 2018, the majority being NHLs (509,590 cases, 2.8% of all cancers) (4). NHL is a leading cause of death amongst the haematological malignancies globally, estimated to cause over 248,000 deaths (2.6% of all cancers) in 2018 (4). The incidence of lymphoma is increasing, with total worldwide incidence projected to reach approximately 919,000 by 2040 (5).The total global economic burden of lymphoma is unknown; however, treatments and supportive care requirements are resource-intensive and associated with significant financial costs for patients/families and healthcare systems. Productivity losses arise from disease and treatment-associated morbidity and premature mortality (6). In 2018, the mean monthly healthcare and utilization costs per patient for diffuse large B-cell lymphoma (DLBCL) and follicular lymphoma (FL) in the USA were approximately US$11,890 and $10,460, respectively (6). In Spain, in 2017 lymphoma represented 45.4% of productivity losses due to haematological malignancies, resulting in €121 million in losses due to premature mortality (7).Current therapeutic advances and cancer detection/diagnosis have improved survival rates for patients with lymphoma (PwL). The age-standardized 5-year net survival of lymphoid malignancies in adults ranges from 40% to 70% globally in 2010–14, with a 5–10% increase in trend for the period 2000–04 (8). The 5-year survival rate in the US in 2010–16 was estimated to be 72.7% for NHL and 87.4% for HL (9). As the incidence of NHL is strongly associated with increasing age, improved supportive care and availability of reduced intensity chemotherapy regimens (such as prednisone, etoposide, procarbazine, and cyclophosphamide – ‘PEP-C’; rituximab, doxorubicin, cyclophosphamide, vincristine, and prednisone – ‘R-miniCHOP’, rituximab, cyclophosphamide, vincristine, prednisolone – ‘R-CVP’) are critical to facilitate deliverable therapy to older patients. Despite these factors, certain lymphomas and their treatment are associated with short- and medium-term residual neurological deficits, leading to physical, cognitive, psychosocial and behavioural impairments, limiting activities of daily living (ADL) and participation (10–13). Treatment procedures can be extensive (e.g., radiotherapy, chemotherapy and/or surgery), and associated with a range of side-effects/complications, such as neuropathy, cardiotoxicity, cachexia, fatigue, deconditioning, myopathy, etc. (14–16). Furthermore, in the transitional period, various adjustment issues are reported, such as increased care needs, inability to drive and return to work, financial constraints, relationship stress, and limitation in societal participation (11, 14, 17, 18). Distressing symptoms, such as fatigue, is a major complaint, reported in 60–100% of patients during or after cancer treatment, which persists for several years after treatment (19–21). Therefore, patients require routine surveillance to monitor complications and relapse and integrated longer-term management, including rehabilitation (22–24).Rehabilitation is an integral part of any cancer management, and there is evidence suggesting the beneficial effect of comprehensive rehabilitation (25–31). Furthermore, a major limitation of delivery of chemotherapy and predictor of inferior outcome is poor performance status (32). As the incidence of older patients treated for lymphoma requiring rehabilitation before or after anti-lymphoma therapy increases, effective evidence-based rehabilitation strategies are expected to play critical and expanding roles in best practice. Currently, a range of rehabilitation interventions are trialled in the management of lymphoma pre-treatment, during adjuvant therapies, and late phases of care, and, for the longer-term, care continuum in the community. The aim is to maximize patient function, promote independence and participation, and improve psychological well-being and quality of life (QoL) (28, 29). Reports suggest that patients with haematological malignancies, including lymphomas, can make functional gains in inpatient rehabilitation settings (31). Maximal exercise capacity seems to decrease before treatment in PwL, especially in patients with advanced disease, and tends to return to close to normal during and/or after treatment (33). Furthermore, comprehensive exercise programmes were found to be effective in reducing disability and symptoms (depression, anxiety, fatigue, pain, etc.), improving functional capacity, muscular strength and QoL (19, 31, 34, 35). One systematic review reported that NHL survivors who met public health exercise guidelines defined by the American College of Sports Medicine (i.e. engaging in >30 min/day of at least moderate physical activity (PA) on ≥ 5 days/week, or > 150 min a week) reported a clinically important better health-related quality of life (HRQoL) than their counterparts who did not meet exercise guidelines (11). Aerobic exercise training interventions were associated with positive effects on cardiorespiratory fitness, fatigue and self-reported physical functioning, and were feasible and safe in PwL (33). Other complementary and alternative therapies, such as mindfulness-based cognitive therapy, meditation, yoga, and tai chi, have shown improvement in cognitive function and QoL (36–38). Another recent systematic review reported that a combination of PA together with mental exercise may be more beneficial to PwL (39). There remains, however, an unmet need in the cancer population, and only a limited number of survivors receive the appropriate rehabilitation intervention that they need (40, 41). Furthermore, despite acknowledging rehabilitation as an integral component of the management of cancer patients, rehabilitation-specific guidelines for many cancer groups are limited, and many general cancer guidelines do not incorporate recommendations for specific rehabilitation interventions (42–44).As mentioned above, various systematic reviews have evaluated the current evidence regarding the effectiveness and safety of different rehabilitation interventions in PwL. However, these published reviews vary in scope, methodology and quality, with diverse, and occasionally discordant, conclusions. The heterogeneity of the lymphoma rehabilitation literature warrants a comprehensive review, with a focus on the evidence for efficacy and potential harm of various rehabilitative strategies. A systematic review of systematic reviews is a new approach to synthesize current evidence across the same or similar interventions, to summarize treatment effect in a much broader concept (45). This approach allows comparison of results from multiple reviews, thereby providing a comprehensive evidence-based summary (45, 46). To our knowledge, systematic reviews of rehabilitation strategies for PwL have not been thoroughly and qualitatively appraised to date. Therefore, this review aimed to systematically evaluate existing evidence from published systematic reviews for the effectiveness of rehabilitation strategies for improved function, impairments and participation in PwL. Specific questions addressed include: Are rehabilitation interventions effective in minimizing impairment, activity limitation, participation restriction and treatment-related complications in PwL?, and: What specific types of rehabilitation interventions are effective in PwL, and in which setting?     

EFFECT OF NEUROMUSCULAR ELECTRICAL STIMULATION ON THE RECOVERY OF PEOPLE WITH COVID-19 ADMITTED TO THE INTENSIVE CARE UNIT: A NARRATIVE REVIEW

The rehabilitation of patients with COVID-19 after prolonged treatment in the intensive care unit is often complex and challenging. Patients may develop a myriad of long-term multi-organ impairments, affecting the respiratory, cardiac, neurological, digestive and musculoskeletal systems. Skeletal muscle dysfunction of respiratory and limb muscles, commonly referred to as intensive care unit acquired weakness, occurs in approximately 40% of all patients admitted to intensive care. The impact on mobility and return to activities of daily living is severe. Furthermore, many patients experience ongoing symptoms of fatigue, weakness and shortness of breath, in what is being described as “long COVID”. Neuromuscular electrical stimulation is a technique in which small electrical impulses are applied to skeletal muscle to cause contractions when voluntary muscle contraction is difficult or impossible. Neuromuscular electrical stimulation can prevent muscle atrophy, improve muscle strength and function, maintain blood flow and reduce oedema. This review examines the evidence, current guidelines, and proposed benefits of using neuromuscular electrical stimulation with patients admitted to the intensive care unit. Practical recommendations for using electrical muscle stimulation in patients with COVID-19 are provided, and suggestions for further research are proposed.Evidence suggests NMES may play a role in the weaning of patients from ventilators and can be continued in the post-acute and longer-term phases of recovery. As such, NMES may be a suitable treatment modality to implement within rehabilitation pathways for COVID-19, with consideration of the practical and safety issues highlighted within this review. LAY ABSTRACTMany patients with COVID-19 are admitted to the intensive care unit with ongoing symptoms of fatigue, weakness and shortness of breath. Neuromuscular electrical stimulation is a technique in which small electrical impulses are applied to skeletal muscle to cause contractions when voluntary muscle contraction is difficult or impossible. It can prevent muscle atrophy, improve muscle strength and function, maintain blood flow and reduce oedema. This review examines the evidence, current guidelines, and proposed benefits of using neuromuscular electrical stimulation with patients admitted to the intensive care unit. Practical recommendations for using electrical muscle stimulation with COVID-19 patients are provided and suggestions for further research are proposed. Evidence suggests NMES may play a role in the weaning of patients from ventilators and can be continued in the post-acute and longer-term phases of recovery. As such, NMES may be a suitable treatment modality to implement within rehabilitation pathways for COVID-19, with consideration of the practical and safety issues highlighted within this review. Key words: critical care, rehabilitation, neuromuscular electrical stimulation, muscular atrophy, coronavirus infection, COVID-19

The COVID-19 pandemic has seen unprecedented numbers of people being treated in intensive care units (ICUs) worldwide. Many patients have received artificial ventilation, and some have been ventilated for many weeks. Those that survive are often left with long-term disabilities as a result of the effects of both the disease and of the treatments necessary to keep them alive. A myriad of multi-organ impairments is associated with COVID-19 including respiratory, cardiac, neurological, bowel and kidney dysfunction (1). The unexpectedly large number of COVID-19 patients requiring a prolonged stay in ICU additionally increases the risk of dysfunction of both respiratory and skeletal muscle, commonly referred to as ICU-acquired weakness (ICUAW). A conspicuous feature of COVID-19 is the persistence of symptoms, which may appear to resolve, but then recur. As a result, many survivors are left needing significant rehabilitation at a time when such services are under great stress. This has led to the blanket term “long COVID”, which describes ongoing symptoms, which may include fatigue, weakness and delayed recovery (2).Strikingly, in the first 7 months of 2020, there were more than 10,000 COVID-19 admissions to critical care in the UK National Health Service (NHS), which is 4 times greater than historic annual cases of viral pneumonia (3). Our experience of COVID-19 in the UK is that critically unwell patients generally require a longer course of respiratory support, exacerbating other risk factors for ICUAW (3). At present, ICUAW is seen in approximately 20–50% of patients with COVID-19 admitted to the ICU (4). General deconditioning, muscle atrophy, inflammation, and functional disability often necessitate transfer from the ICU to a long-term care facility. Exacerbations of chronic comorbidities and the cycle of prolonged bed rest, ongoing inflammation and malnutrition can lead to continued functional disability, immobility and continued ventilation support. Data from the UK Intensive Care National Audit and Research Centre (ICNARC) database indicates that older age, obesity, multiple deprivation, and the requirement for assistance in activities of daily living (ADL) are predictors for severe disease requiring admission to critical care (3). These risk factors are associated with a reduced level of background fitness, malnutrition and neuropathy. Infection with COVID-19 characteristically causes myalgia, lethargy and a loss of appetite, which are likely to exacerbate this pre-morbid condition. Further deconditioning may result from constrained normal daily activities. This may be due to the disease itself, causing shortness of breath on exertion or delirium (5), or may be the result of supportive interventions and infection control measures. It is also noteworthy that proximal myopathy is associated with the use of therapeutic dexamethasone, a drug that has been shown to reduce 28-day mortality in COVID-19 (6).Table IRisk factors for deconditioning and intensive care unit associated weakness (ICUAW) in patients with COVID-19 in comparison with those with viral pneumonia (3)

EFFECTIVENESS OF REHABILITATION INTERVENTIONS IN ADULTS WITH MULTIORGAN DYSFUNCTION SYNDROME: A RAPID REVIEW

BackgroundMultiple organ dysfunction syndrome, defined as altered organ function in critically ill patients, is a possible consequence of COVID-19. Investigating the current evidence is therefore crucial in this pandemic, as early rehabilitation could be effective for the functioning of patients with multiple organ failure. This rapid review assesses the effectiveness of rehabilitation interventions in adults with multiple organ dysfunction syndrome.MethodsA rapid review was conducted including only randomised control trials, published until 30 November 2020. All databases were investigated and the results synthesized narratively, evaluating the risk of bias and quality of evidence in all included studies.ResultsA total of 404 records were identified through database searches. After removal of duplicates 346 articles remained. After screening, 3 studies (90 participants) met the inclusion criteria. All studies reported positive effects of neuromuscular electrical stimulation on muscle mass preservation compared with no treatment or standard physiotherapy.ConclusionThe lack of evidence on the effectiveness of rehabilitation interventions does not allow any firm conclusion to be drawn. Neuromuscular electrical stimulation might be a possible rehabilitation intervention to prevent muscle volume loss and improve function in patients with multiple organ dysfunction syndrome. However, further studies are needed to support these preliminary findings.LAY ABSTRACTThis paper synthesizes the current evidence on the effects of rehabilitation interventions in patients with multi-organ dysfunction syndrome. The results show that neuromuscular electrical stimulation may be a feasible treatment to prevent muscle mass loss and increase upper and lower limb strength in this population. Following multi-organ dysfunction syndrome people frequently experience new or worsened disabilities. Therefore, it is relevant to provide the clinician with the best current evidence on treatment that could be applied in the acute phase, in order to enhance the recovery of these patients. This is even more applicable while the COVID-19 pandemic is raging globally, as multi-organ dysfunction syndrome is one of the worst possible consequences of the disease.Key words: multiple organ failure, rehabilitation, rapid review

Multiple organ dysfunction syndrome (MODS) is defined as altered organ function in an acutely ill patient (1). MODS usually involves 2 or more organ systems among the respiratory, cardiovascular, renal, hepatic, gastrointestinal, haematological, endocrine, and central nervous system (2). Once the syndrome has developed, there is no effective therapy for modulating the inflammatory response and reducing the severity of MODS. Therefore, treatment is focused on prevention and treating individual organ dysfunction as it develops, and supportive measures are required (3).The survival of critically ill patients is frequently associated with significant functional impairment and reduced health-related quality of life (4). Although the pathophysiology of MODS is not entirely understood, the dysregulated immune response to critical illness plays a central role in determining the severity of the disease (3). MODS can be classified as primary (immediately after several specific traumas, such as extensive injuries of tissues, hypoxia and the ischaemia-reperfusion syndrome) or secondary (end-stage of a systemic inflammatory response syndrome, commonly involving sepsis) (5). The clinical course of MODS is divided by the Sequential Organ Failure Assessment (SOFA) score system into 4 stages, according to the degree of dysfunction of 6 organ systems (respiration, coagulation, liver, cardiovascular, central nervous system, renal). The SOFA score is instrumental in predicting the outcome (6). Independent of the initial score, an increase in SOFA during the first 48 h in the intensive care unit (ICU) predicts a mortality rate of at least 50% (7). The first clinical objective in MODS is always patient survival. Having assured survival, the objective shifts into improvement in as much as possible of health-related quality of life, reducing any organ dysfunction, and preventing all the possible sequelae of MODS or a long period of hospitalization (8). Therefore, rehabilitation interventions could cover an essential role in the accomplishment of functional recovery.MODS is one of the worst possible manifestations of COVID-19, along with respiratory failure, neurological symptoms, septic shock, or a combination of all of these (9). To date, there is no effective treatment for COVID-19, except for supportive care, including oxygen and mechanical ventilation. As with MODS, severely ill patients with COVID-19 require a lengthy period of hospitalization and experience a massive alteration in their life (10). Due to the similarities, rehabilitation interventions for MODS could also help manage patients with COVID-19. Therefore, a rapid review of rehabilitation interventions for MODS could be highly relevant in the current pandemic, because it is a form of knowledge synthesis that accelerates the process of conducting a traditional systematic review, to produce evidence for stakeholders in a resourceefficient manner under pandemic circumstances (11).This rapid review assessed the effectiveness of rehabilitation interventions on functional outcomes in adults with MODS.     

IMPLEMENTATION OF EVIDENCE-BASED ASSESSMENT OF UPPER EXTREMITY IN STROKE REHABILITATION: FROM EVIDENCE TO CLINICAL PRACTICE

ObjectiveThere is an evidence–practice gap in assessment of the upper extremities during acute and subacute stroke rehabilitation. The aim of this study was to target this gap by describing and evaluating the implementation of, and adherence to, an evidence-based clinical practice guideline for occupational therapists and physiotherapists.MethodsThe upper extremity assessment implementation process at Sahlgrenska University Hospital comprised 5 stages: mapping clinical practice, identifying evidence-based outcome measures, development of a guideline, implementation, and evaluation. A systematic theoretical framework was used to guide and facilitate the implementation process. A survey, answered by 44 clinicians (23 physiotherapists and 21 occupational therapists), was used for evaluation.ResultsThe guideline includes 6 primary standardized assessments (Shoulder Abduction, Finger Extension (SAFE), 2 items of the Actions Research Arm Test (ARAT-2), Fugl-Meyer Assessment of Upper Extremity (FMA-UE), Box and Block Test (BBT), 9-Hole Peg Test (9HPT), and grip strength (Jamar hand dynamometer)) performed at specified time-points post-stroke. More than 80% (35 to 42) clinicians reported reported being content with the guideline and the implementation process. Approximately 60–90% of the clinicians reported good adherence to specific assessments, and approximately 50% reported good adherence to the agreed time-points. Comprehensive scales were more difficult to implement compared with the shorter screening scales. High levels of work rotation among staff, and the need to prioritize other assessments during the first week after stroke, hindered to implementation.ConclusionThe robustness of evidence, adequate support and receptive context facilitated the implementation process. The guideline enables a more structured, knowledge-based and consistent assessment, and thereby supports clinical decision-making and patient involvement.LAY ABSTRACTCurrently available clinical practice guidelines do not specify which outcome measures should be used at which time-points for people after stroke. This study describes the implementation process and evaluation of a clinical practice guideline developed for the assessment of upper extremity function after stroke. The guideline is based on recent research evidence and defines the assessments, and the time-points at which the assessments should be performed. An evaluation survey showed that clinicians valued the clear structure of the guideline and found it useful for prognosis and treatment planning. Robust evidence, and active involvement of clinicians and leaders, were important elements of implementation. The guideline will potentially improve the quality of rehabilitation through increased knowledge of prognosis and treatment effects, based on the assessment of arm function in people with stroke, thereby enabling a more evidence-based, consistent, and individually tailored rehabilitation.Key words: clinical practice guideline, evidence-based practice, implementation science, stroke, rehabilitation, knowledge translation, upper extremity, assessment

Considerable efforts have been made recently in the field of stroke rehabilitation to develop evidence-based agreed guidelines for upper extremity assessment (1–4). Advances in predicting stroke outcomes, in terms of motor function and activity, have been the primary driver of this development (5–7). There is, however, a clear evidence–practice gap, since the use of recommended upper extremity outcome measures in day-to-day clinical practice is sparse. It is well recognized that valid, reliable and responsive outcome measures, performed at pre-defined time-points after stroke, are required for effective rehabilitation (2–4). Currently available clinical guidelines recommend the use of standardized outcome measures, but often do not specify what outcome measures should be used, at what frequency, or in what settings (2).The implementation of standardized recommended upper extremity outcome measures in clinical routine practice takes time and effort. Increased and consistent use of such measures is, however, required to enable person-centred informed clinical decision-making throughout the rehabilitation pathway, and thereby improve patient outcomes. Overall adherence to stroke guidelines varies, but, in general, it is greater when the implementation process includes systematic and well-defined activities (8–10). There are no recognized “gold standard” implementation activities, although multifaceted interventions involving educational outreach and a structured theoretical approach have been suggested to work best (8, 9). Organizational and multidisciplinary team factors, staff beliefs regarding the guidelines, integration of patient-centred recommendations into practice, awareness of guidelines, changing routines, and necessary time investment, are known factors affecting adherence (8, 10).The successful implementation of evidence into practice is dependent on the quality of evidence, the context, and how the evidence is introduced into practice (facilitators) (11). These 3 key elements, being part of the Promoting Action on Research Implementation in Health Services (PARIHS) theoretical framework, have been employed widely in different implementation activities (11, 12). This theoretical model prerequisites that the evidence is robust, practitioners agree with it, and the context is receptive, including the formal leaders, and that appropriate facilitation is ensured (11, 13). The Knowledge to Action (KTA) framework is another theoretical tool that has been widely used to make the process of knowledge translation into practice more systematic (14). The KTA emphasizes the importance of adapting knowledge to the local context, of involving stakeholders, and of being aware of barriers, facilitators and user needs (14).The literature is extensive regarding the implementation of stroke guidelines into clinical practice (8, 9), but only a few studies have specifically targeted assessment and use of standardized outcome measures (15, 16). More recent work on recommendations regarding upper extremity outcome measures (3) also imply a need to move this research evidence into stroke rehabilitation practice.The aim of this study was to describe and evaluate the implementation process and adherence to an evidence-based clinical practice guideline (CPG) for physical therapists (PT) and occupational therapists (OT) in the assessment of upper extremity function and activity during acute and subacute stroke rehabilitation.     

EFFECTS OF VIRTUAL REALITY-BASED NECK-SPECIFIC SENSORIMOTORTRAINING IN PATIENTS WITH CHRONIC NECK PAIN: A RANDOMIZED CONTROLLED PILOT TRIAL

ObjectiveTo evaluate the effects of neck-specific sensorimotor training using a virtual reality device compared with 2 standard rehabilitation programmes: with, and without general sensorimotor training, in patients with non-traumatic chronic neck pain.DesignPilot randomized control study.Patients and methodsA total of 51 participants were randomly assigned to 1 of 3 groups: 1: control group; 2: sensorimotor group; 3: virtual reality group. All 3 groups received the clinic’s standard rehabilitation programme. Group 2 also received “general sensorimotor training” in the form of group therapy, for a total of 120 min. Group 3 received additional virtual reality-based “neck-specific sensorimotor training” for a total of 120 min. Participants’ neck pain, headaches, active cervical range of motion, and Neck Disability Index were determined before and after 3 weeks of intervention.ResultsCompared with the control group, the virtual reality group showed significant (p < 0.05) advantages in relief of headaches, and active cervical range of motion in flexion and extension. Compared with the sensorimotor group, the virtual reality group showed significant improvements in cervical extension.ConclusionVirtual reality-based sensorimotor training may increase the effects of a standard rehabilitation programme for patients with non-traumatic chronic neck pain, especially active cervical range of motion in extension.LAY ABSTRACTThe aim of this study was to evaluate the effectiveness of neck-specific coordination training using a virtual reality device, in comparison with general coordination training and a standard exercise programme as part of inpatient rehabilitation for patients with chronic neck pain. Pain, disability and mobility of the neck were determined before and after 3 weeks of training intervention in 51 patients. The virtual reality training group exhibited greater effects in relief of headaches, and bending the neck forwards and backwards compared with the standard exercise group, and an increased ability to bend the neck backwards compared with the coordination training group. The results suggest that neck-specific coordination training using a virtual reality device increases the benefits of standard inpatient rehabilitation in patients with chronic neck pain, particularly in bending the neck backwards.Key words: neck pain, rehabilitation, virtual reality, kinematics

Neck pain is a widespread problem; 60–80% of individuals develop neck pain during their life-time, with 30–50% of the general population reporting neck pain annually (1–3). Many patients experience neck pain as a complex biopsychosocial disorder, with problematic physical and psychological symptoms (3), such as reduced cervical range of motion, headaches, lack of concentration, emotional and cognitive disorders (4, 5). Aside from the decreased quality of life, these complaints are a major cause of inability to work (6, 7) and lead to considerable economic damage (8). Hence, the demand for an effective treatment is indisputable.According to a recently published review (9), the strongest treatment effects for neck pain are those associated with exercise. However, the evidence for this claim is only of moderate quality. Since there is no data available at present to show that any one form of exercise is evidentially more effective than another, multimodal care is concordantly recommended by leading experts (3, 9).Sensorimotor training methods are a current trend in exercise therapy, and for the first time they take into account the special function of the neck, by including connections between the perceptions of sensory organs located in the head and neck muscles (10–14). Alterations of sensorimotor control have been identified in many patients with neck pain, and are thought to play an important role in the aetiology and maintenance of associated disorders (14, 15).To date, there are only a few sensorimotor training concepts that have been specially developed for the neck region. Initial studies found that patients undergoing these training methods experienced reduced neck pain, as well as improvements in cervical range of motion, self-reported disability, and general health (11, 13, 14, 16). However, a systematic review from 2014 (17) revealed very little evidence for eye-neck coordination and proprioceptive exercises. Furthermore, a randomized controlled trial (RCT) found that neck coordination exercises did not produce a larger effect than strength training and massages (18).Application of a virtual reality (VR) device is a novel and promising option for training cervical kinematics (10, 12, 19). In theory, this technique provides several advantages: distracting attention and therefore reducing pain and kinesiophobia (20, 21), engaging and motivating physical activities, and improving the effectiveness of exercise (22, 23).To date, only one RCT has compared the effects of VR-based training with conventional kinematic training using laser beams in patients with chronic neck pain (12). The VR group exhibited significant improvements in motion velocity, pain intensity, health status, and accuracy of neck motion.Due to the conflicting evidence and lack of research, there is a need for more studies that consider the effectiveness of VR-based sensorimotor training concepts, especially in combination with other effective therapeutic exercises or as part of individually tailored programmes (12).The aim of this study was therefore to evaluate the effects of neck-specific sensorimotor training using a VR device, in comparison with standard rehabilitation programmes, both with and without general sensorimotor training, in patients with non-traumatic chronic neck pain.     

RECOVERY OF ARM FUNCTION DURING ACUTE TO CHRONIC STAGES OF STROKE QUANTIFIED BY KINEMATICS

ObjectiveTo quantify the longitudinal changes in upper limb kinematics within the first year after stroke and to identify the factors that are associated with these changes.MethodsA total of 66 individuals with stroke from the Stroke Arm Longitudinal Study at the University of Gothenburg (SALGOT) cohort were included if they were able to perform the target-to-target task. Data from a virtual reality haptic target-to-target task at 6 time-points between 3 days and 12 months after stroke were analysed by linear mixed models, while controlling for the impact of cofactors (stroke severity, age, type and side of stroke, sex and presence of diabetes).ResultsKinematic variables of movement time, mean velocity and number of velocity peaks improved over time and were positively associated with younger age, less severe stroke and ischaemic compared with haemorrhagic stroke. Most of the improvement occurred within 4 weeks after stroke, although movement time and number of velocity peaks also improved between 3 and 6 months after stroke.ConclusionKinematic variables of movement time, mean velocity and number of velocity peaks were effective in quantifying the longitudinal changes in upper limb kinematics within the first year after stroke.LAY ABSTRACTRecovery of arm function after stroke can be measured using virtual reality technology, which, in contrast to traditional clinical assessments, enables objective and highly precise measurement of different aspects of movement, such as speed and smoothness, termed kinematics. This study aimed to measure the recovery of arm movements between 3 days and 12 months after stroke using kinematic measures, and to identify factors that affect recovery. The results showed that movement time, mean velocity and smoothness improved with time after stroke. These data also suggest that younger stroke survivors, those with less severe stroke, and those with stroke caused by a clot, as opposed to a bleed, undergo greater improvements. Most of the improvement was seen early after stroke, within the first 4 weeks, but both movement time and smoothness also continued to improve between 3 and 6 months. The results show that kinematic analysis can effectively show the changes in arm movement within the first year after stroke.Key words: upper extremity, kinematics, outcome assessment, virtual reality, stroke recovery

Upper limb motor impairment occurs in approximately 50–80% of individuals in the acute stage of stroke (1–3) and continues in 40–50% in the chronic stage (2, 4). Approximately 65% of hospitalized individuals with initial motor deficits show some degree of motor recovery, while complete motor recovery occurs in less than 15% of individuals (5). Clinical recovery of upper limb motor function is most rapid during the first 4 weeks following stroke, and most recovery occurs during the first 3 months post-stroke (5, 6). Additional recovery has also been shown to occur after 3 months following stroke, usually in combination with intensive rehabilitation (5–7).The time course of functional recovery after stroke is dependent on several factors. There is a strong negative association of initial grade of stroke paresis and age with functional recovery after stroke (5, 8, 9). According to a retrospective observational study, individuals with haemorrhagic stroke had higher initial impairment compared with those with ischaemic stroke, as demonstrated by Fugl-Meyer Assessment of the Upper Extremity (FMA-UE) scores at admission (10). However, the haemorrhagic stroke group showed greater recovery in arm function and activity capacity, such that individuals in both groups had similar function at 3 months after stroke (11). It is not clear whether the same factors are reflected in the change in kinematic variables of arm function during the recovery of upper limb in individuals with stroke.Kinematic measurements of movement performance are recommended as core measures to be included in every stroke recovery trial (12). Kinematic assessment of upper limbs after stroke is often performed using optoelectronic cameras (13–15), robotic techniques (16) and virtual reality (VR) (17, 18). VR coupled with haptic devices can provide sensitive assessment of the kinematic function of the upper limb after stroke (19, 20). Haptic-enabled VR can measure end-point kinematics of common daily tasks, such as pointing, while allowing free arm movements in a 3D space (17). Despite VR systems being in use in stroke rehabilitation (21), there are sparse data from longitudinal studies, although some data on the responsiveness of upper limb kinematics are available from robotic studies (22–24). Haptic devices coupled with VR systems are suitable for use in the assessment and rehabilitation of post-stroke individuals, even in telemedicine settings (25).Longitudinal studies of upper limb recovery after stroke using optoelectronic cameras have shown that movement time and smoothness improved up to 3 months after stroke (14, 15, 26). Kinematic movement deficits observed at 3 months post-stroke remained unchanged at 12 months in individuals with mild stroke impairment (13). Thus, the recovery of kinematics seems to follow a similar recovery pattern as observed in clinical assessments, although the evidence in kinematics remains sparse and varies between studies. In addition, longitudinal changes in the kinematics of the upper limb after stroke have not been studied using the pointing task in 3D virtual space.The aims of this study were to quantify the longitudinal changes in upper limb kinematics between day 3 and month 12 after stroke, and to identify the factors that affect this change, using the target-to-target pointing task performed in VR.     

COMPARISON OF USE OF PLASTER CASTING VERSUS ELASTIC BANDAGE FOLLOWING CARPAL TUNNEL RELEASE: A RANDOMIZED CONTROLLED STUDY

ObjectiveTo compare the effects of two postoperative regimens following carpal tunnel release; plaster casting and elastic bandaging.DesignA randomized controlled study.PatientsPatients with carpal tunnel syndrome and planned surgical carpal tunnel release were invited to participate.MethodsA total of 94 patients were randomized to either plaster casting or elastic bandaging to be used 2 weeks postoperatively. Muscle strength, pain rated on a visual analogue scale, range of movement, sensibility, oedema, and different scores regarding symptoms and function were measured before and 2, 4, 6, 8 and 26 weeks after surgery.ResultsNo differences were found between the 2 groups for any measurement, except for the DASH (Disability of the Arm, Shoulder and Hand) Health Score and daily function, rated 2 weeks postoperatively, in which the bandage group scored better. Both groups improved significantly over time for all measurements, sensibility was improved after 2 weeks, while strength was not fully recovered until week 26.ConclusionFollowing carpal tunnel release no benefits were found in using plaster casting, compared with elastic bandaging. Among these patients there was more discomfort during plaster casting compared with elastic bandaging; therefore plaster casting is not recommended following this type of surgery.LAY ABSTRACTNo clear consensus exists regarding benefits of use of plaster casting following carpal tunnel release. This study aimed to compare two different postoperative regimens in a randomized controlled study. A total of 94 patients were randomized to either plaster casting or elastic bandage to be used for 2 weeks after surgery for carpal tunnel release. Muscle strength, rated pain, range of movement, sensibility, oedema, and different scores regarding symptoms and function were measured before and 2, 4, 6, 8 and 26 weeks after surgery. No differences were found between the 2 groups for any measurement, except for health score and rated daily function 2 weeks postoperatively, in which the bandage group scored better. Both groups improved significantly over time for all measurements, sensibility was improved after 2 weeks, while strength was not fully recovered until week 26. This study found no benefits, but some disadvantages, of plaster casting following carpal tunnel release, and therefore plaster casting is not recommended for these patients.Key words: carpal tunnel syndrome, hand strength, range of motion, rehabilitation, self-assessment

Following open carpal tunnel release surgery, volar or dorsal plaster casting is sometimes used for a few weeks. However, the use of plaster casting is questioned and, frequently, an elastic bandage alone is used (1, 2). The benefit of casting is considered to be unloading of the surgical site and the nerve, thus facilitating healing and promoting pain relief (3). On the other hand, an elastic bandage is thought to enable early movement training to counteract stiffness and promote more rapid restoration of hand function (2).Previous studies have found no significant difference between the postoperative methods concerning function (4, 5), pain (6, 7), hand strength (7), sensibility (8), complications (5, 7, 8), and continuing symptoms using self-assessment (3, 4, 8, 9), while more pain and impaired strength with plaster casting in the short term was indicated in one study (5). Many previous studies had a limited number of patients and showed wide disparity regarding the number of days with a cast (2–21 days), the degree of mobilization of patients without a cast, treatment procedures, follow-up time-points and outcome measures (4–8, 10). Hence, a need for a prospective randomized multifactorial study that evaluates rehabilitation with or without cast treatment following carpal tunnel release has been proposed (9, 11). As the evidence is not clear, and plaster casting following carpal tunnel surgery is still in use at hospitals in Sweden, a randomized controlled study was necessary. In fact, the differences in clinical practice among hospitals in our region led to the initiation of this study.The aim of this study was to examine the rehabilitation process with or without the use of plaster casting, following carpal tunnel release, regarding strength, pain, flexibility, sensibility, swelling and self-rated function, with grip strength as the primary outcome measure. It was hypothesized that there would be no significant differences between the groups regarding any of these parameters.     

TEMPORAL EVOLUTION AND PREDICTORS OF SUBJECTIVE COGNITIVE COMPLAINTS UP TO 4 YEARS AFTER STROKE

ObjectiveTo examine the temporal evolution of subjective cognitive complaints in the long-term after stroke, and to identify predictors of long-term subjective cognitive complaints.MethodsProspective cohort study including 395 stroke patients. Subjective cognitive complaints were assessed at 2 months, 6 months and 4 years post-stroke, using the Checklist for Cognitive and Emotional consequences following stroke (CLCE-24). The temporal evolution of subjective cognitive complaints was described using multilevel growth modelling. Associations between CLCE-24 cognition score at 4 years post-stroke and baseline characteristics, depression, anxiety, cognitive test performance, and adaptive and maladaptive psychological factors were examined. Significant predictors were entered in a multivariate multilevel model.ResultsA significant increase in subjective cognitive complaints from 2 months up to 4 years (mean 3.7 years, standard deviation (SD) 0.6 years) post-stroke was observed (p≤0.001). Two months post-stroke, 76% of patients reported at least one cognitive complaint, 72% at 6 months, and 89% at 4 years post-stroke. A higher level of subjective cognitive complaints at 2 months and lower scores on adaptive and maladaptive psychological factors were significant independent predictors of a higher level of subjective cognitive complaints at 4 years post-stroke.ConclusionPost-stroke subjective cognitive complaints increase over time and can be predicted by the extent of subjective cognitive complaints and the presence of adaptive and maladaptive psychological factors in the early phases after stroke.LAY ABSTRACTMany people suffer a stroke in the brain leading to consequences in different areas of functioning. Complaints in the domain of thinking (memory, attention, planning and organization) are frequent post-stroke. This study investigated the occurrence and type of complaints experienced in the first years after a stroke. The study found that these complaints increase over time. Longterm complaints are found in those people who already have problems early after stroke.Key words: stroke, rehabilitation, cognition, cognitive complaints

Subjective cognitive complaints (SCC) are common after stroke, with prevalence rates varying between 28.6% (1) and 90.2%, (2), depending on stroke characteristics, time since stroke, SCC definitions and the instruments used. The most commonly reported complaints are mental slowness (in 46–80% of patients) and difficulties in concentration and memory (in 38–68% and 38–94% of patients, respectively) (3). Previous cross-sectional studies showed that SCC are present in both the early stages after stroke (1–6 months after stroke) (4–6), and in the long-term (> 1 year after stroke) (1, 7, 8). To date only a few studies have examined the temporal evolution of SCC. Tinson & Lincoln observed an increase in SCC between 1 and 7 months post-stroke (n = 95) (9). The authors used the Everyday Memory Questionnaire (10), focusing on memory-related complaints. Wilz & Barskova also found an increase in SCC over time after stroke (3 vs 15 months post-stroke, n = 81) (11). SCC were measured with the Patient Competency Rating Scale cognition subscale (12). Van Rijsbergen et al., who used the Checklist for Cognitive and Emotional consequences following stroke (CLCE-24) (13), recently found that SCC remained stable between 3 and 12 months after stroke (n = 155) (14). Long-term results on the course of post-stroke SCC are lacking. Since SCC were found to be independently related to lower quality of life in patients with mild cognitive impairment (15), and patients with subarachnoid haemorrhage (16), it is important to assess SCC after stroke. Furthermore, earlier research showed that SCC were most strongly associated with participation after stroke, compared with cognitive tests in a neuropsychological test battery, and the Montreal Cognitive Assessment (MoCA) (17, 18). Hence, in order to improve participation and integration in society after stroke, it is important to take the patients’ perspective into account, rather than only determining objective cognitive measures.The presence and severity of SCC is expected to be a direct reflection of the presence and severity of cognitive deficits. However, previous studies investigating the relationship between SCC and cognitive performance in stroke patients have shown conflicting results (1–4, 7, 8, 13, 19, 20). Other factors have shown to be related to SCC, in particular psychological factors, such as depressive symptoms (2, 4, 6, 7, 21), anxiety (21, 22), perceived stress (14), personality traits (7, 22), and coping style (23). To date, only one study on SCC used a longitudinal design (14), which prevents conclusions on the temporal evolution of SCC in stroke patients in the long term. Since more stroke patients survive, recover well and are discharged home nowadays, it is important to address predictors of SCC in the early phases after stroke, in order to identify patients who need more intensive monitoring at follow-up. Once identified, it is possible to investigate whether the patients will benefit from more focused rehabilitation programmes.The aim of this longitudinal study was to examine the temporal evolution of SCC, from 2 months until 4 years post-stroke. Furthermore, the study assessed which factors are predictive of SCC at 4 years post-stroke, taking into account demographic and stroke-related characteristics at baseline, and cognitive deficits and psychological factors measured at 2 months post-stroke.     

DESCRIBING COMMUNITY-BASED REHABILITATION SERVICES IN INDONESIA BY USING THE INTERNATIONAL CLASSIFICATION OF SERVICE ORGANIZATION IN REHABILITATION 2.0

ObjectiveDescribing rehabilitation services in a standardized way is a challenge. The International Classification of Service Organizations in Rehabilitation (ICSO-R) 2.0 was published for this purpose. The ICSO-R was criticized for being tested mainly in high-income countries, and because the testing in lower-income countries did not include community-based rehabilitation services. Therefore, this study was performed to describe community-based rehabilitation services by using ICSO-R 2.0.MethodsThe ICSO-R 2.0 was used to describe 8 community-based rehabilitation services located in 3 cities in 3 different provinces in Indonesia: 6 community-based rehabilitation services in Bandung, West Java; 1 in Tanah Datar, West Sumatra; and 1 in Gowa, South Sulawesi.ResultsAll the community-based rehabilitation services were owned by the government, as a public body, and in the context of the community. The 6 community-based rehabilitation services in Bandung, West Java, are under the government city of Bandung, while the other 2, from Tanah Datar and Gowa, are integrated within primary healthcare centres. Social welfare supports all 6 community-based rehabilitation services in Bandung. The other 2 community-based rehabilitation services are supported by their respective primary healthcare centres.ConclusionThe ICSO-R 2.0 is a feasible tool to describe rehabilitation services, including community-based rehabilitation.LAY ABSTRACTThe International Classification of Service Organizations in Rehabilitation (ICSO-R) 2.0 was published as a framework to support describing rehabilitation service organizations. The process of development of the ICSO-R did not include Community-Based Rehabilitation Services. Therefore, to rectify this, ICSO-R 2.0 was used for this study. Eight community-based rehabilitation services were surveyed, located in 3 cities in Indonesia; namely Bandung, Tanah Datar, and Gowa. This study found that ICSO-R 2.0 can be used to describe rehabilitation services not only in hospitals, but also in the community.Key words: International Classification of Service Organizations in Rehabilitation, ICSO-R, classification, community-based rehabilitation, rehabilitation, health service organization

Strengthening rehabilitation in health systems has become a worldwide agenda. It was accelerated after the launched of the United Nations Convention on the Rights of People with Disabilities (UN-CRPD; (1)), particularly article 26, which mentions habilitation and rehabilitation. Later, the adoption of the Global Disability Action Plan of WHO in 2014 (2), Rehabilitation 2030: A Call for Action (3), and Recommendations for Rehabilitation in the Health System (4) clearly stated the need to strengthen rehabilitation services. In addition, rehabilitation services are also mentioned in the World Report on Disability (1–3, 5).Rehabilitation services have 2 definitions. The first definition is “a set of measures that assist individuals who experience, or are likely to experience, disability to achieve and maintain optimal functioning in interaction with their environments” (5). This definition describes rehabilitation programmes for health conditions (rehabilitation at the micro-level). Another defines rehabilitation services based on how the rehabilitation service is organized (6, 7). The latter definition is related to rehabilitation at the meso-level of the health system (8). Responding to the latter definition, which was not clearly defined, the International Society of Physical and Rehabilitation Medicine – World Health Organization Liaison Committee (ISPRM-WHO LC) working group published its first proposal, which is called the International Classification of Service Organizations in Rehabilitation (ICSO-R) (6). Following testing and review by international experts, the second version was published recently (ICSO-R 2.0) (7). ICSO-R 2.0 consists of 2 dimensions; service providers and service delivery. These dimensions consist of 9 and 14 categories, respectively.According to the Rehabilitation Recommendations of WHO (4), rehabilitation services should be integrated into the health system, including availability both in hospitals and the community. In Indonesia, rehabilitation services should be integrated into tertiary and secondary hospitals (9). In addition, rehabilitation services are also available at rehabilitation medicine practices, organized by physical and rehabilitation medicine (PRM) physicians, physiotherapists (PTs), occupational therapists (OTs), and speech and language therapists (SLT). In Indonesia, at the community level, rehabilitation services are delivered at communitybased rehabilitation (CBR) services, particularly in areas where rehabilitation services at the hospital are unavailable or lacking.CBR is one type of rehabilitation service that is mostly provided in the community (10). It was originally established to give access to people with disability where there was no access to rehabilitation services in hospital. Many studies have reported on rehabilitation programmes for different health conditions, provided at CBRs, such as schizophrenia (11), stroke (12), spinal cord injury (13), and post knee arthroplasty patients (14).Structurally, CBRs can be categorized as one type of rehabilitation service organization. However, to the best of our knowledge, there has been no study describing CBRs as an organization delivering services, or describing how CBRs are organized systematically. Before publishing the ICSO-R 2.0, the testing of the first version of the ICSO-R was performed mostly at tertiary or academic level hospitals. Therefore, this study aimed to review the feasibility of using the ICSO-R 2.0 to describe CBR services.     

EFFECTIVENESS OF SPECIALIZED REHABILITATION AFTER MILD TRAUMATIC BRAIN INJURY: A SYSTEMATIC REVIEW AND META-ANALYSIS

ObjectiveTo determine the effectiveness of specialized rehabilitation in adults with prolonged symptoms, or risk of prolonged symptoms, following mild traumatic brain injury.Data sourcesRandomized controlled trials or non-randomized controlled studies published between 1 Jan 2000 and 10 Mar 2019 in Cochrane Controlled Register of Trials, PubMed, EMBASE, CINAHL or PsycINFO. Meta-analyses were performed for studies of similar interventions when identical or comparable outcomes were reported.Study selection and data extractionScreening, data extraction, and risk of bias assessment were carried out by 2 independent researchers. Quality of evidence was assessed using Grading of Recommendations Assessment, Development, and Evaluation.Data synthesisA total of 9 studies were identified, which were divided into 3 subgroups. Results from meta-analyses implied that problem-solving therapy and cognitive behavioural therapy reduce residual symptoms, improve psychological functioning, decrease depression, increase activity and participation, and improve quality of life, compared with usual care. The meta-analyses also suggested that specialized interdisciplinary rehabilitation reduces residual symptoms.ConclusionPersons with mild traumatic brain injury who are at risk of, or who experience, prolonged symptoms should be considered for specialist treatment, as they may experience positive effects from cognitive behavioural therapy, problem-solving therapy, or interdisciplinary team rehabilitation. Further research is required to strengthen the evidence.LAY ABSTRACTThe aim of this study was to determine what type of rehabilitation is most effective for prolonged symptoms in adults following mild traumatic brain injury. The study compared specialized rehabilitation, carried out by healthcare professionals specialized in brain injury rehabilitation, with less specialized rehabilitation, or no rehabilitation at all. Several established databases were searched, yielding 9 relevant studies. There was some evidence that problem-solving therapy and cognitive behavioural therapy reduce symptoms, improve psychological functioning, decrease depression, increase activity and participation, and improve quality of life compared with usual care. There was also some evidence that specialized interdisciplinary rehabilitation reduces residual symptoms. However, few studies assessed the same type of rehabilitation or used the same outcome measures. Further research is therefore required to strengthen the certainty of this evidence.Key words: brain injury, traumatic, cognitive behavioural therapy, post-concussion syndrome, problem-solving, rehabilitation, quality of life

Mild traumatic brain injury (mTBI) accounts for the majority of all brain injuries worldwide (1). The estimated annual incidence of persons seeking hospital care after traumatic brain injury (TBI) in the European Union (EU) is approximately 490 per 100,000, of which 90% are mTBI (1), and a significant number of persons experience prolonged symptoms for months, and, in many cases, years (2–4). Results from a large European multi-centre study imply that up to 46% of subjects experience persisting symptoms at 3 months after mTBI in complicated cases (presence of intracranial injury on computed tomography (CT) scan), and 35% in uncomplicated cases (5). In a US multi-centre study (TRACK-TBI study), 53% reported functional limitation 12 months after the injury compared with 38% of the orthopaedic controls (6). In the TRACK-TBI study, 23% of the mTBI population had had a previous TBI, which may have affected the high prevalence of prolonged functional limitations (6). Commonly reported symptoms are fatigue, forgetfulness, and slowing of thinking, but also emotional symptoms (5). However, only a minority of patients have abnormal findings on CT after mTBI (7), and several factors contribute to the reports of prolonged symptoms (8).Development of long-term sequelae is debated, as the outcomes of different studies diverge. This could be due to several factors (9). One important aspect is the ambiguity regarding the definition of mTBI. In the World Health Organization (WHO) Task Force report, 38 different definitions were listed (10). Although most current studies apply the criteria of the American Congress of Rehabilitation Medicine (ACRM) (11) or WHO Task Force criteria (10), the definition is broad, making the study population heterogeneous regarding, for example, the degree of severity of mTBI (12). This, in combination with other factors regarding recruitment strategies in studies, such as different inclusion and exclusion criteria, including age, timing, and setting, may contribute to difficulties in comparing studies and explain the diverging results (13, 14).The choice of measurement instruments could be another factor that contributes to the ambiguity. Self-experienced cognitive symptoms do not always correspond to objective test results (15), results from self-rating instruments often correlate with depression and other inner states (16), and if objective tests are used there is a risk that they may not be sensitive enough to capture the subtle cognitive impairments that result from mild TBI (9). The above-mentioned factors, combined with great individual variation in cognitive function, makes it difficult to predict outcome and contributes to a lack of consensus and limited evidence on how to treat these symptoms.Taken together, mTBI can lead to a variety of prolonged symptoms, but ambiguities regarding expected symptoms and which treatments are effective can lead to unequal care and sometimes to misdiagnosis (e.g. depression). Although there are many practice guidelines on how to manage prolonged symptoms after mTBI (17), there is a lack of evidence-based treatments, leading to a risk of inappropriate treatments or no treatment at all. A systematic Cochrane review (18) found strong evidence for a good recovery for the majority of patients with mTBI if appropriate information and advice was offered early after injury (18).To the best of our knowledge, no systematic review has assessed the effectiveness of specialized rehabilitation in adults with prolonged symptoms of mTBI. The objective of this systematic review and meta-analysis was to determine the effectiveness of specialized rehabilitation in adults with prolonged symptoms, or who are at risk of prolonged symptoms following mTBI.     

EFFECT OF A COMPREHENSIVE EREHABILITATION INTERVENTION ALONGSIDE CONVENTIONAL STROKE REHABILITATION ON DISABILITY AND HEALTH-RELATED QUALITY OF LIFE: A PRE–POST COMPARISON

ObjectiveTo compare the effect on disability and quality of life, of conventional rehabilitation (control group) with individualized, tailored eRehabilitation intervention alongside conventional rehabilitation (Fast@home; intervention group), for people with stroke.METHODSPre–post design. The intervention comprised cognitive (Braingymmer®) and physical (Telerevalidatie®/Physitrack®) exercises, activity-tracking (Activ8®) and psycho-education. Assessments were made at admission (T0) and after 3 (T3) and 6 months (T6). The primary outcome concerned disability (Stroke Impact Scale; SIS). Secondary outcomes were: health-related quality of life, fatigue, self-management, participation and physical activity. Changes in scores between T0–T3, T3–T6, and T0–T6 were compared by analysis of variance and linear mixed models.ResultsThe study included 153 and 165 people with stroke in the control and intervention groups, respectively. In the intervention group, 82 (50%) people received the intervention, of whom 54 (66%) used it. Between T3 and T6, the change in scores for the SIS subscales Communication (control group/intervention group –1.7/–0.3) and Physical strength (–5.7/3.3) were significantly greater in the total intervention group (all mean differences< minimally clinically important differences). No significant differences were found for other SIS subscales or secondary outcomes, or between T0–T3 and T0–T6.ConclusioneRehabilitation alongside conventional stroke rehabilitation had a small positive effect on communication and physical strength on the longer term, compared to conventional rehabilitation only.LAY ABSTRACTDigital eRehabilitation, including cognitive/physical exercises, activity-tracking and psycho-education, is available for rehabilitation after stroke. In daily practice, these are used in parallel, and evidence regarding the effect of combining applications is scarce. The aim of this study was to investigate the effect of eRehabilitation in clinical practice. Outcomes for 153 people with stroke admitted to conventional rehabilitation only (control group) were compared with the outcomes for 165 people with stroke admitted when eRehabilitation was available (intervention group). A total of 82 people in the intervention group (50%) received the intervention, of whom 54 (66%) used it. In the first 3 months of rehabilitation, no differences were found between the groups. Between 3 and 6 months, the intervention group as a whole showed greater improvements regarding communication and physical strength. However, differences were below minimal clinical importance. In conclusion, adding eRehabilitation alongside conventional stroke rehabilitation had a small positive effect on communication and physical strength on the longer term, compared to conventional rehabilitation only.Key words: eHealth, stroke, rehabilitation, comprehensive healthcare, patient-reported outcome measures, telerehabilitation, Stroke Impact Scale, eRehabilitation

Worldwide, approximately 9 million people have a stroke each year, in many cases leading to a broad range of long-term disabilities with a major impact on multiple areas of life (1). More than half of people with stroke still have physical, mental and/or cognitive impairments 6 months post-stroke (2, 3). In order to enhance recovery of functioning, people with stroke may be referred to inpatient or outpatient specialized rehabilitation facilities offering multidisciplinary treatment (4). In the Netherlands, approximately 10% of people with stroke are admitted to such facilities, mostly those with severe disability and the potential for recovery (5).During the last decade there has been increasing interest in the use of digital technologies to deliver rehabilitation, termed eRehabilitation, in specialized rehabilitation facilities. Examples of eRehabilitation applications relevant for stroke rehabilitation are: virtual reality (6), online communication and consultation (7, 8), and applications for the delivery of specific physical or cognitive exercises (9). A number of systematic reviews on eRehabilitation in stroke, published in the past 10 years, have assessed their effectiveness within the first 6 months after stroke, and concluded that these applications may result in increased access to care (9) and time spent on therapy-related activities (6). Moreover, improved healthcare outcomes, such as in walking speed, balance and mobility (6), cognition and mood (8), and health-related quality of life (HRQoL) (7), were found.To date, most studies on eRehabilitation in stroke have focused on interventions targeting a single domain of rehabilitation treatment (9). In daily practice, however, people with stroke face multiple and distinct problems. Therefore, different applications may be useful at the same time. However, making an appropriate selection and handling different means of access are only a few of the many challenges people with stroke and healthcare professionals face in the use of eRehabilitation. Integrating a selection of various eRehabilitation applications within a single combined intervention would greatly increase their user-friendliness, especially if the selection appropriately addresses the needs of the individual patient (10).Evidence on the effectiveness of such comprehensive eRehabilitation interventions, combining eRehabilitation applications covering more than one domain of early rehabilitation treatment is scarce. Three controlled clinical trials have studied multiple applications combined in a single intervention, i.e. online exercise programmes with activity tracking or stroke-related education (11–13). All 3 studies compared a comprehensive eRehabilitation intervention with conventional rehabilitation, showing equal effect with respect to improvement in motor function and knowledge about stroke (11–13). However, none of these studies included people with stroke admitted to a specialized rehabilitation facility (14), nor did they explore the effects of eRehabilitation when integrated with conventional rehabilitation service delivery. The latter is striking, as it is suggested that eRehabilitation should preferably be offered alongside conventional stroke rehabilitation in order to achieve its full potential (15).The aim of the current study was to compare the effect on disability and HRQoL of a comprehensive eRehabilitation intervention, Fit After STroke @home (Fast@home), consisting of different components offered in addition to conventional stroke rehabilitation in a specialized rehabilitation facility.     

PARTICIPATION AND QUALITY OF LIFE IN PERSONS LIVING WITH SPINAL CORD INJURY IN NORWAY

ObjectivesTo describe the association between sociodemographic and spinal cord injury characteristics, of people living with spinal cord injury, and participation and quality of life, and to study the association between participation and quality of life in this group of people.DesignPersons registered in the Norwegian Spinal Cord Injury Registry after post-acute rehabilitation between 2011 and 2017 were invited to participate in a survey in 2019 when they were in a community setting.SubjectsA total of 339 people living with spinal cord injury.MethodsThe Frequency scale and Restrictions scale of the Utrecht Scale for Evaluation of Rehabilitation-Participation were used to measure participation. Quality of life was measured as life satisfaction with the World Health Organization Quality of life assessment (WHOQoL-5) and mental health was measured using the Mental Health subscale (MHI-5).ResultsOverall, sociodemographic characteristics were more prominently associated with quality of life and participation than were spinal cord injury characteristics. Currently working as main activity and having a family income in the highest quartile were associated with higher scores on all 4 measures of participation and quality of life. There was a strong gradient between higher level of participation (frequency and restrictions) and better quality of life.ConclusionParticipation was strongly associated with life satisfaction and mental health in people living with spinal cord injury. This indicates that participation issues should be given greater priority during post-acute rehabilitation, follow-up and subsequent care efforts provided in the community.LAY ABSTRACTHaving paid work, leisure-time activities and good relationships with other people is important for one’s quality of life. For people living with spinal cord injury, it may be more difficult to participate in such activities than it is for people without health problems. A survey on participation problems was carried out among Norwegians living with spinal cord injury. Sociodemographic factors, such as family income and education, were found to have a greater impact on quality of life and participation, than the severity of the injury itself. Participation was strongly associated with life satisfaction and mental health. This indicates that participation issues should be given greater priority.Key words: spinal cord injuries, participation, quality of life, Norway

Participation provides opportunities for the fulfilment of basic human needs and can be an important determinant of quality of life (QoL) (1). Persons living with spinal cord injury (SCI) may, however, experience restrictions or barriers to participation in different domains, including employment or social-recreational activities (2). Research on issues related to participation problems among persons with SCI is, however, limited. In a critical systematic review on social and community participation following SCI (3), the authors emphasized that the samples in the reviewed studies were relatively small, that the instruments used were often developed before the introduction of the International Classification of Functioning, Disability and Health (ICF), and that the use of the term ”participation” varied. In addition, knowledge about the impact of injury characteristics on participation is underdeveloped (2). Furthermore, limited attention has been given in the literature to how clinical practice can be adapted to improve participation in persons with SCI. To do so, more knowledge of factors influencing participation is needed.In the ICF, ”participation” refers to the involvement of an individual in a life situation and represents the social perspective on functioning (4). To measure participation, it has been recommended to measure participation both as the so-called objective state and subjective experience (5). Objective participation can be measured as self-reported frequencies of behaviour, while subjective participation concerns self-reported experienced restrictions in participation in society. It has been commented that the ICF definition of participation does not adequately capture this (6).QoL is a broad concept, and has been defined by the World Health Organization (WHO) as the individuals’ perceptions of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards and concerns. It can be operationalized to distinguish between the cognitive component that refers to life satisfaction and the emotional component that refers to a person’s affect or mental health (8).People with SCI experience lower QoL, as shown by higher levels of distress, worse mental health and lower levels of life satisfaction compared with the general population (9, 10). Studies have indicated that decreased mobility (11, 12), having secondary impairments (11, 12), pain (11, 13) and unemployment (14) are associated with lower QoL. Increased QoL has been associated with psychosocial characteristics, such as higher self-efficacy (15), good social skills (15), more social support (9) and a feeling of acceptance (16). The associations between QoL and age, sex, education, injury level and injury duration are inconsistent (9, 12, 17). However, there is variation in study design, inclusion criteria, and measure instruments, and cohort studies with a representative sample and sufficient sample size have been requested (9).Studies exploring the association between participation and QoL indicate that participation is related to higher life satisfaction (1, 18). However, little is known about risk groups for poor participation and poor QoL and knowledge about risk profiles can help in intervention planning.The objectives of this study were therefore to assess participation and QoL with validated generic measurement instruments in a representative sample. Specific aims were: (i) to describe the association between sociodemographic and SCI characteristics with participation and QoL; (ii) to detect groups at risk for low participation/poor QoL; and (iii) to study the association between participation and QoL.     

MEASUREMENTS OF THE CENTRE OF PRESSURE OF INDIVIDUAL LEGS REVEAL NEW CHARACTERISTICS OF REDUCED ANTICIPATORY POSTURAL ADJUSTMENTS DURING GAIT INITIATION IN PATIENTS WITH POST-STROKE HEMIPLEGIA

ObjectivesTo determine whether individual measurements of the centre of pressure for the stance and stepping legs can reveal new characteristics of reduced anticipatory postural adjustments during gait initiation in post-stroke hemiplegic patients.MethodsSubjects included 30 stroke patients and 10 healthy age-matched controls. The acceleration of the trunk, and the centre of pressure of each leg, were measured during gait initiation, 3 times each with the paretic and non-paretic legs leading. Anticipatory postural adjustments were characterized using trunk acceleration and centre of pressure displacement data.ResultsLatency of the posterior displacement peak of the paretic leg centre of pressure with either the paretic or non-paretic leg leading was significantly longer in stroke patients compared with controls, and was also longer than that of the non-paretic leg. The magnitude of the posterior displacement peak of the paretic leg centre of pressure was smaller than that of the non-paretic leg. Peak latency of the paretic stepping leg centre of pressure correlated with the clinical measures of motor dysfunction, postural balance, and gait ability.ConclusionMeasurements of the latency and magnitude of centre of pressure displacement peak individually for the paretic and non-paretic legs can help elucidate the mechanism behind reduced anticipatory postural adjustments. This information will be useful in designing new treatment strategies for stroke patients.LAY ABSTRACTMeasuring the centre of pressure individually for the stance and stepping legs can reveal what happens during initiation of gait in stroke patients. The latency and magnitude of the centre of pressure displacement peak showed characteristic differences between stroke patients and control subjects, and between paretic and non-paretic legs. The peak latency of the paretic stepping leg centre of pressure correlated significantly with clinical measures of motor dysfunction, postural balance, and gait ability. These findings may contribute to the development of effective rehabilitation exercises for stroke patients.Key words: postural control, balance, posture, kinematics, gait

Balance control during gait initiation is crucial for starting stable gait, both in healthy individuals and in people with neuromuscular limitations (1, 2). Motion analyses of electromyograms, accelerations, and ground reaction forces during gait initiation can provide important clinical information for understanding the balance control mechanism. In post-stroke hemiplegic patients, sensory and motor impairments often make good balance control challenging (3–6). In particular, spasticity interferes not only with balance and gait, but also leads to suppression of the soleus muscle, which is required for gait initiation, and makes initiation of gait more difficult (4, 7, 8). The basic problems include motion asymmetry and unstable weight shift to the stance side during gait initiation. The unstable gait initiation is thought to be due to hypometric anticipatory postural adjustments (APAs) (8–10).APAs are changes in posture prior to voluntary movement, which contribute to postural adjustments during gait initiation (11). Gait initiation APAs include activation of the tibialis anterior and suppression of the soleus prior to the start of movement (12, 13), along with posterior shift of the centre of pressure (COP) (14, 15). APAs might account for the time required for the combined COP, i.e. the mean COP of both legs, to shift from the centre of both soles to the posterior part of the stepping leg and then to the posterior part of the stance leg (16). APA occurs in the postural phase, and some reports have determined COP changes until heel-off of the stepping leg (17), while other reports have used COP changes until foot-off as the end of the APA period (16). Lateral and posterior shifts of the combined COP, which are typical measures of APAs during gait initiation, are known to be smaller in stroke patients (3, 10). Furthermore, in stroke patients, inactivation of the tibialis anterior on the paretic side, prolonged latent suppression of the soleus, and smaller shifts of the combined COP indicate reduced APA function (3, 8).To the best of our knowledge, there are no detailed reports of the relationship between reduced APA function and the COP of the stance and stepping legs or of the paretic and non-paretic legs during gait initiation in stroke patients. Assessing COP in each leg individually might provide a better understanding of reduced APAs in stroke patients, with a view to devising better treatments while noting that asymmetry between the stance and stepping legs during gait initiation, and non-uniformity in the vertical component of the ground reaction force have been reported in healthy adults and elderly people (18, 19). Therefore, in post-stroke hemiplegic patients also, it is necessary to look for the details of reduced APA in individual COPs. The latency of muscle activity is important in assessing APA, and has been reported in many studies (17). On the other hand, when assessing APA, changes on each side in individual COPs remain unclear. Investigating factors in the reduced APAs with a focus on individual COPs is thus important in obtaining clinical treatment suggestions for post-stroke hemiplegic patients. The stabilometers used to assess individual COPs are compact and inexpensive, and are widely used even in clinical practice to quantify posture and balance. Electromyograms are often used to analyse APAs (8, 20), but accelerometers and stabilometers are also coming into widespread use because of the low burden on the patient and the simplicity of clinical measurements (10, 21).The aim of the current study was therefore to investigate whether individual COPs show new characteristics of reduced APAs in post-stroke hemiplegic patients. The initial hypothesis was that the peak latency and the peak magnitude of displacement in individual COPs, as characteristics of the reduced APAs in post-stroke hemiplegic patients, are asymmetrically prolonged and decreased, respectively. The second hypothesis was that the characteristic changes in individual COPs are associated with motor impairments, balance indices, and gait ability in post-stroke hemiplegic patients.     

COGNITIVE FUNCTION AND PERFORMANCE OF EVERYDAY ACTIVITIES IN ADULTS WITH SPINA BIFIDA

Background and objectiveIndividuals with spina bifida often have cognitive impairments leading to difficulties in education and daily activities. The aims of this study were to explore cognitive impairments in adults with spina bifida and to consider associations between impairments, educational outcome and performance of daily activities, comparing individuals with and without intellectual disability.MethodsData were collected on 35 adults with spina bifida via cognitive tests and Assessment of Motor and Process Skills (AMPS). Participants were divided into 3 groups: individuals without intellectual disability who completed compulsory education (NID-C); those without intellectual disability, who failed to successfully pass compulsory education (NID-F); and those with intellectual disability failed to successfully pass compulsory education (ID-F).ResultsAll individuals with intellectual disability failed to successfully pass compulsory education (group ID-F) and had poorer scores across almost all measures than group NID-F and significantly poorer scores than group NID-C. All except 6 individuals scored below cut-off levels for effort and safety on both AMPS motor and process scales; more significant associations were seen between the cognitive tests and the motor rather than process scale.ConclusionCognitive impairments, irrespective of intellectual disability, impact on the performance of everyday activities and on educational achievement, and thus need to be considered in assessments and interventions to improve outcomes and promote independence in people with spina bifida.LAY ABSTRACTIndividuals with spina bifida often have cognitive impairments, resulting in difficulties in performing their everyday life activities at home, in education, training and social life. These difficulties are often not recognized, and the individuals do not receive the support they need from society. This study investigated the relationship between cognitive impairments, school achievements and performance of daily life activities of 35 adults with spina bifida. The study examined whether individuals had an intellectual disability, and whether they had completed compulsory education, and compared this with their cognitive function and performance in everyday activities. The results confirm that individuals with cognitive impairments, even those without intellectual disabilities, often have considerable difficulties in school achievements, and performance of daily life activities, reducing their ability to live independently.Key words: disability evaluation, intellectual disability, cognitive function, activities of daily living, spina bifida

Spina bifida (SB) is caused by the incomplete closing of the embryonic neural tube, which can affect brain development, with consequent sensory and motor difficulties (1, 2). Hydrocephalus is present at birth in 80–85% of individuals with SB (3), and by adulthood 63% are estimated to have hydrocephalus (4). Hydrocephalus leads to structural anomalies in the brain (1), which seem to contribute to a cognitive phenotype with relative strengths and weaknesses (5) and differing degrees of cognitive impairments amongst individuals with SB (6). One in 5 individuals with SB and hydrocephalus are reported to have an intellectual disability (ID) (intelligence quotient (IQ) < 70) (7). Furthermore, according to several studies many other individuals with SB show impaired executive functions (EF)¹, which become more evident when performing more complex activities (5). Impaired working memory (9), a part of EF (8), and prospective memory (10) are also common, as well as attention disorders (11), impaired processing speed, timing deficits (5), problems with time management (12) and with getting things done (13). Impaired visuospatial function is also common (11). In general, individuals with SB have no limitations in reading, vocabulary, grammar, and sentence structure, but may have difficulties in understanding the underlying meaning of words and in drawing conclusions (5). Reduced reading comprehension and reduced numeracy are also common (5). Learning capacity is often unaffected, but individuals may have difficulties in processing and retrieving information (5). These cognitive impairments can be observed in childhood and become more evident during adolescence and adulthood, when activities of daily living (especially taking care of your own household), education, work and relations put increased demands on the person (14). Several studies found that cognitive impairments in individuals with SB do not decrease with maturity, but persist into adulthood (9, 14). Furthermore, impairments in prospective memory have also been shown to increase for persons over 32 years of age (10). Few studies have examined the effects of ageing on cognitive function in individuals with SB (9).Cognitive impairments are associated with quality of life (15) and affect performance of daily activities negatively for adults with SB (16), with potential impact on health and wellbeing (4, 17). Impaired EF may limit young adults in achieving milestones of independence in life, like education, work, relationships and assuming responsibility for their own household (18). Many individuals with SB do not reach secondary education and have difficulties in obtaining a job (19). Further challenges may appear in adulthood with the need to manage contacts with authorities regarding special transportation services, housing, and community-based support services, etc. (20). Moreover, management of personal hygiene and medication due to complex SB-related disabilities put additional demands on EF (20). Consequently, impaired EF increases risks for complications, such as pressure ulcers, urinary infections, incontinence, and constipation (21). However, individuals with SB are often highly verbal, giving the impression of managing everyday life well (22). Thus, healthcare professionals and others not specialized in the field seldom recognize these cognitive limitations (23). The need for support may go unrecognized, and interventions may be insufficient or even fail (24).In order to provide appropriate support, there is a need for assessments to recognize the range of cognitive impairments in individuals with SB and to consider how these impact on educational outcomes (completion of compulsory education²) and performance of daily activities (especially household activities). The aims of the current study were to explore cognitive impairments in adults with SB and to consider associations between these impairments, educational outcome, and performance of daily activities, comparing individuals with and without intellectual disabilities (ID).     

IMPACT OF REHABILITATION START TIME ON FUNCTIONAL OUTCOMES AFTER STROKE

ObjectiveTo investigate the optimum rehabilitation start timing for improved functional outcomes after stroke in Japan.DesignA retrospective database study.SubjectsA total of 140,655 patients with stroke from 1,161 acute hospitals in Japan. Only data for those patients who were discharged alive was included in the analysis.MethodsActivities of daily living were assessed. Comparisons were made using the rehabilitation start day after hospital admission. Reference day 2 was compared with days 1, 3, 4, 5, and 6 or later. Modified Rankin Scale at time of discharge was used as the primary outcome. In addition, cases of ischaemic stroke and haemorrhagic stroke were analysed as separate subgroups.ResultsUnivariate and multivariate logistic regression analyses showed that starting rehabilitation on day 2 resulted in a better outcome than starting on day 3 or later. There was no significant difference in outcome between starting rehabilitation on days 1 or 2 in all cases and subgroup of patient with infarction stroke. For a subgroup of patients with haemorrhagic stroke, starting rehabilitation on day 2 resulted in a better outcome than starting on day 1.ConclusionStarting post-stroke rehabilitation on the day of admission or second day of hospitalization may be the optimum timing for functional outcomes. However, for haemorrhagic stroke, starting rehabilitation on the second day of hospitalization may be more effective than on the day of admission.LAY ABSTRACTThis study examined the effect on functional outcomes of the time after stroke of starting rehabilitation. A large national database was searched for eligible stroke patients, resulting in a total of 140,655 patients from 1,161 hospitals. Starting rehabilitation on the day of admission or second day of hospitalization after stroke was found to be associated with better functional outcomes at discharge than starting rehabilitation on the third day or later. For patients with haemorrhagic stroke, those who started rehabilitation on the second day of hospitalization had better functional outcome at discharge than those who started on the day of admission. Thus, starting rehabilitation on the day of admission or the second day of hospitalization after stroke may be the best timing for improved functional outcomes. However, among patients with haemorrhagic stroke, starting rehabilitation on the second day of hospitalization may result in better outcomes than starting on the day of admission.Key words: early ambulation, recovery of function, stroke, time factor

Stroke is a major factor in causing functional impairment and often requires more resources for long-term care according to the Comprehensive Survey of Living Conditions in Japan (1). The number of people requiring nursing care and support in Japan’s long-term care insurance system has been increasing every year, with more than 6 million elderly people in 2015. In recent years, there has been increasing emphasis on stroke prevention and quality stroke care to control the further expansion of the number of people requiring care (2).For good-quality stroke care, early rehabilitation after stroke onset has been proposed in several Stroke Treatment Guidelines (3–5). Mechanism that may support the effectiveness of early rehabilitation include restoration of brain function, which promotes neuroplasticity (6), and reduction of bedridden syndrome, infections, deep vein thrombosis, and pressure sores (7). However, some researchers are concerned that starting too early rehabilitation may be harmful. One reason is that a head-up position reduces reperfusion of the penumbra region (8). Another reason is that the destabilization of blood pressure with exercise can inhibit the recovery of brain function (9). In addition, most stroke specialists have concerns about very early rehabilitation, especially in cases of haemorrhagic stroke. A possible reason is that patients with haemorrhagic stroke tend to die early after the attack, although the evidence regarding the timing of rehabilitation is insufficient (10).Several randomized controlled trials (RCTs) have examined the effectiveness of early rehabilitation, but it remains a controversial topic. Two RCTs have provided evidence that early rehabilitation is effective for physical functioning (11, 12), while other RCTs (13, 14) have not found such evidence. The latest multicentre RCT (14) concludes that very early rehabilitation leads to poor outcomes for physical functioning. However, some researchers have criticized the study design due to the short mean difference in rehabilitation start times between the intervention and control groups, being only 4 h. In addition, the variation in the timing of rehabilitation initiation in each RCT makes it difficult to interpret the effectiveness of early rehabilitation. For example, in the AKEMIS study (13), the mean time from stroke onset was set at 13.1 h in the intervention group and 33.3 h in the control group, compared with 18 and 22 h in the AVERT III study, and 27 and 32 h in the VERITAS study (12). Hence, the results of these RCTs may lead many clinicians to query when is the optimum time to start early rehabilitation after stroke.From the clinician’s point of view, it is important to determine whether rehabilitation should be provided very early after stroke, and when is the optimum time to start rehabilitation for good physical functioning outcomes. This study aimed to clarify these clinical questions, by investigating the impact of the timing of rehabilitation initiation after acute stroke on functional outcomes, using patient data from a Japanese multicentre database.