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.     

PHYSICAL ACTIVITY WITH PERSON-CENTRED GUIDANCE SUPPORTED BY A DIGITAL PLATFORM FOR PERSONS WITH CHRONIC WIDESPREAD PAIN: A RANDOMIZED CONTROLLED TRIAL

ObjectiveTo determine the effectiveness of a person-centred intervention, including advice on physical activity, for improving pain intensity, physical activity, and other health-related outcomes in persons with chronic widespread pain, when delivered with digital eHealth support compared with standard telephone follow-up.DesignRandomized controlled trial.SubjectsIndividuals with chronic widespread pain (n = 139), aged 20–65 years, who had previously participated in a pain educational programme at primary healthcare units, were contacted during the period 2018–19 and randomized to an intervention group (n = 69) or an active control group (n = 70).MethodsTogether with a physiotherapist, participants in both groups developed person-centred health plans for physical activity. The intervention group was supported via a digital platform for 6 months. The active control group received support via one follow-up phone call. Primary outcome was pain intensity. Secondary outcomes were physical activity and other health-related outcomes.ResultsNo significant differences were found between the groups after 6 months, except for a significant decrease in global fatigue in the active control group compared with the intervention group.ConclusionFuture development of interventions supporting persons with chronic pain to maintain regular exercise is warranted.LAY ABSTRACTDespite documented positive effects of physical activity in treating persons with chronic widespread pain, it is challenging for many individuals with chronic widespread pain to independently continue to be physically active over time. This study measured the effects of a person-centred health plan to promote physical activity, delivered using eHealth support compared with standard follow-up by telephone, in persons with chronic widespread pain. Participants with chronic widespread pain (n = 139) were randomized into 2 groups: an intervention group, in which participants created an individual health plan together with a physiotherapist and were provided with digital eHealth support for 6 months; and an active control group, who also created an individual health plan together with a physiotherapist, and received one follow-up support phone call. The results showed no significant difference between the groups regarding change in the primary outcome, pain intensity. The active control group showed a significant decrease in global fatigue compared with the intervention group. Future development of interventions supporting persons with chronic pain to maintain regular exercise is warranted.Key words: physiotherapy, chronic pain, eHealth, person-centred, randomized controlled trial, physical activity

Approximately 7–13% of the population of the Western world have chronic widespread pain (CWP) (1–3). CWP is defined as pain in both sides of the body, above and below the waist, and axial pain for at least 3 months (4); it is also characterized by symptoms such as increased tenderness, fatigue, reduced physical capacity and general health, and psychological distress (2, 5).Physical activity is the first-choice treatment for patients with chronic pain conditions, such as CWP and fibromyalgia (FM), as it has been shown to have positive effects on pain and other symptoms (6, 7). Although several clinical trials have shown that persons with CWP can gain positive health effects from regular, individually adjusted physical activity (7–9), it is challenging for many individuals with CWP to continue to be independently physically active over time, and the improvements gained are often lost. A person-centred approach, in which physical activity is adjusted to the individual’s resources, can enable persons with CWP to become regularly physically active (10, 11). Persons with CWP often experience increased pain during and after physical and psychological loading, which could be related to dysfunction in endogenous pain inhibition (12, 13).The use of eHealth interventions in healthcare is increasing rapidly (14). eHealth has been defined as “health services and information delivered or enhanced through the internet and related technologies” (15). eHealth interventions used to manage chronic pain in previous research have been based on providing information about pain, or used for communication between healthcare providers and patients, as an alternative to scheduled healthcare appointments (16). Studies on eHealth interventions in persons with chronic pain have found contradictory results, which may be due to differences in the type of eHealth interventions used. A systematic review of studies of persons with pain found promising evidence that internet-based peer-support programmes can lead to improvements in pain intensity, activity limitations, health distress, and self-efficacy (17). Another study found that persons with FM who received internet-delivered exposure treatment improved in symptoms and overall health status compared with a control group (18). However, a study of persons with CWP found no significant long-term improvements in terms of catastrophizing, daily functioning, symptom levels, acceptance of pain, or emotional distress, when using a smartphone-based intervention comprising diaries and therapist feedback (19).Overall, there is a lack of studies on eHealth interventions in persons with CWP, and specifically, on eHealth as support for physical activity. Although eHealth support to manage chronic pain seems to show encouraging results (16), it is unknown which patients benefit the most (17) or which eHealth techniques are effective.The aim was to determine the effectiveness of a person-centred intervention, including advice on physical activity, for improving pain intensity, physical activity, and other health-related outcomes in persons with CWP, when delivered with digital eHealth support compared with standard telephone follow-up.     

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.     

RESISTANCE BAND TRAINING AFTER TRIAMCINOLONE ACETONIDE INJECTION FOR SUBACROMIAL BURSITIS: A RANDOMIZED CLINICAL TRIAL

ObjectiveTo investigate the effect of progressive resistance training using resistance (elastic) bands on subacromial bursitis following triamcinolone acetonide injection.DesignRandomized clinical trial.PatientsA total of 68 patients with subacromial bursitis were randomized to a triamcinolone acetonide group or a triamcinolone acetonide plus resistance band training group.MethodsVisual analogue scale, Constant scores, range of motion, proprioception, and muscle strength were evaluated at pretreatment and at 3, 12 and 24 weeks’ follow-up. Re-treatment ratio was calculated at one-year follow-up.ResultsAt 3 and 12 weeks, both the triamcinolone acetonide group and triamcinolone acetonide plus resistance band training group showed a significant improvement in Visual analogue scale score, Constant score, range of motion, proprioception and muscle strength. Although the scores in the triamcinolone acetonide group had not increased at 24 weeks compared with baseline, the scores in the triamcinolone acetonide plus resistance band training group showed continued improvement at 24 weeks. A lower proportion of patients in the triamcinolone acetonide plus resistance band training bands group than in the triamcinolone acetonide group had received re-treatment at one-year follow-up (12.1% vs 82.9%).ConclusionProgressive resistance training with resistance (elastic) bands has the advantages of extending the benefits of corticosteroid injection and maintaining long-term effects on shoulder function in patients with subacromial bursitis.LAY ABSTRACTSubacromial bursitis is characterized by pain and stiffness of the shoulders. Corticosteroid injection is widely used in treating subacromial bursitis; however, with differing views on its long-term effects in preventing shoulder symptoms. Resistance (elastic) band training is commonly used to promote muscle activation during shoulder rehabilitation. The aim of this study was to investigate the effect of progressive resistance training with elastic bands on subacromial bursitis following triamcinolone acetonide injection. Patients with subacromial bursitis were randomized to a triamcinolone acetonide group or a triamcinolone acetonide plus resistance band training group. The triamcinolone acetonide group received triamcinolone acetonide injection only. Meanwhile, the triamcinolone acetonide plus resistance band training group received triamcinolone acetonide injection and resistance band training. At 3 and 12 weeks, both the triamcinolone acetonide group and triamcinolone acetonide plus resistance band training group showed a significant improvement in pain relief, mobility, and muscle strength. A lower proportion of patients in the triamcinolone acetonide plus resistance band training group than in the triamcinolone acetonide group had received re-treatment at the oneyear follow-up (12.1% vs 82.9%). Thus, training with resistance (elastic) bands has the advantages of extending the benefits of corticosteroid injection and maintaining long-term effects on shoulder function in subacromial bursitis.Key words: triamcinolone acetonide, elastic band training, resistance band training, subacromial bursitis

Subacromial bursitis (SB) is one of the most common clinical conditions characterized by anterior shoulder pain and restriction of range of motion (ROM) of the shoulder, which usually occurs during abduction and sometimes during rotation of the shoulder (1).Corticosteroid injections are widely used to treat shoulder pain in conditions such as rotator cuff disease, bursitis, and adhesive capsulitis, reducing inflammation and relieving pain (2–4). In some clinical studies, corticosteroid injections are defined as an effective short-term treatment and have potential side-effects with repeated injection. A controlled trial investigating the correlation between injection schedule and shoulder benefits found that the therapeutic effect lasted only 6 weeks after the injection and that the clinical improvements disappeared by 12 weeks, with more than half of patients experiencing recurrence of symptoms (5). Similarly, a study of methylprednisolone injection in the treatment of impingement syndrome also showed significant improvement in activities of daily living (ADL) variables and a decrease in sleep-disturbing pain, although these differences disappeared by 3 months (6). In addition, a review by Buchbinder et al. concluded that corticosteroid injection can be beneficial for shoulder pain, although its effect may be slight and temporary (7). In agreement with the above studies, our clinical practice has found that corticosteroid injection alone does not produce long-term benefits. Therefore, the clinical effect of corticosteroid injection in SB requires discussion and reconsideration.The muscles around the shoulder joint contribute to maintaining shoulder stability. Weakness or imbalance in shoulder muscle strength causes excessive stress on the joint and may lead to changes in shoulder biomechanics and shoulder disease. Muscle strength-training exercises are used to increase muscular development and improve neuromuscular control (8, 9). Progressive resistance training with a gradually increasing load is recommended to achieve neuromuscular activation and muscle strengthening and hypertrophy. Resistance training has been shown to enhance muscle strength and may be important in preventing shoulder injuries (10–12). Elastic bands (EB), a type of resistance training apparatus, can provide variable resistance and allow changes over a range of motions, which can prevent the risk of excessive weight loading during strength-training exercises. In addition, EB can provide efficient resistance and promote high levels of muscle activation for enhancing muscle strength in treating shoulder disease (13–15). Because of their simplicity and their economic and safety advantages, EB are commonly used during rehabilitation programmes and are available in most rehabilitation centres.Based on the above observations, this study aimed to examine the effect of EB training after triamcinolone acetonide (TA) injection on the treatment of SB. It was hypothesized that resistance training with EB could effectively treat SB with long-term benefits.     

SAFETY AND EFFICACY OF MESOTHERAPY IN MUSCULOSKELETAL DISORDERS: A SYSTEMATIC REVIEW OF RANDOMIZED CONTROLLED TRIALS WITH META-ANALYSIS

ObjectivesTo conduct a systematic review of randomized controlled trials about the safety (number and severity of adverse events) and efficacy (pain reduction and functional improvement) of mesotherapy in musculoskeletal disorders, and to compare them with other therapeutic options, in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement.MethodsA search of PubMed, Cochrane Library and Scopus database resulted in an initial total of 16,253 records. A total of 931 articles were included in the study. A final total of 7 articles, published from 1 Jan 1999 until 30 Apr 2020 were selected. Two independent reviewers selected potentially relevant studies based on the inclusion criteria for full-text reading. They evaluated the methodological quality of each study and included only studies of high methodological quality, according to the Physiotherapy Evidence Database scale.ResultsSeven studies were included in the metaanalysis, and visual analogue scale scores before and after mesotherapy were considered. A statistically significant reduction in visual analogue scale score in the mesotherapy group was reported in comparison with the control group in all except one of the trials. Mesotherapy was found to be a safe procedure with mild and temporary side-effects, such as nausea, fatigue, numbness, sweating, headache, ecchymosis, bleeding, pain and local reaction at the injection site.ConclusionMesotherapy proved to be more effective than systemic therapy in the treatment of local pain and functional limitations caused by a variety of musculoskeletal conditions. However, because of the heterogeneity of the analysed studies in terms of injected drugs, administration technique, associated treatments, frequency and total number of sessions, more randomized controlled trials are needed, comparing a standardized mesotherapy protocol with a systemic treatments.LAY ABSTRACTMesotherapy is a minimally invasive technique, based on microinjections of active drugs into the surface layer of the skin in the area to be treated. The treatment implies 2 advantages: a lower dose of drug and a rapid onset with a prolonged duration of action. The aim of this review was to analyse the safety and efficacy of mesotherapy in musculoskeletal disorders comparing it with other therapeutic options. An initial search of the literature retrieved 16,253 records. Two independent reviewers selected relevant studies based on the inclusion criteria. Furthermore, 7 studies were included for meta-analysis. The injected drugs were non-steroidal anti-inflammatory drugs (NSAIDs), corticosteroids, local analgesics and muscle relaxants, of different types and concentrations, alone or variously combined. Mesotherapy was performed in the painful area, via an intradermal or subcutaneous route. It resulted in a statistically significant reduction in visual analogue scale (VAS) score in comparison with the control group in all except one of the trials. Adverse events reported for mesotherapy were generally few and mild. In conclusion, mesotherapy may be effective in enabling pain relief and functional improvement in musculoskeletal disorders, allowing patients early access to rehabilitation services, such as physiotherapy and occupational therapy, in order to achieve better outcomes in terms of independence in activities of daily living.Key words: mesotherapy, intradermal injection, subcutaneous injection, soft-tissue injection, musculoskeletal disorder

Musculoskeletal conditions are extremely common and include more than 100 different syndromes and diseases, which are usually associated with pain and loss of function and are a major cause of disability (1).According to the Fit for Work Europe study, 100 million European citizens have chronic musculoskeletal pain, with high prevalence in the working population (2). Data from the 2016 United States Bone and Joint Initiative suggest that 50% of American people live with a musculoskeletal condition, a prevalence comparable to that of cardiovascular and chronic respiratory diseases combined (3).Musculoskeletal conditions cause more functional limitations in the adult population than any other disorder and are a major cause of years lived with disability worldwide. The prevalence of physical disabilities caused by a musculoskeletal condition has been estimated as to be high as 4–5% of the adult population living in Canada, the USA, and Western Europe (3).The 2016 Global Burden of Disease (GBD) data for non-communicable diseases stated that disability-adjusted life years (DALYs) for musculoskeletal conditions increased by 61.6% between 1990 and 2016, with an increase of 19.6% between 2006 and 2016 (3). In the 2017 GBD study, musculoskeletal conditions were the second highest contributor to global disability, accounting for 16% of all years lived with disability, and lower back pain remained the single leading cause of disability (4).Musculoskeletal pain and physical disability reduce social functioning and mental health, further diminishing the patient’s quality of life, but they also consume a large amount of health and social care resources. Their economic impact is well known, since they are associated with direct and indirect costs, with the latter being predominant (5).It has been estimated that musculoskeletal diseases account for 50% of absence from work and 60% of permanent work incapacity (5). Elderly patients with a musculoskeletal disease have lower level of physical activity, poorer mobility, frailty, depression, cognitive impairment, higher risk of falls, and poorer sleep quality (6, 7).Apart from non-pharmacological approaches, musculoskeletal pain disorders are traditionally managed with drugs to reduce pain, inflammation, and functional disability (8). However, the major drawback of systemic pharmacological therapy with analgesics and anti-inflammatory drugs is the frequent association with adverse effects, some of which can be life-threatening. Side-effects and drug–drug interactions can be detrimental, especially among older patients and those with concomitant disorders needing polytherapy (9, 10).Paracetamol use is associated with gastrointestinal, cardiovascular, hepatic and renal adverse events. Moreover, paracetamol hypersensitivity is not uncommon (11–13). Non-steroidal anti-inflammatory drugs (NSAIDs) have been associated with a wide range of adverse events affecting the gastrointestinal, cardiovascular, and renal systems (14). NSAIDs are recognized to be the most common drugs involved in hypersensitivity drug reactions, in particular in the case of systemic administration (15). Systemic administration of corticosteroids is associated with adverse events, such as hypertension, hyperglycaemia, hyperlipidaemia, weight gain, glaucoma, cataract, gastrointestinal toxicity, osteoporosis, myopathy, avascular necrosis, immunosuppression, impaired wound healing, mood disorders, memory deficit, and even psychosis (16). Opioids, used either alone or in combination with paracetamol and/or NSAIDs, may cause a variety of side-effects, which are dose-limiting and reduce quality of life (17).Among the various attempts to reduce systemic drug toxicity, the use of local therapy (e.g. interventional spine procedures, intra-articular or periarticular injections, topical administration of pharmacological agents) has gained popularity among physicians (18, 19). However, they require appropriately trained staff and equipment, and their therapeutic efficacy is controversial in many musculoskeletal disorders (20, 21). Intra-articular and periarticular injections are a viable option, but side-effects are still possible, such as infections and haematomas (22, 23).Mesotherapy is an alternative therapeutic treatment that can be effective and reliable to treat a variety of painful musculoskeletal syndromes. The term mesotherapy comes from the word “mésothérapie”, introduced by the French physician Michel Pistor (24). It has been defined as a minimally invasive technique, based on microinjections of active ingredients into the surface layer of the skin corresponding to the area to be treated (25). This “micro deposit” gives rise to a slower release of the drug into the surrounding tissues compared with parenteral administration, with the possibility of 2 advantages: a lower dose of active compound can be used; and a rapid onset and prolonged action duration can be achieved (25). The goal of the treatment is to modulate the pharmacokinetics of the injected substance and to prolong the pharmacological effects in the affected area; the local pharmacological effect can be obtained with a lower dosage (26).Concerning safety, some adverse events have been reported, many of which are caused by incorrect procedure, application by non-qualified personnel, or lack of asepsis technique (27).Despite the growing interest in mesotherapy, scientific evidence regarding this technique is weak and there is a paucity of randomized controlled trials (RCTs) on this subject (25–28). In 2011 and 2014 Mammucari et al. conducted a review of the literature concerning mesotherapy and drew up a series of recommendations in the form of consensus report: nevertheless, non-randomized controlled trials were included in the analysis, and the authors confirmed the need for further studies (29, 30). Paolucci et al. performed a systematic review to examine the efficacy and safety of mesotherapy. They found that mesotherapy was effective and well tolerated, but nonrandomized controlled trials were also included, and hence a comparison between different interventions was missing. Moreover, only the intradermal route of administration was considered (31). Recently Plachouri et al. have examined the efficacy of mesotherapy in the medical and cosmetic field, and have confirmed the need for larger systematic studies (27).ObjectivesThe aims of the current study were to conduct a systematic review and meta-analysis of the literature, including only high-quality RCTs, about the safety (number and severity of adverse events) and efficacy (pain reduction and function improvement) of mesotherapy in musculoskeletal disorders; and to compare them with other therapeutic options. Safety was considered the primary outcome and efficacy the secondary outcome. Both the intradermal and subcutaneous routes of administration of mesotherapy were included, despite different pharmacokinetics (28–32).     

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).     

A REHABILITATION PROGRAMME FOCUSSING ON PELVIC FLOOR MUSCLE TRAINING FOR PERSISTENT LUMBOPELVIC PAIN AFTER CHILDBIRTH: A RANDOMIZED CONTROLLED TRIAL

ObjectiveTo evaluate the effects of a rehabilitation programme for lumbopelvic pain after childbirth.MethodsWomen with lumbopelvic pain 3 months postpartum were included in a randomized controlled trial. Patients in the intervention group (n = 48) received pelvic floor muscle training combined with neuromuscular electrical stimulation of the paraspinal muscles for 12 weeks, while patients in the control group (n = 48) received neuromuscular electrical stimulation for 12 weeks. Outcomes were measured with the Triple Numerical Pain Rating Scale (NPRS), Modified Oswestry Disability Questionnaire (MODQ) and Short-Form Health Survey-36 (SF-36).ResultsThe NPRS score was significantly better in the intervention group at 12 weeks compared with the control group (p = 0.000). The MODQ score was significantly better at 6 and 12 weeks compared with the control group (p = 0.009 and p = 0.015, respectively). The mean value of the Physical Components Summary of the SF-36, was significantly better in the intervention group at 6 weeks (p = 0.000) and 12 weeks (p = 0.000) compared with the control group, but there was no significant improvement in Mental Components Summary of the SF-36.ConclusionA postpartum programme for women with lumbopelvic pain is feasible and improves the physical domain of quality of life.LAY ABSTRACTPostpartum lumbopelvic pain is common, and there are a range of treatments available. The aim of this study was to establish a programme for use in clinical practice, comprising pelvic floor muscle training combined with other traditional treatments. The programme was shown to reduce pain and improve patients’ quality of life. No adverse events occurred.Key words: lumbopelvic pain, biofeedback, myoelectric stimulation, pelvic floor, postpartum women

Lumbopelvic pain refers to self-reported pain in the lower back, sacroiliac joints, or a combination of these locations, among pregnant and postnatal women (1). The pain may radiate into the posterior thigh and is also experienced in conjunction with, or separately from, symphysis pubis pain. Approximately 50% of pregnant women report lumbopelvic pain to some degree (1). Although the majority of women recover within 3 months of delivery, in a substantial number of women the pain persists, with prevalence ranging from 26.5% to 91.0% 2–3 years after delivery (2). Risk factors for such pain include maternal age, parity, body mass index, education, and uncomfortable working conditions (3). Recent studies indicate the importance of hip extensors, pelvic floor muscle (PFM) and transverse abdominal muscle (TrAM) in the development of lumbopelvic pain (4). Moreover, pelvic instability, asymmetry and insufficient compression of the sacroiliac joints contribute to continuous lumbopelvic pain after delivery (5). Studies have demonstrated the importance of choosing an optimal treatment strategy in clinical practice, and 5 subgroups of self-rated pain locations have been identified in the pelvic area (6). This study focused on pelvic girdle pain (PGP), or PGP in combination with lumbar pain, since these groups have been shown to have the highest impact on activity levels and health-related quality of life (6).Stabilization exercises that include dynamically controlling the lumbar segments and pelvic joints have been shown to result in functional improvement in patients with lumbopelvic pain (7). Different treatments have been used, including drugs, specific exercises, shortwave therapy, ultrasound, neuromuscular electrical stimulation, corsets, acupuncture and massage (2). The most frequently used interventions are strengthening exercises for the TrAM, PFM training, and a technique involving manipulation of the lumbar multifidus. Although several studies have shown that correct PFM contractions cause co-contractions of the abdominal muscles (8, 9), to date, studies of exercise programmes for treatment of lumbopelvic pain have shown mixed findings and there is insufficient evidence to guide clinical practice in this area. There was also variability across existing randomized controlled trials (RCTs) in the components of programmes, modes of delivery, follow-up times and outcome measures (3, 4, 7). It is therefore not known whether PFM training works well alone, or in combination with other therapies. There is a strong need for the development of a validated postpartum programme.A common concept in PFM training is the use of standardized exercises or electromyographic activity of the PFM (10). Physical therapists are frequently needed to give instructions on how to contract the PFM correctly at hospital or at home. A new validated myoelectric activation method, using biofeedback registration, was used in the current study (11). This technique can be regarded as an adjuvant electromyography, allowing both patients and physical therapists to observe PFM functioning and assess muscle integrity. This technique has been shown to improve self-reported subjective success and satisfaction in patients with pelvic floor dysfunction (11).The aim of the current study was to investigate whether a rehabilitation programme focusing on biofeedback-assisted PFM training is sufficient as treatment for women with PGP or combined pain postnatally.     

OPTIMAL DURATION OF STRETCHING EXERCISE IN PATIENTS WITH CHRONIC MYOFASCIAL PAIN SYNDROME: A RANDOMIZED CONTROLLED TRIAL

ObjectiveTo explore the effect of variable durations of stretching on neural function, pain, and algometric pressure in patients with chronic myofascial pain syndrome.DesignRandomized controlled trial.PatientsA total of 100 participants diagnosed with chronic myofascial pain syndrome were randomly assigned to a control group or 1 of 3 intervention groups.MethodsThe 3 experimental groups received different durations of cervical spine stretching: 15, 30 or 60 s. The control group did not stretch. Primary outcome measures included peak-to-peak somatosensory-evoked potential for dermatomes C6, C7 and C8. Secondary outcome measures included central somatosensory conduction time (N13–N20), pain intensity, and pressure-pain threshold algometric measurements. All outcome measures were assessed immediately after and 2 h after the treatment session.ResultsPost hoc analysis indicated that stretching for 60 s significantly decreased the dermatomal amplitude for C6, C7 and C8 (p < 0.001) and significantly increased the central conduction time, indicating negative effect (p < 0.001). Stretching for 30 and 60 s resulted in greater improvement in pain intensity and algometric pressure than stretching for 15 s or no stretch (control) p < 0.001.ConclusionStretching cervical muscles involved in chronic myofascial pain syndrome for 30 s was optimal in achieving stretching benefits and minimizing the negative effects on the neural function of the involved nerve roots and central nervous system.LAY ABSTRACTThis study measured the effect of different durations of stretching (15 s, 30 s, 60 s and no stretching) of the muscles around the neck and shoulders in 100 participants with chronic myofascial pain syndrome. The outcome measures assessed the effect on neural function. The results show that stretching for 30 s was the optimal time, for achieving stretching benefits and minimizing the negative effects on the neural function of the involved nerve roots and central nervous system. Stretching for a longer time negatively affected the neural function, but decreased the pain level, while stretching for a shorter time did not achieve the optimal muscle length after stretching.Key words: stretching, randomized controlled trial, cervical, neural function, optimal stretching duration

Chronic myofascial pain syndrome (CMPS) is a syndrome of musculoskeletal pain that is typically linked to myofascial trigger points (MTrP) (1, 2). CMPS is mostly prevalent in muscles that are consistently active against gravity or muscles that are essential in repetitive activities, such as the head, neck, shoulders, hips and low back muscles (3). The postural muscles that most commonly tend to be shortened are the upper trapezius and levator scapulae, resulting in limited neck mobility (4) and, due to the continuous demand on these muscles to maintain an upright posture, there appears to be a strong justification for stretching them.Current approaches to the management of CMPS include pharmacological and non-pharmacological interventions (5–7). Among the non-pharmacological approaches, many studies have supported stretching exercises as a beneficial intervention to treat CMPS (8–11). Overall, while the results of these studies are not specific to stretching alone, stretching exercises appear to be an important component of CMPS management. While the benefits of stretching are known, controversy remains about the stretching parameters needed to achieve a particular goal or treatment outcome. In clinical practice, multiple stretching techniques are used; nevertheless, there is no evidence-based agreement on the most effective parameters. One of the parameters that might affect treatment outcome the most is stretching duration; however, to date, there is a little agreement about the optimal duration of stretching (12–15).Of interest, comparison and subsequent conclusions about appropriate stretching times are based mainly on mechanical factors, such as range of motion and flexibility, while ignoring the neural adverse mechanical tension that may be created during sustained stretching exercises. According to the literature (16–18), stretching induces neural tension that may adversely affect the central nervous system and nerve root function, due to the absence of the perineurium, which is the primary load-carrying structure. Thus, safe or unsafe limits of nerve elongation are not well established, despite several basic scientific and clinical studies (19). It is thought that the same phenomenon of tissue loading is applicable to the nervous system. The literature indicates that the most offensive: the most structure damaging postural loading of the central nervous system and related structures occurs in any procedure or position requiring spinal flexion (20).Consequently, the current study aimed to determine whether increased longitudinal strain and stress on the spinal cord and nerve roots from continuous stretching exercises could subtly impair neural function. The study hypothesis is that there is a duration threshold, beyond which adverse neural function will be apparent, resulting in a reduction in either or both latency and amplitudes of evoked potentials.     

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?     

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.     

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.     

CONTEXTUALIZING THE LIVED EXPERIENCES OF PATIENTS WITH LOW BACK PAIN FROM DIFFERENT COUNTRIES ACCORDING TO THE ICF FRAMEWORK

ObjectiveTo explore perspectives, including social and psychological aspects, of patients seeking manual care for low back pain, in order to understand constructs of functioning that are important across different cultural contexts. The International Classification of Functioning, Disability and Health (ICF) emphasizes the importance of these aspects to describe health-related functioning.DesignFocus group interviews.PatientsPatients from Botswana, Canada and Norway seeking manual care for their low back pain. Methods: Interviews were conducted in the 3 countries, transcribed verbatim, translated into English, and linked to the ICF according to established rules.ResultsSeven focus groups yielded 1,863 meaningful concepts that were linked to ICF categories. The largest proportion of responses linked to the Activities and Participation domain. The most frequently mentioned chapters related to pain and its mental aspects, suggesting that the psychological impact of living with low back pain is important to patients.ConclusionDespite cultural differences, patients seeking manual care for low back pain in Botswana, Canada and Norway reported similar experiences of disability across ICF domains. The relatively high ranking of psychosocial factors highlights their importance for patients, in addition to factors of biological origin, and indicates that the contextual nature of the lived experience of low back pain may not be covered in standard examinations used in manual medicine.LAY ABSTRACTThe aim of this study was to understand the experiences of people living with low back pain in 3 countries. The study explored perspectives of patients seeking manual care for low back pain, in order to understand aspects of functioning across different cultural contexts. Seven focus groups with 31 patients seeking manual care for their low back pain in Botswana, Canada and Norway were recorded, transcribed, and coded using the International Classification of Functioning, Disability and Health linking rules to categories. More than 1,800 meaningful concepts were linked to categories, with the largest proportion linked to Activities and Participation. Participants from all 3 countries most frequently mentioned issues related to the pain and mental aspects of health-related functioning, suggesting the psychological impact of living with low back pain is important to patients, regardless of cultural context. While patients seeking manual care are commonly assessed for pain and function, it is also important to capture the lived experiences associated with low back pain.Key words: low back pain, International Classification of Functioning Disability and Health, disability, health manual therapy

Low back pain (LBP) is the leading cause of disability globally (1), and is expected to increase further in the coming decades due to population growth and ageing (2). LBP affects physical wellbeing, but also personal, societal and psychological aspects of life (3). For people living with pain and disability, these aspects significantly influence their lived experiences, mental health, social interaction, quest for diagnosis and expectations of clinical care (4–6).In caring for patients with LBP, patient-reported outcomes, such as pain intensity and disability, are commonly assessed (7). However, these assessments do not capture the biopsychosocial (8) and environmental (9) nature of LBP-related disability, which may influence its management and outcomes.To capture the multifaceted nature and varying patient experiences of disability, the World Health Organization (WHO) developed the International Classification of Functioning, Disability and Health (ICF) framework to collect, document and communicate information about health-related functioning (10). Rather than consider disability a consequence of disease, the ICF operationalizes an integrative model of health and presents related outcomes from the interaction between a person’s health condition and their contextual factors (11) (Fig. 1). The ICF framework applies to all people regardless of sex, age, culture or health condition, and provides a common language to describe functioning across health professions.Open in a separate windowFig. 1Components of the International Classification of Function, Disability and Health (ICF) model.Furthermore, the WHO delineated a system of concepts and a hierarchical classification system based on components, chapters and categories (12). Functional depictions include: Body Functions and Structure according to body regions or systems; Activities and Participation from both individual and societal perspectives; from specific to general Environmental Factors (12). Personal Factors, although considered important to the ICF (13), are not classified because of their wide social and cultural variance (12).The ICF comprises more than 1,400 human functioning categories and serves as a framework to organize information (12). To increase applicability for clinical assessments and research, ICF Core Sets were developed, based on literature reviews, expert surveys and quantitative and qualitative clinical studies (14). Core Sets include category selections that describe the typical spectrum of functioning problems for patients with specific conditions (15).In manual medicine, little is known about the core components of LBP-related disability relevant to patients. Most clinical tools used in manual medicine measure functioning and disability related to Body Functions and Activities and Participation (9). In general, patients’ main reasons for seeking care for LBP are pain (16) and, especially, higher levels of disability (17), but also fear of future job impairment, limited social functioning and engagement in sports (17). However, patients seeking manual medicine may differ from patients seeking traditional medical care (18).The aim of this study was to explore the perspectives of patients seeking manual care for LBP in 3 countries, in order to understand what constructs of functioning are important to them. The ICF framework was used to guide the analysis of lived experiences of persons with LBP and disability. This study is part of an international, collaborative project between Ontario Tech University (Ontario Tech) and the University of Oslo, to identify the aspects of functioning that are most important to patients, and, subsequently, to develop an ICF assessment schedule for manual medicine with standardized measurement and reporting of functioning.     

FEASIBILITY AND RELIABILITY OF A WEB-BASED SMARTPHONE APPLICATION FOR JOINT POSITION MEASUREMENT

ObjectiveMeasurement of joint angles is usually performed using a simple goniometer, which can often be time-consuming and inaccurate, however smartphones can measure angles, this technology could be used to measure joint position. Studies of smartphone applications for this purpose lack consistency and homogeneity. The aim of the current study is to analyse the reliability and accuracy of 3 inertial motion unit-based smartphone applications for goniometric measurement, using 3 different industry standards as external controls.MethodsIn the first 2 phases of the study, measurements of angles between 90° and 165° (simulating knee extension) using 3 smartphone applications were analysed against the 3 industry standards. In the third phase, the smartphone’s raw data was individually analysed against a digital inclinometer across the x, y and z axes.Results and conclusionResults from the 3 phases of this study indicate a high degree of reliability and validity of the applications compared with the industry standards, with no clinically significant deviations. Thus, this technology could be used in a clinical setting. However, further clinical research, focussing on joint motions with greater than a single degree of freedom, is required before the use of such applications for joint position measurement in clinical practice.LAY ABSTRACTThe range of movement of various joints in the human body is regularly measured in a clinical setting, using a traditional angle measurement device (a goniometer), during functional assessments by doctors and physical and occupational therapists. However, such measurements can often be time-consuming and inaccurate. This study analysed the accuracy of smartphone apps for measuring joint angles compared with a goniometer. The results show that smartphone apps could be a good alternative for measuring joint angles.Key words: goniometry, goniometer, measurement, joint angle, smartphone application, joint position, range of motion, proprioception, accelerometer

Joint angle measurement is a fundamental part of functional assessment in diagnosis and rehabilitation, it is routinely used by doctors, physical and occupational therapists to quantify baseline range of movement or their limitations, to plan interventions and subsequently to analyse the efficacy of interventions by use of serial measurements (1, 2). Joint position sense or joint angle reproduction testing using joint angle measurement is also used to analyse proprioceptive performance, which can be reduced in pathologies such as stroke, peripheral nervous disorders, degenerative diseases of joints (e.g. in osteoarthritis or ageing) (3–8).The measurement of joint angle for these purposes is commonly performed in a clinical setting, using a manual goniometer, digital inclinometer or isokinetic dynamometer (4, 9–12). It is generally accepted that individuals with proprioceptive deficit are prone to greater magnitudes of joint position or angle error (3–5, 6, 8). These methods often provide tactical, visual or auditory cues that have a confounding effect on the measurement, and therefore need to be eliminated during testing. However, despite the widespread use of joint position testing, the reliability and validity of these methods have rarely been evaluated against different controls in research (13, 14).The use of a simple goniometer is considered the industry standard for clinical use to measure joint angle, due to its small size, low cost, availability, usability and prevalence in literature (13). However, the greatest limitation with a manual goniometer is the intra- and inter-rater variability. Studies have also reported variable reliability using a simple or universal goniometer with change in direction of motion (13–15). As such, an isokinetic dynamometer is often used, due to increased reliability, and is commonly used for laboratory studies. However, the use of an isokinetic dynamometer in clinical scenarios is limited, due to the cost and large size of the equipment (15, 16).Technological advancement has always been a significant driver of improvements in medical practice. Although smartphones have become an integral part of our lives, their use in the everyday clinical setting is limited. Today’s smartphones have a camera, 3-dimensional accelerometer, magnetometer, gyroscope and an inertial motion unit (IMU), whose potential has not been fully used to improve clinical practice (17–19). IMUs in smartphones are present as a chip, gathering data from the accelerometer, gyroscope and magnetometer to measure velocities and orientation (19).To explore their potential, several researchers have examined the utility of smartphone-based Joint Position Reproduction measurements. Studies by Ferriero et al. and Jeon et al. analysed the reliability and validity of a photography-based DrGoniometer smartphone application (app) (designed by CDM s.r.l., Milano, Italy) as an alternative to a simple manual goniometer (20, 21). Both studies suggested good inter- and intra-rater reliability and validity of the smartphone app (20, 21). The DrGoniometer app was also evaluated by Mitchell et al. and Otter et al. (22, 23), who agreed that smartphone-based goniometric measurements could prove a viable alternative in clinical practice for joint angle measurement. However, Mitchell et al. concluded that an inclinometer-based GetMyROM app (designed by Interactive Medical Productions, LLC, Hampton, New Hampshire, USA) was superior to the photography-based DrGoniometer app. Ockendon & Gilbert tested a novel accelerometer-based app (24)against a simple goniometer among healthy volunteers to measure knee joint angle. The study reported excellent reliability of the app and recommended its use in clinical settings (24).Together, the data from these studies suggest that a smartphone app could be a valid alternative to a standard manual goniometer and an isokinetic dynamometer; however, there are some inconsistencies in the study designs and outcomes. Although most studies report superior or similar outcomes to a simple goniometer, the necessary controls and the smartphone apps used in these studies, vary. Most studies compared the measurements of photography-based and accelerometer/gyroscope-based apps against a simple or universal goniometer, both of which have inherent issues. To date, an isokinetic dynamometer has not been used to compare static angle measurements, despite its superior reliability to a simple goniometer (15, 16). In addition, the studies have not evaluated raw data collected from a smartphone against a simple goniometer or an isokinetic dynamometer; instead they rely on data from third-party apps, which process and present the data to the observer.The objective of this study was to analyse the reliability and accuracy of smartphone-based goniometric measurements, by comparing the results from 3 apps against various external controls. Although this study did not aim to measure dynamic angular movements, an isokinetic dynamometer was used as the main control for static angle measurements during testing as it has already been demonstrated to have superior reliability compared with a simple hand-held manual goniometer (15, 16). A manual goniometer, along with a digital inclinometer, were also used as external controls to be compared with 3 different iPhone® (Apple Inc., Cupertino, CA, USA) apps used to measure angles.     

CLINICAL SPASTICITY ASSESSMENT USING THE MODIFIED TARDIEU SCALE DOES NOT REFLECT JOINT ANGULAR VELOCITY OR RANGE OF MOTION DURING WALKING: ASSESSMENT TOOL IMPLICATIONS

ObjectiveSpasticity assessment is often used to guide treatment decision-making. Assessment tool limitations may influence the conflicting evidence surrounding the relationship between spasticity and walking. This study investigated whether testing speeds and joint angles during a Modified Tardieu assessment matched lower-limb angular velocity and range of motion during walking.DesignObservational study.SubjectsThirty-five adults with a neurological condition and 34 assessors.MethodsThe Modified Tardieu Scale was completed. Joint angles and peak testing speed during V3 (fast) trials were compared with the same variables during walking in healthy people, at 0.40–0.59, 0.60–0.79 and 1.40–1.60 m/s. The proportion of trials in which the testing speed, start angle, and angle of muscle reaction matched the relevant joint angles and angular velocity during walking were analysed.ResultsThe Modified Tardieu Scale was completed faster than the angular velocities seen during walking in 88.7% (0.40–0.59 m/s), 78.9% (0.60– 0.79 m/s) and 56.2% (1.40–1.60 m/s) of trials. When compared with the normative dataset, 4.2%, 9.5% and 13.7% of the trials met all criteria for each respective walking speed.ConclusionWhen applied according to the standardized procedure and compared with joint angular velocity during walking, clinicians performed the Modified Tardieu Scale too quickly.LAY ABSTRACTSpasticity is an abnormal increase in muscle tightness, which is common following neurological injury. Spasticity has been shown to have a profound impact on an individual’s independence and quality of life. The main goal reported by patients in this population is to return to independent, normal walking. Yet, despite this there is a lack of consensus regarding the relationship between spasticity and walking outcomes. This may be due to a disconnect between clinical, bed-based assessment methods and how spasticity manifests during walking. This study aimed to establish how well a routine clinical assessment (the Modified Tardieu Scale) matched the speed and range of joint movement during walking. The findings suggest that, currently, clinicians performed the assessment too fast, which may lead to “false-positive” assessment findings. This may result in the identification and treatment of spasticity that is not impacting walking, leading to sub-optimal patient outcomes and significant healthcare wastage.Key words: muscle spasticity, patient outcome assessment, rehabilitation, brain injuries, gait, walking

Spasticity is a common impairment following neurological injury (1–5). The effective assessment and management of spasticity receives significant attention due to the detrimental effects it has on patient outcomes, carer burden, and quality of life (6, 7). Current spasticity guidelines recommend that only spasticity impacting function should receive intervention (8). As such, the role of a clinical assessment is to identify the presence of spasticity and decipher whether the spasticity warrants intervention, such as botulinum toxin-A (BoNT-A).Walking limitations are the most significant selfperceived, functional problem reported by individuals following neurological injury (9). A primary rehabilitation goal is often to improve walking independence, quality, speed, and endurance (10–12). In relation to spasticity, the clinician’s role is to identify whether spasticity is present, and subsequently determine if a patient’s walking may benefit from spasticity-related interventions.A definition of spasticity published by Pandyan et al. (13); “disordered sensori-motor control, resulting from an upper motor neurone lesion, presenting as intermittent or sustained involuntary activation of muscles’’, encompasses all the positive features of upper motor neurone syndrome (UMNS) under an umbrella term of spasticity. This terminology defines spasticity as a broader sensori-motor phenomenon (13), when compared with the more constrained, velocity-dependent definition published by Lance (14);”a motor disorder characterized by a velocity-dependent increase in tonic stretch reflexes (muscle tone) with exaggerated tendon jerks, resulting from hyper-excitability of the stretch reflexes, as one component of the UMNS” (14). For the purpose of this study, Lance’s definition has been used to define spasticity, since, with this definition, spasticity can be assessed as an individual construct. The Modified Tardieu Scale (MTS) is an often-recommended spasticity assessment, aligning with Lance’s (14) definition of spasticity (15–17). The MTS classifies the response of a relaxed muscle to a fast, passive stretch (V3). The assessment protocol involves a clinician moving the joint “as fast as possible” through its full range of motion (ROM) without specifying or measuring the speed of completion. The MTS is applied according to this standardized protocol regardless of the functional status or goals of the patient. For example, a household ambulator walking at ≤ 0.30 m/s is assessed at the same speed as a community ambulator walking at ≥ 0.80 m/s, whose muscles and joints are moving much faster when walking (18). This “one-size-fits” all approach does not take into account the variability in joint ROM and angular velocity (or speed of lowerlimb movement) with changes in walking speed (19). As such, the MTS may not sensitively discriminate individuals who have spasticity impacting their walking.While it is well established that interventions, such as BoNT-A, reduce spasticity at an impairment-based level, current treatment modalities for spasticity do not necessarily lead to improved walking outcomes (20–22). This may be because standardized protocols for scales such as the MTS do not reflect joint movement during walking (23–25). For example, if clinicians test at a speed that is slower than the joint angular velocity seen during walking, they may fail to identify spasticity that is affecting walking (i.e. false-negative). Conversely, if clinicians test at a speed that exceeds the joint angular velocity seen during walking, they may identify spasticity that is not impacting walking (i.e. false-positive).Matching the joint angles and testing speed of the MTS to the ROM and angular velocity seen during walking may assist in identifying patients who have spasticity impacting functional performance, leading to treatment decisions that optimize patient outcomes and healthcare resources. This study aimed to compare the joint start angle, angle of muscle reaction, and testing speed during a standardized MTS assessment of 4 major muscle groups of the lower-limb, collected in people with neurological conditions, with joint ROM and angular velocity in a healthy population walking at a range of speeds.     

EFFECTS OF ORTHOPAEDIC INSOLES ON PATIENTS WITH KNEE OSTEOARTHRITIS: A META-ANALYSIS AND SYSTEMATIC REVIEW

ObjectiveRecent clinical evidence supports that orthopaedic insoles, especially lateral-wedge insoles, can significantly benefit patients with knee osteoarthritis. The aim of this study is to explore the effects of orthopaedic insoles in patients with knee osteoarthritis.MethodsRandomized controlled trials evaluating the effects of orthopaedic insoles on patients with knee osteoarthritis, published up to 16 February 2021, were reviewed and outcomes quantitatively summarized.ResultsA total of 15 studies from 13 randomized controlled trials that involved 1,086 participants were included in this study. All the included studies exhibited a moderate bias risk and were of acceptable quality. The pooled mean difference of pain determined by the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) was –1.21 (p < 0.001, 95% confidence interval (95% CI) –2.61–0.18) with a high heterogeneity (I² = 75%). In the sensitivity analysis, the overall incidence was –0.20 (p= 0.62, 95% CI= –0.87–0.46) with an accepted heterogeneity (I² = 0%). No difference was observed between the Asian and Caucasian groups (p= 0.28). No significant difference was found in the pain score, Lequesne index or functional improvements.ConclusionMeta-analysis revealed that orthopaedic insoles do not provide relief of pain or improve functionality in patients with knee osteoarthritis.LAY ABSTRACTOsteoarthritis of the knee joint is a progressive degenerative disease, which is fairly common in older adults, and leads to major pain and disability. The development and progression of knee osteoarthritis is exacerbated by excessive load on the medial knee joint. Various forms of orthopaedic insoles, such as insoles that provide arch support, shock-absorbing insoles, and lateral-wedge insoles, are widely used by patients with knee osteoarthritis, and are claimed to provide comfort and better support during walking. However, this meta-analysis and systematic review of randomized controlled trials evaluating the effects of orthopaedic insoles on knee osteoarthritis patients found that orthopaedic insoles do not provide relief of pain or improve functionality in patients with knee osteoarthritis.Key words: osteoarthritis, knee, knee joint, systematic review, meta-analysis

Osteoarthritis (OA) of the knee joint is a chronic degenerative disease, which is progressive and disabling, and is fairly common in older adults. OA of the knee produces major pain and disability is a continuous burden for patients (1, 2). As no cure exists, the aims of clinical management are to minimize pain, improve knee functioning and, crucially, enhance the quality of life of patients. Therefore, conservative non-surgical strategies are normally the first choice for clinical management of knee OA (3).The development and progression of OA of the knee is exacerbated by an excessive load on the medial knee joint (4). Therefore, reducing this load is a vital management strategy for patients with knee OA. During the stance phase of walking, the knee varus moment has been measured to assess the effects of therapy (5). Non-surgical interventions, including valgus bracing, can effectively improve clinical results and reduce the knee adduction moment (6, 7). These treatments, however, are cumbersome and expensive, and may not be appropriate for long-term therapy. In recent years, footwear modifications have been considered as an extensive palliative treatment for patients with knee OA. Orthopaedic insoles are designed to limit medial knee compartment load and effectively to reduce knee varus moment in patients with OA. Various other forms of orthopaedic insoles, such as insoles that provide arch support, shock-absorbing insoles and lateral-wedge insoles, are widely used by patients with knee OA, and are claimed to provide comfort and better support during walking. In recent years, clinical evidence has shown that orthopaedic insoles, especially lateral-wedge insoles, can significantly benefit patients with knee OA (8, 9).A previous meta-analysis (10) reported that knee pain was not attenuated by lateral-wedge insoles and did not facilitate improvements in knee functioning in patients with OA compared with healthy control subjects. However, limited by few included studies, the previous study could not perform more stratified analyses and draw strong conclusions. Several recent randomized controlled trials (RCTs) (11, 12) have focused on this topic and provided new evidence. The current meta-analysis and systematic review investigated the potential benefits of orthopaedic insoles in subjects with knee OA.     

LONG-TERM EMPLOYMENT STATUS AND THE ASSOCIATION WITH FATIGUE IN PATIENTS WITH GRADE II GLIOMAS

ObjectiveTo investigate employment status and return to work in relation to fatigue in patients with World Health Organization (WHO) grade II glioma.DesignExploratory cross-sectional study.SubjectsPatients with grade II glioma, who underwent surgery between 2005 and 2016.MethodsA postal survey was sent in 2019, which included the Short Form-Health and Labour Questionnaire and the Multi-dimensional Fatigue Index. Outcomes of fatigue in subgroups of (not-) return to work were compared using independent t-tests and x² tests. The association between fatigue and return to work was analysed using multivariable logistic regression.ResultsIn total, 73 patients were included in the study (age at diagnosis 41.0 years (standard deviation (SD) 9.2 years), time post-diagnosis 8.0 years (interquartile range (IQR) 6-11 years). At diagnosis, 61 patients were employed and 32 returned to work during follow-up. The return to work group was significantly younger than the not-return to work group (p = 0.007). The proportion of patients who indicated that the consequences of glioma had affected return to work, in terms of demotion or reduced working hours, was 68.7%. The not-return to work group reported significantly more fatigue in all domains than the return to work group (p < 0.05). Mental fatigue (p = 0.023) and physical fatigue (p = 0.065) were independently associated with return to work, adjusted for age, sex and the use of anti-epileptic drugs.ConclusionLong-term fatigue is associated with return to work in patients with grade II glioma. Patients who were able to work in the long term were less fatigued, younger, more often male, and used less anti-epileptic drugs than the patients who did not return to work.LAY ABSTRACTPatients with glioma have adult brain cancer. These patients are relatively young and are of working age when they develop this disease. Treatment options for glioma have improved over recent years, and patients will survive approximately 5-15 years. Almost all patients are of working age. Because of the increased survival time, patients find it important to continue to participate in society, especially in work. This study examined working patterns in patients with glioma several years after the start of their disease. Fifty-two percent of patients were working 8 years after the diagnosis of glioma. Many patients with brain tumours felt tired (fatigued), both mentally and physically. Patients who were able to work in the long term were less fatigued, younger, more often male, and used less anti-epileptic drugs than the patients who did not return to work.Key words: employment, glioma, return to work, fatigue

Engagement in work is very important from a societal perspective and from an individual perspective, in preventing financial stress, social isolation and loss of self-esteem (1–3).In the general cancer population, improvements in diagnosis and treatment have increased the prognosis of patients, and an increasing number of patients return to work (RTW) following treatment or continue to work during therapy (4). A focus on RTW is part of the societal reintegration of cancer survivors (5).Rates of RTW in the overall cancer population range widely, from 30% to 93% (5–7). A metaanalysis reported that cancer survivors overall were 1.37 times more likely to be unemployed than healthy control participants, but patients with a central nervous system cancer were 1.78 times more likely to be unemployed (7).Patients diagnosed with grade II glioma are usually early in their working age and have a favourable midterm prognosis, with a survival time between 5 and 15 years (8, 9). RTW has long been an understudied aspect. Recently, Yoshida et al. (10) and Senft et al. (11) studied rates of RTW for patients with grade II and III glioma. They reported a RTW rate of 54.0% one year after surgery and after a median follow-up of 43.8 months (range 11–82 months) 70.7% of patients were able to resume a working life.Fatigue is a highly prevalent and debilitating symptom in cancer survivors, including patients with glioma (12). Cancer-related fatigue is defined as a “persistent, subjective sense of tiredness related to cancer and cancer treatment that interferes with usual functioning” It is described as a multidimensional phenomenon. In all types of cancer, fatigue is common during treatment and follow-up (13, 14).Fatigue is a negative predictor of RTW in patients who survive cancer (1, 15, 16). Fatigue and treatment-related symptoms are important reasons for not returning to work in diffuse glioma of all grades (11, 17). Since many patients with low-grade glioma have a relatively favourable prognosis, RTW is an important element of survival. The present study therefore investigated employment status and RTW in patients who underwent surgery for a grade II glioma after diagnosis, and the association between fatigue and employment status.     

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.     

EFFECTIVENESS OF EXERCISE INTERVENTIONS FOR CHILDREN WITH CEREBRAL PALSY: A SYSTEMATIC REVIEW AND META-ANALYSIS OF RANDOMIZED CONTROLLED TRIALS

ObjectiveThe results of previous research into exercise interventions for children with cerebral palsy are inconsistent. The aim of this study is to assess the effectiveness of such exercise interventions.DesignSystematic review and meta-analysis.MethodsSystematic searches of the PubMed, Embase and Cochrane Library databases for randomized controlled trials involving exercise interventions for children with cerebral palsy, from inception to January 2020, were performed. Pooled weighted mean differences (WMDs) with 95% confidence intervals (95% CI) for gross motor function, gait speed, and muscle strength were calculated using random-effects models.ResultsA final total of 27 trials, including 834 children with cerebral palsy, were selected for quantitative analysis. Exercise interventions had no significant effect on the level of gross motor function (WMD 1.19; 95% CI −1.07 to 3.46; p = 0.302). However, exercise interventions were associated with higher levels of gait speed (WMD 0.05; 95% CI 0.00–0.10; p = 0.032) and muscle strength (WMD 0.92; 95% CI 0.19–1.64; p = 0.013).ConclusionThese results suggest that exercise interventions may have beneficial effects on gait speed and muscle strength, but no significant effect on gross motor function in children with cerebral palsy.LAY ABSTRACTCerebral palsy is the most common cause of physical impairment in children. This study evaluated the effectiveness of exercise interventions for children with cerebral palsy. Exercise interventions were significantly associated with increased gait speed and muscle strength, while gross motor function was not affected. Exercise interventions should therefore be used for children with cerebral palsy.Key words: cerebral palsy, child, exercise, meta-analysis, systematic review

Cerebral palsy is the most common cause of physical impairment in children and is characterized by gait abnormalities (1–3). The characteristics of cerebral palsy are associated with damage to the immature brain, which causes subsequent primary impairments, including decreased muscle tone, loss of selective motor control, and impaired balance. Secondary impairments include muscle shortening or weakness and decreased range of motion (4, 5). The prevalence of cerebral palsy is approximately 2.1 in every 1,000 births, and children account for 74% of cases worldwide (6, 7). Children with cerebral palsy are significantly affected by epilepsy and by disorders in motor function, sensation, perception, communication, and behaviour, which significantly affect quality of life and result in huge economic and psychological burdens (8–11).Currently, the primary therapeutic goals for cerebral palsy are aimed at improving mobility and upper limb function (12). Exercise interventions may also play an important role in improving muscle strength, endurance, and cardiorespiratory fitness. Several systematic reviews and meta-analyses have illustrated the potential role of exercise interventions for children with cerebral palsy; however, results regarding gross motor function, gait speed, and muscle strength are inconsistent (13–15). Exercise programmes usually include resistance and/ or aerobic training. Children with cerebral palsy have reduced muscle strength, and resistance exercise can maintain or increase muscle performance (16, 17), while aerobic training can improve cardiorespiratory fitness. Studies have found that muscle stretching can increase range of motion (18, 19). It is important to clarify the effectiveness of exercise interventions for treatment of cerebral palsy in children, and to determine the role of the type of training for children with cerebral palsy. A meta-analysis of randomized controlled trials (RCTs) of exercise interventions for children with cerebral palsy was therefore performed in order to assess the effectiveness of this treatment.     

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.