The impact of female reproductive function on outcomes after traumatic brain injury

Ripley DL, Harrison-Felix C, Sendroy-Terrill M, Cusick CP, Dannels-McClure A, Morey C. The impact of female reproductive function on outcomes after traumatic brain injury.

Objectives

To determine the impact of traumatic brain injury (TBI) on female menstrual and reproductive functioning and to examine the relationships between severity of injury, duration of amenorrhea, and TBI outcomes.

Design

Retrospective cohort survey.

Setting

Telephone interview.

Participants

Women (N=30; age range, 18-45y), between 1 and 3 years postinjury, who had completed inpatient rehabilitation for TBI.

Interventions

Not applicable.

Main Outcome Measures

Data collected included menstrual and reproductive functioning pre- and postinjury, demographic, and injury characteristics. Outcome measures included the Glasgow Outcome Scale-Extended (GOS-E), the Mayo-Portland Adaptability Inventory-4 (MPAI-4), and the Medical Outcome Study 12-Item Short-Form Health Survey, Version 2 (SF-12v2).

Results

The median duration of amenorrhea was 61 days (range, 20-344d). Many subjects' menstrual function changed after TBI, reporting a significant increase in skipped menses postinjury (P<.001) and a trend toward more painful menses (P=.061). More severe TBI, as measured by the duration of posttraumatic amnesia, was significantly predictive of a longer duration of amenorrhea (P=.004). Subjects with a shorter duration of amenorrhea scored significantly better on the SF-12 physical component subscale (P=.004), the GOS-E (P=.05), and the MPAI-4 participation subscale (P=.05) after controlling for age, injury severity, and time postinjury.

Conclusions

The severity of TBI was predictive of duration of amenorrhea and a shorter duration of amenorrhea was predictive of better ratings of global outcome, community participation, and health-related quality of life postinjury.     

Modality-Specific, Multitask Locomotor Deficits Persist Despite Good Recovery After a Traumatic Brain Injury

McFadyen BJ, Cantin J-F, Swaine B, Duchesneau G, Doyon J, Dumas D, Fait P. Modality-specific, multitask locomotor deficits persist despite good recovery after a traumatic brain injury.

Objective

To study the effects of sensory modality of simultaneous tasks during walking with and without obstacles after moderate to severe traumatic brain injury (TBI).

Design

Group comparison study.

Setting

Gait analysis laboratory within a postacute rehabilitation facility.

Participants

Volunteer sample (N=18). Persons with moderate to severe TBI (n=11) (9 men, 3 women; age, 37.56±13.79y) and a comparison group (n=7) of subjects without neurologic problems matched on average for body mass index and age (4 men, 3 women; age, 39.19±17.35y).

Interventions

Not applicable.

Main Outcome Measures

Magnitudes and variability for walking speeds, foot clearance margins (ratio of foot clearance distance to obstacle height), and response reaction times (both direct and as a relative cost because of obstacle avoidance).

Results

The TBI group had well-recovered walking speeds and a general ability to avoid obstacles. However, these subjects did show lower trail limb toe clearances (P=.003) across all conditions. Response reaction times to the Stroop tasks were longer in general for the TBI group (P=.017), and this group showed significant increases in response reaction times for the visual modality within the more challenging obstacle avoidance task that was not observed for control subjects. A measure of multitask costs related to differences in response reaction times between obstructed and unobstructed trials also only showed increased attention costs for the visual over the auditory stimuli for the TBI group (P=.002).

Conclusions

Mobility is a complex construct, and the present results provide preliminary findings that, even after good locomotor recovery, subjects with moderate to severe TBI show residual locomotor deficits in multitasking. Furthermore, our results suggest that sensory modality is important, and greater multitask costs occur during sensory competition (ie, visual interference).     

Weight Lifting in Patients With Lower-Extremity Lymphedema Secondary to Cancer: A Pilot and Feasibility Study

Katz E, Dugan NL, Cohn JC, Chu C, Smith RG, Schmitz KH. Weight lifting in patients with lower-extremity lymphedema secondary to cancer: a pilot and feasibility study.

Objective

To assess the feasibility of recruiting and retaining cancer survivors with lower-limb lymphedema into an exercise intervention study. To develop preliminary estimates regarding the safety and efficacy of this intervention. We hypothesized that progressive weight training would not exacerbate leg swelling and that the intervention would improve functional mobility and quality of life.

Design

Before-after pilot study with a duration of 5 months.

Setting

University of Pennsylvania.

Participants

Cancer survivors with a known diagnosis of lower-limb lymphedema (N=10) were directly referred by University of Pennsylvania clinicians. All 10 participants completed the study.

Intervention

Twice weekly slowly progressive weight lifting, supervised for 2 months, unsupervised for 3 months.

Main Outcome Measures

The primary outcome was interlimb volume differences as measured by optoelectronic perometry. Additional outcome measures included safety (adverse events), muscle strength, objective physical function, and quality of life.

Results

Interlimb volume differences were 44.4% and 45.3% at baseline and 5 months, respectively (pre-post comparison, P=.70). There were 2 unexpected incident cases of cellulitis within the first 2 months. Both resolved with oral antibiotics and complete decongestive therapy by 5 months. Bench and leg press strength increased by 47% and 27% over 5 months (P=.001 and P=.07, respectively). Distance walked in 6 minutes increased by 7% in 5 months (P=.01). No improvement was noted in self-reported quality of life.

Conclusions

Recruitment of patients with lower-limb-lymphedema into an exercise program is feasible. Despite some indications that the intervention may be safe (eg, a lack of clinically significant interlimb volume increases over 5mo), the unexpected finding of 2 cellulitic infections among the 10 participants suggests additional study is required before concluding that patients with lower-extremity lymphedema can safely perform weight lifting.     

An Integrated Motor Imagery Program to Improve Functional Task Performance in Neurorehabilitation: A Single-Blind Randomized Controlled Trial

Bovend'Eerdt TJ, Dawes H, Sackley C, Izadi H, Wade DT. An integrated motor imagery program to improve functional task performance in neurorehabilitation: a single-blind randomized controlled trial.

Objective

To investigate the feasibility of a motor imagery program integrated into physiotherapy and occupational therapy.

Design

A parallel-group, phase II, assessor-blind randomized controlled trial comparing motor imagery embedded in usual therapy with usual therapy only.

Setting

A neurologic rehabilitation center (Oxford, United Kingdom).

Participants

Inpatients and outpatients diagnosed with stroke, brain injury, or multiple sclerosis, participating in a rehabilitation program with sufficient language skills to undertake the intervention were recruited (N=30) and assessed at baseline, after 6 weeks (postintervention), and after 12 weeks (follow-up).

Interventions

A motor imagery strategy was developed that could be integrated into usual therapy, tailored to individual goals, and used for any activity. The control group received standard care.

Main Outcome Measures

Goal attainment scaling was used as the primary outcome measure. Other measures included the Barthel activities of daily living index and the Rivermead Mobility Index.

Results

Compliance with advised treatment was poor in 85% of the therapists and in 72% of the patients. Goal attainment scaling scores significantly improved at postintervention and follow-up (F_2,27=45.159; P<.001), but no significant difference was observed between the groups over time (F_1,28=.039; P=.845).

Conclusions

Therapist and patient compliance with performing the intervention was low, restricting the conclusions regarding the effectiveness of the integrated motor imagery program. Future studies will need to explore barriers and facilitators to uptake of this intervention in clinical practice. Trial recruitment and retention were good. The study demonstrated that imagery could be successfully integrated into usual therapy and tailored for a wide range of functional activities.     

Pre-existing Health Conditions and Repeat Traumatic Brain Injury

Saunders LL, Selassie AW, Hill EG, Horner MD, Nicholas JS, Lackland DT, Corrigan JD. Pre-existing health conditions and repeat traumatic brain injury.

Objective

To assess and compare the effect of Pre-existing epilepsy/seizure disorder and drug/alcohol problem on the hazard of repeat traumatic brain injury (TBI) in persons with TBI who participated in a follow-up study.

Design

Retrospective cohort.

Setting

Acute care hospitals in South Carolina.

Participants

Participants were from the South Carolina Traumatic Brain Injury Follow-up Registry cohort of persons (N=2118) who were discharged from an acute care hospital in South Carolina and who participated in a year-1 follow-up interview.

Interventions

Not applicable.

Main Outcome Measures

Repeat TBI was defined by 2 isolated events of TBI in the same person at least 72 hours apart and recorded in hospital discharge or emergency department records from 1999 through 2005.

Results

A Cox proportional hazards model was used to assess the associations of Pre-existing epilepsy/seizure disorder and drug/alcohol problem with time to repeat TBI, controlling for other confounding factors. There were 2099 persons with information on both Pre-existing conditions. There were 147 (7%) persons who sustained repeat TBI after recruitment to the follow-up study, and 82 (3.9%) had a previous TBI before recruitment for which they were seen in the hospital discharge or emergency department since 1996. The hazard of repeat TBI for persons with Pre-existing epilepsy/seizure disorder was 2.3 times the hazard for those without (hazard ratio, 2.3; 95% confidence interval, 1.2-4.4; P=.011). Pre-existing drug/alcohol problem was not associated with repeat TBI. Other variables significantly associated with repeat TBI were having a prior TBI, being insured under Medicaid, and having no insurance.

Conclusions

Pre-existing epilepsy/seizure disorder predisposes to repeat TBI. Appropriate management of seizure control may be an important strategy to allay the occurrence of repeat TBI.     

Stability of Kyphosis, Strength, and Physical Performance Gains 1 Year After a Group Exercise Program in Community-Dwelling Hyperkyphotic Older Women

Pawlowsky SB, Hamel KA, Katzman WB. Stability of kyphosis, strength, and physical performance gains 1 year after a group exercise program in community-dwelling hyperkyphotic older women.

Objective

To determine if subjects maintained improvements in kyphosis, spinal extensor strength, and physical performance 1 year after a 12-week multidimensional group exercise program.

Design

Follow-up data compared with posttest outcome measures.

Setting

Outpatient academic medical center.

Participants

Nineteen of the initial 21 women, ages 65 to 80, with thoracic kyphosis of 50° or greater at the onset of the study completed follow-up testing.

Interventions

Initial intervention included multidimensional group exercise performed 2 times a week for 12 weeks, consisting of spinal extensor strengthening, flexibility exercises, and integrated spinal proprioception training. Subjects exercised independently during the following year.

Main Outcome Measures

Primary measures at the 1-year follow-up were usual and best kyphosis. Secondary measures included spinal extensor strength, modified Physical Performance Test (PPT), and the Jug Test.

Results

Subjects maintained gains at the 1-year follow-up (P>.05). Best kyphosis improved by 3° during the follow-up year (P=.022). There were no significant declines in usual kyphosis (P=.302), spinal extensor strength (P=.999), PPT (P=.087), and the Jug Test (P=.999) at follow-up.

Conclusions

Hyperkyphotic women maintained gains in usual kyphosis, spinal extensor strength, and physical performance 1 year after a group exercise program. Improvement in best kyphosis in the year after the intervention was also observed. Detraining effects may be minimized by multidimensional exercises.     

Effects of concurrent strength and endurance training on physical fitness and symptoms in postmenopausal women with fibromyalgia: a randomized controlled trial

Valkeinen H, Alén M, Häkkinen A, Hannonen P, Kukkonen-Harjula K, Häkkinen K. Effects of concurrent strength and endurance training on physical fitness and symptoms in postmenopausal women with fibromyalgia: a randomized controlled trial.

Objective

To examine the effectiveness of concurrent strength and endurance training on muscle strength, aerobic and functional performance, and symptoms in postmenopausal women with fibromyalgia (FM).

Design

Randomized controlled trial.

Setting

Local gym and university research laboratory.

Participants

Twenty-six women with FM.

Intervention

Progressive and supervised 21-week concurrent strength and endurance training.

Main Outcome Measures

Muscle strength of leg extensors, upper extremities, and trunk; peak oxygen uptake (Vo₂peak), maximal workload (Wmax), and work time; 10-m walking and 10-step stair-climbing time and self-reported functional capacity (Health Assessment Questionnaire); and symptoms of FM.

Results

After concurrent strength and endurance training, the groups differed significantly in Wmax (P=.001), work time (P=.001), concentric leg extension force (P=.043), walking (P=.001) and stair-climbing (P<.001) time, and fatigue (P=.038). The training led to an increase of 10% (P=.004) in Wmax and 13% (P=.004) in work time on the bicycle but no change in Vo₂peak.

Conclusions

Concurrent strength and endurance training in low to moderate volume improves the muscle strength of leg extensors, Wmax, work time, and functional performance as well as perceived symptoms, fatigue in particular. Concurrent strength and endurance training is beneficial to postmenopausal women with FM without adversities, but more extensive studies are needed to confirm the results.     

A randomized clinical trial of an activity and exercise adherence intervention in chronic pulmonary disease

Steele BG, Belza B, Cain KC, Coppersmith J, Lakshminarayan S, Howard J, Haselkorn JK. A randomized clinical trial of an activity and exercise adherence intervention in chronic pulmonary disease.

Objectives

To evaluate the effectiveness of an exercise adherence intervention to maintain daily activity, adherence to exercise, and exercise capacity over 1 year after completion of an outpatient pulmonary rehabilitation program.

Design

A 2-group, experimental design was used with randomization into intervention and usual care groups.

Setting

Outpatient pulmonary rehabilitation program in a university-affiliated medical center.

Participants

One hundred six subjects (98 men; 98 with chronic obstructive pulmonary disease) with a mean age of 67 years and chronic lung disease.

Intervention

Twelve-week adherence intervention (weekly phone calls and home visit) including counseling on establishing, monitoring, and problem-solving in maintaining a home exercise program.

Main Outcome Measures

Primary outcomes included daily activity (accelerometer), exercise adherence (exercise diary), and exercise capacity (six-minute walk test). All measures were performed at baseline, after the pulmonary rehabilitation program (8wk), after the adherence intervention (20wk), and at 1 year.

Results

A rank-based analysis of covariance showed less decline at 20 weeks in exercise adherence (intervention mean, +3min; control mean, −13min; P=.015) and exercise capacity (intervention mean, −10.7m; control mean, −35.4m; P=.023). There were no differences in daily activity at 20 weeks or any differences in any primary variable at 1 year.

Conclusions

The intervention enhanced exercise adherence and exercise capacity in the short term but produced no long-term benefit. These findings are in part attributed to the disappointing measurement characteristics of the accelerometer used to measure daily activity. The intervention was acceptable to participants. Further study is needed to fashion interventions that have more persistent benefit.     

Posttraumatic hydrocephalus: a clinical, neuroradiologic, and neuropsychologic assessment of long-term outcome

Mazzini L, Campini R, Angelino E, Rognone F, Pastore I, Oliveri G. Posttraumatic hydrocephalus: a clinical, neuroradiologic, and neuropsychologic assessment of long-term outcome. Arch Phys Med Rehabil 2003;84:1637-41.

Objectives

To detect the clinical and radiologic characteristics of posttraumatic hydrocephalus (PTH), to define its prognostic value, and to assess the effects of shunt surgery.

Design

Correlational study on a prospective cohort.

Setting

Brain injury rehabilitation center.

Participants

One hundred forty patients with severe traumatic brain injury (TBI) referred to an inpatient intensive rehabilitation unit of primary care in a university-based system.

Interventions

Not applicable.

Main outcome measures

The Glasgow Outcome Scale (GOS), Disability Rating Scale (DRS), FIM™ instrument, and Neurobehavioural Rating Scale (NRS), as well as single-photon emission computed tomography (SPECT) and magnetic resonance imaging.

Results

PTH was found in 45% of patients. Risk factors for PTH were as follows: age (P<.04), duration of coma (P<.0001), and decompressive craniectomy (P<.0001). PTH correlated with the degree of hypoperfusion in the temporal lobes (P<.001). Patients who showed clinical deterioration improved after surgery. PTH correlated significantly with GOS, DRS, FIM, and NRS (P<.0001) 1 year after the trauma, and it influenced the appearance of posttraumatic epilepsy (P<.02).

Conclusions

PTH concerns about 50% of patients with severe TBI. It influences functional and behavioral outcome and the appearance of posttraumatic epilepsy. The selection of patients for surgery can be defined principally on a clinical basis. SPECT may be helpful for differentiating ventricular enlargement due to cortical atrophy and hydrocephalus.     

Improving older adults' knowledge and practice of preventive measures through a telephone health education during the SARS epidemic in Hong Kong: a pilot study

Background

The outbreak of severe acute respiratory syndrome (SARS) in Hong Kong posed many challenges for health promotion activities among a group of older adults with low socio-economic status (SES). With concerns that this vulnerable group could be at higher risk of contracting the disease or spreading it to others, the implementation of health promotion activities appropriate to this group was considered to be essential during the epidemic.

Objectives

To assess the effectiveness of delivering a telephone health education programme dealing with anxiety levels, and knowledge and practice of measures to prevent transmission of SARS among a group of older adults with low SES.

Design

Pretest/posttest design.

Settings

Subjects were recruited from registered members of a government subsidized social service center in Hong Kong and living in low-cost housing estates.

Participants

The eligibility criteria were: (1) aged 55 or above; (2) able to speak Cantonese; (3) no hearing impairment, and (4) reachable by telephone. Of the 295 eligible subjects, 122 older adults completed the whole study.

Methods

The interviewers approached all eligible subjects by telephone during the period of 15-25 May 2003. After obtaining the participants’ verbal consent, the interviewer collected baseline data by use of a questionnaire and implemented a health education programme. A follow-up telephone call was made a week later using the same questionnaire.

Results

The level of anxiety was lowered (t=3.28, p<0.001), and knowledge regarding the transmission routes of droplets (p<0.001) and urine and feaces (p<0.01) were improved after the intervention. Although statistical significant difference was found in the practice of identified preventive measures before and after intervention, influence on behavioral changes needed further exploration.

Conclusion

The telephone health education seemed to be effective in relieving anxiety and improving knowledge of the main transmission routes of SARS in this group, but not the practice of preventing SARS. Telephone contact appears to be a practical way of providing health education to vulnerable groups when face-to-face measure is not feasible and may be useful in raising health awareness during future outbreaks of emerging infections.     

Exercise prevents fatigue and improves quality of life in prostate cancer patients undergoing radiotherapy

Monga U, Garber SL, Thornby J, Vallbona C, Kerrigan AJ, Monga TN, Zimmermann KP. Exercise prevents fatigue and improves quality of life in prostate cancer patients undergoing radiotherapy.

Objective

To show fatigue prevention and quality of life (QOL) improvement from cardiovascular exercise during radiotherapy.

Design

Prospective enrollment (n=21), randomized to exercise (n=11) and control groups (n=10), with pre- and post-radiotherapy between- and within-group comparisons.

Setting

Academic medical center.

Participants

Localized prostate cancer patients undergoing radiotherapy.

Interventions

The interventional group received radiotherapy plus aerobic exercise 3 times a week for 8 weeks whereas the control group received radiotherapy without exercise.

Main Outcome Measures

Pre- and post-radiotherapy differences in cardiac fitness, fatigue, depression, functional status, physical, social, and functional well-being, leg strength, and flexibility were examined within and between 2 groups.

Results

No significant differences existed between 2 groups at pre-radiotherapy assessment. At post-radiotherapy assessment, the exercise group showed significant within group improvements in: cardiac fitness (P<.001), fatigue (P=.02), Functional Assessment of Cancer Therapy-Prostate (FACT-P) (P=.04), physical well-being (P=.002), social well-being (P=.02), flexibility (P=.006), and leg strength (P=.000). Within the control group, there was a significant increase in fatigue score (P=.004) and a decline in social well-being (P<.05) at post-radiotherapy assessment. Between-group differences at post-radiotherapy assessment were significant in cardiac fitness (P=.006), strength (P=.000), flexibility (P<.01), fatigue (P<.001), FACT-P (P=.006), physical well-being (P<.001), social well-being (P=.002), and functional well-being (P=.04).

Conclusions

An 8-week cardiovascular exercise program in patients with localized prostate cancer undergoing radiotherapy improved cardiovascular fitness, flexibility, muscle strength, and overall QOL and prevented fatigue.     

Muscle strength and flexibility characteristics of people displaying excessive medial knee displacement

Bell DR, Padua DA, Clark MA. Muscle strength and flexibility characteristics of people displaying excessive medial knee displacement.

Objective

To determine differences in strength and range of motion (ROM) between participants who exhibit medial knee displacement (MKD) during a squat that is corrected by a heel lift and those who do not.

Design

Case control.

Setting

Sports medicine research laboratory.

Participants

Thirty-seven healthy subjects (control, 19; MKD, 18) with no lower-extremity injury in the past 6 months volunteered to participate.

Interventions

Not applicable.

Main Outcome Measures

Peak force was measured in newtons using a hand-held dynamometer and passive ROM was measured in degrees with a goniometer. Separate multivariate analyses of variance were used to determine differences in strength and ROM between groups. Post hoc testing was used to elucidate differences between groups.

Results

The MKD group had the following: greater hip external rotation strength (P=.03), increased hip extension strength (P=.01), less plantarflexion strength (P=.007), and increased hip external rotation ROM (P=.008).

Conclusions

The MKD group exhibited tight and weak ankle musculature. Interventions focusing on improving strength and ROM of the ankle may improve kinematics during a squat.     

Fewer adverse events as a result of the SAFE or SORRY? programme in hospitals and nursing homes. part i: primary outcome of a cluster randomised trial

Background

Patient care guidelines are usually implemented one at a time, yet patients are at risk for multiple, often preventable, adverse events simultaneously.

Objective

This study aimed to test the effect of the SAFE or SORRY? programme on the incidence of three adverse events (pressure ulcers, urinary tract infections and falls). This paper describes Part I of the study: the effect on the incidence of adverse events.

Design

A cluster randomised trial was conducted between September 2006 and November 2008. After a three-month baseline period the intervention was implemented followed by a nine-month follow-up period.

Settings

Ten wards from four hospitals and ten wards from six nursing homes were stratified for institute and ward type and then randomised to intervention or usual care group.

Participants

During baseline and follow-up, patients (≥18 years) with an expected length of stay of at least five days, were asked to participate.

Methods

The SAFE or SORRY? programme consisted of the essential recommendations of guidelines for the three adverse events. A multifaceted implementation strategy was used for the implementation: education, patient involvement and feedback on process and outcome indicators. The usual care group continued care as usual. Data were collected on the incidence of adverse events and a Poisson regression model was used to estimate the rate ratio of the adverse events between the intervention and the usual care group at follow-up.

Results

At follow-up, 2201 hospital patients with 3358 patient weeks and 392 nursing home patients with 5799 patient weeks were observed. Poisson regression analyses showed a rate ratio for the development of an adverse event in favour of the intervention group of 0.57 (95% CI: 0.34-0.95) and 0.67 (95% CI: 0.48-0.99) for hospital patients and nursing home patients respectively.

Conclusion

This study showed that implementing multiple guidelines simultaneously is possible, which is promising. Patients in the intervention groups developed 43% and 33% fewer adverse events compared to the usual care groups in hospitals and nursing homes respectively. Even so, more research is necessary to underline these results.

Trial registration

clinicaltrials.gov, number NCT00365430.     

The efficacy of telephone counseling for health promotion in people with multiple sclerosis: a randomized controlled trial

Bombardier CH, Cunniffe M, Wadhwani R, Gibbons LE, Blake KD, Kraft GH. The efficacy of telephone counseling for health promotion in people with multiple sclerosis: a randomized controlled trial.

Objective

To determine if motivational interviewing-based telephone counseling increases health promotion activities and improves other health outcomes in people with multiple sclerosis (MS).

Design

Randomized controlled trial with wait-list controls and single-blinded outcome assessments conducted at baseline and at 12 weeks.

Setting

MS research and training center in the Pacific Northwest.

Participants

Community-residing persons (N=130) with physician confirmed MS aged 18 or older who were able to walk unassisted at least 90m (300ft).

Intervention

A single in-person motivational interview followed by 5 scheduled telephone counseling sessions to facilitate improvement in 1 of 6 health promotion areas: exercise, fatigue management, communication and/or social support, anxiety and/or stress management, and reducing alcohol or other drug use.

Main Outcome Measures

Health Promotion Lifestyle Profile II plus fatigue impact, subjective health, and objective measures of strength, fitness, and cognition. Intent-to-treat analyses of change scores were analyzed using nonparametric tests.

Results

Seventy persons were randomized to treatment and 60 to the control condition. The treatment group reported significantly greater improvement in health promotion activities, including physical activity, spiritual growth, and stress management as well as in fatigue impact and mental health compared with controls. In addition, the exerciser subgroup showed greater improvement than controls in self-selected walking speed.

Conclusions

A less intensive, more accessible approach to health promotion based on telephone counseling and motivational interviewing shows promise and merits further study.     

The efficacy of a multidisciplinary falls prevention clinic with an extended step-down community program

Sze P-C, Cheung W-H, Lam P-S, Lo HS-D, Leung K-S, Chan T. The efficacy of a multidisciplinary falls prevention clinic with an extended step-down community program.

Objective

To investigate the efficacy of a falls prevention clinic and a community step-down program in reducing the number of falls among community-dwelling elderly at high risk of fall.

Design

Prospective cohort.

Setting

Community.

Participants

Community-dwelling elderly (N=200) were screened for risk of fall; 60 were identified as being at high risk and were referred to the intervention program.

Intervention

Twelve sessions of a once-a-week falls prevention clinic, including fall evaluation, balance training, home hazard management program, and medical referrals, were provided in the first 3 months. The community step-down program, including falls prevention education, a weekly exercise class, and 2 home visitations, was provided in the following 9 months.

Main Outcome Measures

Fall rate, injurious fall, and its associated medical consultation were recorded during the intervention period and the year before intervention. Balance tests included the Berg Balance Scale (BBS), Sensory Organization Test, and limits of stability test; fear of falling, as evaluated using the Activities-specific Balance Confidence (ABC) scale, was measured at baseline and after the training in the falls prevention clinic.

Results

Significant reductions in fall rate (74%), injurious falls (43%), and fall-associated medical consultation (47%) were noted. Significant improvement in balance scores (BBS, P<.001; endpoint excursion in limits of stability test, P=.004) and fear of falling (ABC scale, P=.001) was shown.

Conclusions

The programs in the falls prevention clinic were effective in reducing the number of falls and injurious falls. The community step-down programs were crucial in maintaining the intervention effects of the falls prevention clinic.     

The effects of hip and ankle stretching on gait function of older people

Christiansen CL. The effects of hip and ankle stretching on gait function of older people.

Objective

To examine effects of hip and ankle stretching on gait function of older people.

Design

Randomized controlled trial.

Setting

Flexibility training was performed in participants' homes. Assessments were performed in a biomechanics laboratory.

Participants

Forty healthy volunteers (mean age ± SD, 72.1±4.7y) randomized to 2 groups: intervention (n=20) and control (n=20).

Intervention

Intervention participants performed an 8-week stretching program, and control group participants maintained activity level for 8 weeks. One investigator made weekly visits to instruct and monitor participants.

Main Outcome Measures

Primary outcome measures were passive joint motion for hip extension and ankle dorsiflexion and freely chosen gait speed. Secondary outcome measures were gait parameters during freely chosen gait speed and set gait speed walking (stride length, joint displacement).

Results

Compared with the control group, the intervention group had increased combined hip and knee motion (P=.023), ankle motion (P=.020), and freely chosen gait speed (P=.016). The intervention group showed statistically nonsignificant trends of increased stride length at freely chosen gait speed and set gait speed.

Conclusions

Findings suggest joint motion is a modifiable impairment that is effectively targeted with flexibility training for older people. Participants in the intervention group had improvements in joint motion as well as increased freely chosen gait speed. Mechanisms responsible for changes in freely chosen gait speed warrant further investigation.     

Longitudinal Changes in the Health-Related Quality of Life During the First Year After Traumatic Brain Injury

Lin M-R, Chiu W-T, Chen Y-J, Yu W-Y, Huang S-J, Tsai M-D. Longitudinal changes in the health-related quality of life during the first year after traumatic brain injury.

Objective

To track the health-related quality of life (HRQL) at discharge and at 6 and 12 months after a traumatic brain injury (TBI) and examine factors associated with changes in each HRQL domain.

Design

Longitudinal cohort study.

Setting

Using codes of the International Classification of Diseases, eligible participants who had a newly diagnosed TBI were identified from discharge records of 4 hospitals in northern Taiwan. Information on the HRQL and injury-related characteristics at the initial and 2 follow-up assessments was collected by extracting medical records and conducting telephone interviews.

Participants

Subjects (N=158) participated in the initial assessment, and 147 and 146, respectively, completed the follow-up assessments at 6 and 12 months after injury.

Interventions

Not applicable.

Main Outcome Measure

The brief version of the World Health Organization Quality of Life (WHOQOL-BREF) with 4 domains of physical capacity, psychologic well being, social relationships, and environment.

Results

Scores on all WHOQOL-BREF domains except social relationships greatly improved over the first 6 months and showed continued improvement at 12 months after injury. The domain scores of the WHOQOL-BREF at discharge were significantly associated with the preinjury HRQL level, marital status, alcohol consumption at the time of injury, Glasgow Outcome Scale (GOS) level, cognition, activities of daily living, social support, and depressive status. However, after adjusting for these baseline differences, only the GOS level and depressive status significantly influenced longitudinal changes in the psychologic and social domains over the 12-month period. Changes in the physical and environmental domains were not significantly associated with any characteristics of the study.

Conclusions

During the first year after a TBI, the magnitude of HRQL recovery differed across different HRQL domains. Many factors may have significant associations with the initial domain scores of HRQL after TBI; however, only a few factors can significantly influence longitudinal changes in the HRQL.     

Validity and Responsiveness of the Care and Needs Scale for Assessing Support Needs After Traumatic Brain Injury

So C, Tate RL, Aird V, Allaous J, Browne S, Carr B, Coulston C, Diffley L, Gurka J, Hummell J. Validity and responsiveness of the Care and Needs Scale for assessing support needs after traumatic brain injury.

Objective

To investigate the validity and responsiveness of the Care and Needs Scale (CANS), which was designed to assess support needs of people with traumatic brain injury (TBI).

Design

Two samples of community clients (n=38, n=30) were recruited to examine concurrent, convergent/divergent, and discriminant validity. The ability of the CANS to detect change over a 6-month period from the time of inpatient rehabilitation discharge (predictive validity and responsiveness) was investigated in a third sample of 40 rehabilitation inpatients.

Setting

Two Brain Injury Rehabilitation Units in Sydney, Australia.

Participants

People (N=108) aged between 16 and 70 years admitted for rehabilitation after TBI.

Interventions

Not applicable.

Main Outcome Measures

The CANS, Supervision Rating Scale, FIM, Sydney Psychosocial Reintegration Scale, and Disability Rating Scale.

Results

Evidence for concurrent validity was shown with fair to moderate correlation coefficients between the CANS and measures of supervision, functional independence, and psychosocial functioning (absolute value, r_s=.43-.68; P<.01). Support for convergent and divergent validity was provided by correlation coefficients that were higher for measures tapping similar constructs (absolute value, r_s=46; P<.01) but lower for measures of dissimilar constructs (absolute value, r_s=.07-.26; not significant). In addition, the CANS discriminated between levels of injury severity, functional independence, and overall functioning (P<.01). In terms of predictive validity and responsiveness, CANS scores at inpatient rehabilitation discharge predicted the participant's functioning 6 months later.

Conclusions

These results show the CANS is a valid and responsive tool and, together with its previously shown reliability, is suitable for routine application in clinical and research practice.     

Team training and stroke rehabilitation outcomes: a cluster randomized trial

Strasser DC, Falconer JA, Stevens AB, Uomoto JM, Herrin J, Bowen SE, Burridge AB. Team training and stroke rehabilitation outcomes: a cluster randomized trial.

Objective

To test whether a team training intervention in stroke rehabilitation is associated with improved patient outcomes.

Design

A cluster randomized trial of 31 rehabilitation units comparing stroke outcomes between intervention and control groups.

Setting

Thirty-one Veterans Affairs medical centers.

Participants

A total of 237 clinical staff on 16 control teams and 227 staff on 15 intervention teams. Stroke patients (N=487) treated by these teams before and after the intervention.

Intervention

The intervention consisted of a multiphase, staff training program delivered over 6 months, including: an off-site workshop emphasizing team dynamics, problem solving, and the use of performance feedback data; and action plans for process improvement; and telephone and videoconference consultations. Control and intervention teams received site-specific team performance profiles with recommendations to use this information to modify team process.

Main Outcome Measures

Three patient outcomes: functional improvement as measured by the change in motor items of the FIM instrument, community discharge, and length of stay (LOS).

Results

For both the primary (stroke only) and secondary analyses (all patients), there was a significant difference in improvement of functional outcome between the 2 groups, with the percentage of stroke patients gaining more than a median FIM gain of 23 points increasing significantly more in the intervention group (difference in increase, 13.6%; P=.032). There was no significant difference in LOS or rates of community discharge.

Conclusions

Stroke patients treated by staff who participated in a team training program were more likely to make functional gains than those treated by staff receiving information only. Team based clinicians are encouraged to examine their own team. (ClinicalTrials.gov identifier NCT00237757).