Contractures with special reference in elderly: definition and risk factors – a systematic review with practical implications

Abstract

Purpose: Contractures are common problems for the elderly with far reaching functional and medical consequences. The aim of this systematic literature review was to give an overview of contracture and to identify potential risk factors associated with contractures. Methods: A systematic literature search with two objectives limited to the last 10 years was performed to identify studies dealing with definition of contracture (objective 1?=?O1) and with risk factors (objective 2?=?O2). Predefined information including age, sample size, study design, setting, condition, joint, definition of contracture, mode of measurement, and whether inter- and/or intra-rater reliability were assessed, as well as risk factors of contracture were extracted. Results: One hundred and sixty one and 25 studies were retrieved. After applying exclusion criteria 47 studies (O1) and 3 studies (O2) remained. Only 9 studies (O1) provided a definition of contracture. In 3 studies (O2) several potential risk factors were identified. Conclusions: In most of the studies it seems that the presence of a contracture is equivalent with the presence of restriction in the range of motion (ROM) of a joint. Very little is known about risk factors for contractures. But it seems that immobility may play a pivotal role in the development of this condition.

• Implication for Rehabilitation

• The prevalence of contractures in nursing home residents is estimated at 55% with significant functional and medical consequences.

• In most studies, which were published in the last 10 years, the presence of a contracture is equivalent with the presence of restriction in the range of motion of a joint.

• Immobility seems to play a role in the development of contractures.

• Potential avenues to prevention of contractures and subsequent functional limitations are exercise programmes for and maintenance of mobility of the elderly.

     

Cryoablation of liver tumours – a review of mechanisms,techniques and clinical outcome

Several techniques exist for in situ destruction or ablation of liver tumours not eligible for resection. Cryoablation, i.e. the use of low temperatures to induce local tissue necrosis, was among the first of the thermal ablative techniques widely used. The procedures have typically been performed by surgeons during laparotomy, but recently minimally invasive cryoablation has been reported feasible. The present review focuses on mechanisms of tissue destruction, techniques of ablation including procedural monitoring, and clinical outcome following cryoablation of liver tumours. Plausible causes of tumour persistence at the site of ablation, i.e. local treatment failure, are discussed. Shortcomings exist in monitoring of the freezing process and may be a main cause. The evidence for the long‐term outcome following liver tumour cryoablation needs to be improved. Cryoablation has been challenged by other techniques of tumour ablation such as radiofrequency ablation. Randomised trials against these modern techniques may define the role of cryoablation in the treatment of liver tumours. With improved imaging technology and patient selection, cryoablation of liver tumours may hold promise for selected patients.     

Strategies to improve non-viral vectors – potential applications in clinical transplantation

Prevention of acute rejection has been well controlled with immunosuppressive drugs. However, the long-term control of rejection is less satisfactory and the side effects of chronic usage of these drugs are far from acceptable. Thus, more imaginative options for therapy need to be explored. Gene therapy has potential promise in preserving allografts, preventing rejection and inducing tolerance. Despite this initial promise in many animal models, the translation of gene therapy to the clinical arena has been slow. This may be related in part to the deficiencies in vector development. Existing viral vectors are efficient at transducing allografts, but they induce inflammatory and pathogenic effects. Although the alternative non-viral systems are relatively innocuous, they are less efficient at gene delivery. This review systematically analyses the limitations of non-viral vector technology and the strategies that have been developed to overcome these limitations. Future development of non-viral vectors may have potential application in clinical transplantation.     

Does renin‐angiotensin system blockade have a role in preventing diabetic retinopathy? A clinical review

Diabetes management has increasingly focused on the prevention of macrovascular disease, in particular for type 2 diabetes. Diabetic retinopathy, one of the main microvascular complications of diabetes, is also an important public health problem. Much of the care invested in retinopathy relates to treatment rather than prevention of disease. Tight glycaemic and blood pressure control helps to reduce the risk of retinopathy, but this is not easy to achieve in practice and additional treatments are needed for both primary and secondary prevention of retinopathy. A renin-angiotensin system (RAS) has been identified in the eye and found to be upregulated in retinopathy. This has led to specific interest in the role of RAS blockade in retinopathy prevention. The recent DIRECT programme assessed use of the angiotensin receptor blocker (ARB) candesartan in type 1 and type 2 diabetes. Although the primary trial end-points were not met, there was a clear trend to less severe retinopathy with RAS blockade. A smaller trial, RASS, reported reduced retinopathy progression in type 1 diabetes from RAS blockade with both the ARB losartan and the angiotensin converting enzyme (ACE) inhibitor enalapril. The clinical implications of these new data are discussed.     

Elbow dysplasia – a review and surgical approaches

ABSTRACT:

Elbow dysplasia (ED) is a complex disorder that leads to degeneration of the elbow joint through a series of developmental abnormalities. It is the most common cause of elbow pain and lameness in the canine species, particularly large breeds. Diagnosis and treatment of this disorder may be complex, requiring specialist imaging and surgical techniques in order to achieve the best outcomes. A general understanding of ED is important when providing the nursing care of affected animals.     

Procalcitonin-guided therapy in intensive care unit patients with severe sepsis and septic shock – a systematic review and meta-analysis

Introduction

Procalcitonin (PCT) algorithms for antibiotic treatment decisions have been studied in adult patients from primary care, emergency department, and intensive care unit (ICU) settings, suggesting that procalcitonin-guided therapy may reduce antibiotic exposure without increasing the mortality rate. However, information on the efficacy and safety of this approach in the most vulnerable population of critically ill patients with severe sepsis and septic shock is missing.

Method

Two reviewers independently performed a systematic search in PubMed, Embase, ISI Web of Knowledge, BioMed Central, ScienceDirect, Cochrane Central Register of Controlled Trials, http://www.ClinicalTrials.gov and http://www.ISRCTN.org.Eligible studies had to be randomized controlled clinical trials or cohort studies which compare procalcitonin-guided therapy with standard care in severe sepsis patients and report at least one of the following outcomes: hospital mortality, 28-day mortality, duration of antimicrobial therapy, length of stay in the intensive care unit or length of hospital stay. Disagreements about inclusion of studies and judgment of bias were solved by consensus.

Results

Finally seven studies comprising a total of 1,075 patients with severe sepsis or septic shock were included in the meta-analysis.Both hospital mortality (RR [relative risk]: 0.91, 95%CI [confidence interval]: 0.61; 1.36) and 28-day mortality (RR: 1.02, 95%CI: 0.85; 1.23) were not different between procalcitonin-guided therapy and standard treatment groups.Duration of antimicrobial therapy was significantly reduced in favor of procalcitonin-guided therapy (HR [hazard ratio]: 1.27, 95%CI: 1.01; 1.53). Combined estimates of the length of stay in the ICU and in hospital did not differ between groups.

Conclusion

Procalcitonin-guided therapy is a helpful approach to guide antibiotic therapy and surgical interventions without a beneficial effect on mortality. The major benefit of PCT-guided therapy consists of a shorter duration of antibiotic treatment compared to standard care.Trials are needed to investigate the effect of PCT-guided therapy on mortality, length of ICU and in-hospital stay in severe sepsis patients.     

Do sex differences exist in opioid analgesia? A systematic review and meta-analysis of human experimental and clinical studies

Although a contribution of sex in opioid efficacy has garnered much attention, the confirmation and direction of any such difference remain elusive. We performed a systematic review of the available literature on sex differences in μ and mixed μ/κ opioid effect on acute and experimental pain. Fifty unique studies (including three unpublished studies) were included in the analyses. Across the 25 clinical studies on μ-opioids there was no significant sex-analgesia association. Restricting the analysis to patient-controlled analgesia (PCA) studies (irrespective of the opioid) yielded greater analgesia in women (n = 15, effect size 0.22, 95% c.i. 0.02-0.42, P = 0.028). Further restricting the analysis to PCA morphine studies yielded an even greater effect in women (n = 11, effect size = 0.36, 95% c.i. 0.17-0.56, P = 0.003). Meta-regression indicated that the longer the duration of PCA, the difference in effect between the sexes further increased. Across experimental pain studies on μ-opioids women had greater antinociception from opioids (n = 11, effect size = 0.35; 95% c.i. 0.01-0.69, P = 0.047), which was predominantly due to 6 morphine studies. Female patients had greater μ/κ opioid analgesia (n = 7, effect size 0.84; 95% c.i. 0.25-1.43, P = 0.005), but no sex-analgesia association was present in experimental studies (n = 7). Sex differences exist in morphine-induced analgesia in both experimental pain studies and clinical PCA studies, with greater morphine efficacy in women. The data on non-morphine μ and mixed μ/κ-opioids are less convincing and require further study.     

Learning with and from each other: promoting international and interprofessional collaborations in physiotherapy education research – a literature review

Background: Best practice in physical therapy education requires good quality and quantity of research based on authentic learning settings and teaching practices. Facilitating large multisite research and large data sets for analysis has the potential to contribute to a strong research base. Clinical research makes use of international and interprofessional consortiums to produce quantity and quality of research outcomes.

Objectives: The paper aimed to investigate international and interprofessional co-authorship in educational research in a single journal and describe two collaborative models. Methods: The paper has two sections. (1) A review of co-authorship in 113 papers published in the Journal of Physical Therapy Education over a three and a half year period (2014 to 2017). (2) Two models of collaboration in educational research are described.

Results: The literature review highlighted a pattern of almost no international collaborations but close to 27% of papers with interprofessional collaborations. Two collaborative models were presented, one an international and intraprofessional model and the second an international and interprofessional research approach.

Conclusions: It is argued that creating consortiums with international and interprofessional health professionals will progress the quality of educational research in physical therapy, assisting with our educational decision-making and further improving on our learning and teaching practices.     

Radiofrequency-based treatment in therapy-related clinical practice – a narrative review. Part II: chronic conditions

Background: Radiofrequency (RF)-based electrophysical agents (EPAs) have been employed in therapy-related clinical practice for several decades. They are used to reduce pain and inflammation and promote tissue healing. Although deemed less popular in current therapy practice, surveys suggest that some of these EPAs are still used reasonably widely.

Objective: To review the evidence for the use of non-invasive low-frequency RFs (30?kHz - 30?MHz) for treating chronic therapy-related clinical conditions.

Major findings: All relevant peer-reviewed clinical studies published in English, concerning low-frequency RFs were sought. Identified literature was stratified as ‘acute’ and ‘chronic’ based on their clinical area. The studies on chronic conditions were reviewed for this paper and analysed to assess the volume and scope of current evidence. Out of 120 studies identified, 90 related to chronic conditions. The majority of them (82 studies) employed shortwave therapy (SWT) in continuous (CSWT) or pulsed (PSWT) modes. Only eight studies employed frequencies other than shortwave. Overall 67 studies investigated conditions relating to ‘pain and inflammation’, 16 to ‘tissue healing’ and 7 studies to other less reported conditions.

Conclusions: Evidence favouring and against RF-based EPAs is available. There is moderate evidence favouring the use of SWT (mainly PSWT) in knee osteoarthritis. Some evidence also exists for CSWT in chronic low back pain and PSWT for treating chronic wounds. Evidence for other conditions is insufficient and conflicting. A general lack of research emphasis in the non-shortwave RF band is evident. Further and wider research in this area is necessary.     

Relationship between blood toxin level and clinical features in patients with grayanotoxin poisoning – six clinical cases

Background: The purpose of this study was to investigate grayanotoxin (GTX) levels in the blood of patients with GTX intoxication and in the consumed Rhododendron liqueur, and to determine whether there was an association between blood GTX level and the patient’s clinical status.

Methods: In September 2015, six patients were concurrently presented to the emergency department with various toxicity symptoms, which occurred after the consumption of Rhododendron liqueur at the same toxin concentration. Liquid chromatography–tandem mass spectrometry analysis was conducted on blood samples obtained from six cases of GTX intoxication treated in our emergency department.

Results: At the initial evaluation in the emergency department, the mean arterial pressure of the patients ranged from 36.7 to 76.7?mm?Hg. The concentrations of GTX-I and GTX-III in Rhododendron liqueur were 1.436 and 16.907?ng/mL, respectively. The initial blood GTX-III and GTX-I levels ranged from 2.9 to 58.0?ng/mL and the lower limit of quantification (LLOQ) to 8.33?ng/mL, respectively. After 20?h, the mean arterial pressure ranged from 76.7 to 93.3?mm?Hg, while the blood GTX-III and GTX-I levels ranged from the LLOQ to 17.8 and 2.52?ng/mL, respectively.

Discussion: We estimated that the minimum blood GTX-III and GTX-I levels that caused hypotension were between 17.83 and 27.3?ng/mL, and 2.52 and 4.55?ng/mL, respectively.     

Radiofrequency-based treatment in therapy-related clinical practice – a narrative review. Part I: acute conditions

Abstract

Background: The effectiveness of orthotics as an injury prevention strategy for the military has not been well established.

Objectives: To estimate the effectiveness of an orthotic intervention in preventing specific injuries among military personnel.

Methods: A systematic review of English and translated articles from: CINAHL, Cochrane, Medline, PubMed, Scopus, and Web of Science as well as reference lists of relevant articles and a hand search was completed. The criteria for inclusion were: randomized controlled trials (RCTs) investigating the use of orthotics as an injury prevention strategy for military personnel, which used a prospective design and followed participants for a minimum of 3 months, where comparison involved a parallel control group.

Results: Seven trials were identified which met the inclusion criteria. Results were pooled into specific injuries. Based on a meta-analysis of specific injuries, orthotic use was found to have no effect for 8 out of 10 overuse injuries of the lower limb and back. Of the remaining injuries (femoral stress fractures and tibial stress fractures) orthotic use had a significant injury reduction effect. However, the overall quality was poor, with five out of seven studies being of low quality.

Conclusions: The findings of this systematic review indicate that no strong conclusions can be made on the use of orthotics as a preventive measure for overuse injury in the military. Orthotic provision was only found to be effective as a prevention strategy for 2 out of 10 overuse injuries identified as commonly occurring within the military. Unfortunately, the practicality of their supply is still unknown due to the absence of intention to treat analyses. This, along with other findings, should be addressed in future research.     

Safety and feasibility of transcranial direct current stimulation in amyotrophic lateral sclerosis – a pilot study with a single subject experimental design

Introduction: Transcranial direct current stimulation (tDCS) has been explored as a neuromodulatory tool to prime motor function in several neurological disorders. Studies using tDCS in amyotrophic lateral sclerosis (ALS) are limited. We investigated the safety, feasibility and effects of long-term tDCS in an individual with ALS. Methods: A 36-year-old male diagnosed with clinically definite ALS received 12 sessions each of anodal, sham, and cathodal tDCS. Outcome measures included disease progression (revised ALS functional rating scale (ALSFRS-R)), clinical measures of endurance and mobility, and corticomotor excitability. Results: No adverse events or change in disease progression were noticed during the study. Small improvement in gait speed (15% increase) was noticed with anodal tDCS only. Conclusions: This case study demonstrates the safety and feasibility of long-term facilitatory and inhibitory tDCS on a single participant with ALS. This study serves as a guideline for implementing tDCS in future ALS trials.     

Procalcitonin – a new diagnostic tool in complications following liver transplantation

Objective: Does procalcitonin (PCT) allow differentiation between infection and rejection following liver transplantation in the case of fever of unknown origin (FUO)?¶Design: Open prospective trial.¶Setting: transplant intensive care unit at a university hospital.¶Patients: Forty patients after liver transplantation.¶Interventions: Liver biopsy for diagnosis of rejection, transcutaneous aspiration cytology for monitoring of lymphocyte activation.¶Measurements: Procalcitonin from EDTA plasma, APACHE II, Sepsis score (Elbute and Stoner).¶Results: Eleven patients suffered an infectious complication resulting in an increase in PCT levels (2.2–41.7 ng/ml). Eleven patients developed a rejection episode; none of these patients showed a rise in PCT levels. The statistical difference between PCT levels in rejection and infection was significant (p < 0.05) on the day of diagnosis.¶Conclusion: PCT allows differentiation between rejection and infection in the case of FUO. Elevation of PCT plasma levels develops early postoperatively due to operation trauma, and, in the case of FUO with no rise in PCT, a rejection may be suspected.     

Swimming induced pulmonary oedema in athletes – a systematic review and best evidence synthesis

Background

Swimming induced pulmonary oedema is an uncommon occurrence and usually presents during strenuous distance swimming in cold water. The prevalence is most likely underreported and the underlying mechanisms are controversial. The purpose of this study was to summarize the evidence with regards to prevalence, pathophysiology and treatment of swimming induced pulmonary oedema in endurance athletes.

Methods

Medline, Embase, Scopus and Google Scholar were searched and level I-IV from 1970 to 2017 were included. For clinical studies, only publications reporting on swimming-induced pulmonary oedema were considered. Risk of bias was assessed with the ROBINS-I tool, and the quality of evidence was assessed with the Cochrane GRADE system. For data synthesis and analysis, a best evidence synthesis was used.

Results

A total of 29 studies were included (174 athletes). The most common symptom was cough, dyspnoea, froth and haemoptysis. The risk of bias for the clinical studies included 13 with moderate risk, 3 with serious, and 4 with critical. Four of the pathophysiology studies had a moderate risk, 3 a serious risk, and 1 a critical risk of bias. A best evidence analysis demonstrated a strong association between cold water immersion and in increases of CVP (central venous pressure), MPAP (mean pulmonary arterial pressure), PVR (peripheral vascular resistance) and PAWP (pulmonary arterial wedge pressure) resulting in interstitial asymptomatic oedema.

Conclusion

The results of this study suggest a moderate association between water temperature and the prevalence of SIPE. The presence of the clinical symptoms cough, dyspnoea, froth and haemoptysis are strongly suggestive of SIPE during or immediately following swimming. There is only limited evidence to suggest that there are pre-existing risk factors leading to SIPE with exposure to strenuous physical activity during swimming. There is strong evidence that sudden deaths of triathletes are often associated with cardiac abnormalities.

     

The effects and experiences of goal setting in stroke rehabilitation – a systematic review

Objective: To systematically integrate and appraise the evidence for effects and experiences of goal setting in stroke rehabilitation.

Design: Systematic review of quantitative and qualitative studies.

Methods: Relevant databases were searched from start of database to 30 April 2011. Studies of any design employing goal setting, reporting stroke-specific data and evaluating its effects and/ or experiences were included.

Results: From a total of 53998 hits, 112 full texts were analysed and 17 studies were included, of which seven evaluated effects while ten explored experiences of goal setting. No eligible randomized controlled trials were identified. Most of the included studies had weak to moderate methodological strengths. The design, methods of goal setting and outcome measures differed, making pooling of results difficult. Goal setting appeared to improve recovery, performance and goal achievement, and positively influenced patients’ perceptions of self-care ability and engagement in rehabilitation. However, the actual extent of patient involvement in the goal setting process was not made clear. Patients were often unclear about their role in this process. Professionals reported higher levels of collaboration during goal setting than patients. Patients and professionals differed on how they set goals, types of goals set, and on how they perceived goal attainment. Barriers to goal setting outnumbered the facilitators.

Conclusion: Due to the heterogeneity and quality of included studies, no firm conclusions could be made on the effectiveness, feasibility and acceptability of goal setting in stroke rehabilitation. Further rigorous research is required to strengthen the evidence base. Better collaboration and communication between patients and professionals and relevant education are recommended for best practice.

Implications for Rehabilitation

• Communication is key to collaborative goal setting.

• Education and training of professionals regarding goal setting is recommended, especially in relation to methods of involving people with communication and cognitive impairments.

• Educating patients about stroke and goal setting could enhance their participation in goal setting.

     

Measuring elderly dysphagic patients' performance in eating – a review

Purpose.?This review aims to identify psychometrically robust assessment tools suitable for measuring elderly dysphagic patients' performance in eating for use in clinical practice and research.

Method.?Electronic databases, related citations and references were searched to identify assessment tools integrating the complexity of the eating process. Papers were selected according to criteria defined a priori. Data were extracted regarding characteristics of the assessment tools and the evidence of reliability, validity and responsiveness. Quality appraisal was undertaken using developed criteria concerning the study design, the statistics used for the psychometric evaluation and the reported values.

Results.?Eight of fourteen identified assessment tools met the inclusion criteria. Three assessment tools were specific to dementia, two were specific to stroke and three targeted a range of neurological and geriatric conditions. The rigor of the assessment tools' psychometric properties varied from no evidence available to excellent evidence. Only two assessment tools were rated adequate to excellent.

Conclusion.?‘The Minimal Eating Observation Form-Version II’ to be used for screening and ‘The McGill Ingestive Skills Assessment’ to be used for treatment planning and monitoring appeared to be psychometrically robust for clinical practice and research. However, further research on their psychometric properties is needed.     

Instruments measuring interprofessional collaboration in healthcare – a scoping review

ABSTRACT

Worldwide there is growing understanding of the importance of interprofessional collaboration in providing well-functioning healthcare. However, little is known about how interprofessional collaboration can be measured between different health-care professionals. In this review, we aim to fill this gap, by identifying and analyzing the existing instruments measuring interprofessional collaboration in healthcare. A scoping review design was applied. A systematic literature search of two electronic databases, Medline (PubMed) and CINAHL, was conducted in 03/2018. The search yielded 1020 studies, of which 35 were selected for the review. The data were analyzed by content analysis. In total, 29 instruments measuring interprofessional collaboration were found. Interprofessional collaboration was measured predominantly between nurses and physicians with different instruments in various health-care settings. Psychometric testing was unsystematic, focusing predominantly on construct and content validity and internal consistency, thus further validation studies with comprehensive testing are suggested. The results of this review can be used to select instruments measuring interprofessional collaboration in practice or research. Future research is needed to strengthen the evidence of reliability and validity of these instruments.     

Comparison of rehabilitation outcomes in day hospital and home settings for people with acquired brain injury – a systematic review

Purpose.?To conduct a systematic literature review that identifies and summarises the findings of studies that have compared the outcomes of outpatient, brain injury rehabilitation programmes conducted in real-life home settings and day hospital clinic settings.

Method.?A systematic search, using specific inclusion and exclusion criteria, of English language electronic databases, as well as manual search of reference lists of identified articles. Each study was evaluated and rated using 11 methodological criteria. The findings are summarised.

Results.?Database searches, using key terms, initially yielded 4484 articles. Of these articles, 17 articles were included in the review and rated according to methodological quality. The majority of studies indicated that the outcomes of rehabilitation programmes conducted in home settings are at least equivalent to rehabilitation conducted in day hospital and outpatient settings for people with acquired brain injury. Most identified studies (15/17) were with groups of people with a diagnosis of stroke, primarily over the age of 65 years. Assessments of impairment or activity limitation were primarily used to reflect outcomes and no studies used participation or goal-based outcome measures.

Conclusions.?The available studies indicate that outcomes of outpatient rehabilitation programmes delivered at home, of short-term duration (mostly 3 months) for people with stroke recently discharged from hospital, are at least equivalent to day hospital-based outpatient rehabilitation programme outcomes. However, there have been no controlled studies designed to investigate the influence of therapy context (home and clinic settings) on outcomes for people receiving outpatient neurological rehabilitation. Furthermore, investigations of the efficacy of community-based rehabilitation with younger people with brain injuries, caused by mechanisms other than stroke, are required.