Method: Four databases were searched for studies published before August 2016 using database-specific keywords and synonyms for amputation, cardiovascular diseases and mobility. Assessment of the publications was performed based on predefined criteria; first title and abstract and thereafter the full text.
Results: Of the 1704 titles and abstracts, 51 full texts were assessed. Ten studies were included. Cardiovascular diseases were associated with cardiac complications during rehabilitation. Prosthetic training improved cardiac function. Seven studies showed that cardiovascular diseases were associated with a smaller chance of becoming a prosthetic walker, and with poorer mobility outcomes.
Conclusion: Evidence for effects of cardiovascular diseases on mobility in persons with a lower limb amputation is heterogeneous. Cardiovascular diseases reduce the chance of becoming a prosthetic walker and reduce mobility outcomes after a lower limb amputation. More research with adequate quality about cardiovascular diseases in persons requiring a lower limb amputation is needed, to enable informed choices in the pre- and post-amputation rehabilitation.
- Implications for rehabilitation
Data about the effect of cardiovascular diseases on mobility in persons with a lower limb amputation is limited.
More research about cardiovascular diseases in persons requiring a lower limb amputation is needed, to enable informed choices in the pre- and post-amputation rehabilitation.
Objective: To examine the associations between patients’ self-rated health and their sleep problems, somatic health complaints, and unmet needs in interpersonal relationships.
Design: We collected data via questionnaires for this cross-sectional study from general practice.
Setting: Primary health care in Norway.
Subjects: 1302 consecutive patients participated.
Main outcome measures: The questionnaire included a single question about SRH, the Bergen Insomnia Scale (BIS), five questions on somatic health complaints, and three questions from the Basic Psychological Needs Scale (BPNS) pertaining to the relationships domain. We analyzed our data using ordinal logistic regression models.
Results: Our response rate was 74%. The prevalence of fair/poor SRH was 26%, with no gender differences. We revealed a significant association between increasing age and reduced SRH. The study showed that sleep problems and somatic health complaints were strongly associated with SRH, and unmet needs in relationships were also significantly and independently associated with reduced SRH in a full model analysis.
Conclusion: Sleep problems, somatic health complaints, and unmet needs in interpersonal relationships were all associated with reduced SRH. These factors are all modifiable and could be managed both within and outside a primary care setting in order to improve SRH.
- Key Points
There was a high prevalence of reduced SRH in clinical general practice
Sleep problems, somatic health complaints, and unmet needs in interpersonal relationships were all associated with reduced SRH
These predictors are all modifiable with a potential to improve SRH
Method: Thirteen pwMS and 14 chronic stroke patients performed 36 (stroke) or 40 (pwMS) training sessions with the I-TRAVLE system. Evaluation of upper limb function was performed at baseline, after training and at 3 months follow-up. Clinical outcome measures consisted of active range of motion (ROM), Motricity Index, Jamar handgrip strength, perceived fatigue and strength, Wolf Motor Function Test (WFMT) and ABILHAND. Robot-generated outcome measures consisted of movement velocity, ROM and actual covered distance compared to straight-line distance.
Results: In pwMS, significant improvements were found after training in active shoulder ROM, handgrip strength, perceived strength and WMFT activities. No significant change in clinical outcome was found in stroke patients, except for perceived strength. Significant improvement in speed and movement duration was found after training in both groups. At follow-up, clinical outcome deteriorated in pwMS and was maintained in stroke patients.
Conclusions: Robot-mediated training resulted in improved movement coordination in both groups, as well as clinical improvement in pwMS. Absence of functional improvements in stroke patients may relate to severe upper limb dysfunction at baseline.
- Implications for Rehabilitation
Robot-mediated training improved strength, active range of motion and upper limb capacity in pwMS.
Robot-mediated therapy allows for adapted training difficulty.
Design: A retrospective interrupted times series study.
Setting: Two multidisciplinary general practitioner (GP) practices.
Intervention: An internist provided in-house patient consultations in two GP practices and participated in the multidisciplinary meetings.
Subjects: The referral data extracted from the electronic medical record system of the GP practices, including all referral letters from the GPs to specialist care in the hospital setting.
Main outcome measures: The number of referrals to internal medicine in the hospital setting. This study used an autoregressive integrated moving average model to estimate the effect of the intervention taking account of a time trend and autocorrelation among the observations, comparing the pre-intervention period with the intervention period.
Results: It was found that the referrals to internal medicine did not statistically significant decrease during the intervention period.
Conclusions: This small explorative study did not find any clues to support that an in-house internist at a primary care setting results in a decrease of referrals to internal medicine in the hospital setting.
- Key Points
An in-house internist at a primary care setting did not result in a significant decrease of referrals to specialist care in the hospital setting.
The GPs and internist experience a learning-effect, i.e. an increase of knowledge about internal medicine issues.
Design: Randomised survey study.
Setting: Denmark.
Subjects: A random sample of women from the birth cohorts 1993, 1994 and 1995 drawn from the general population.
Interventions: A web-based questionnaire and information intervention. We randomised potential respondents to one of the following four different information modules about benefits and harms of cervical screening: no information; non-numerical information; and two numerical information modules. Moreover, we provided HPV-vaccinated women in one of the arms with numerical information about benefits and harms in two steps: firstly, information without consideration of HPV vaccination and subsequently information conditional on HPV vaccination.
Main outcome measure: Self-reported intention to participate in cervical screening.
Results: A significantly lower proportion intended to participate in screening in the two groups of women receiving numerical information compared to controls with absolute differences of 10.5 (95% CI: 3.3–17.6) and 7.7 (95% CI: 0.4–14.9) percentage points, respectively. Among HPV-vaccinated women, we found a significantly lower intention to participate in screening after numerical information specific to vaccinated women (OR of 0.38).
Conclusions: Women are sensitive to numerical information about the benefits and harms of cervical screening. Specifically, our results suggest that HPV-vaccinated women are sensitive to information about the expected changes in benefits and harms of cervical screening after implementation of HPV vaccination.
- KEY POINTS
Women were less likely to participate in cervical screening when they received numerical information about benefits and harms compared to non-numerical or no information.
Specifically, numerical information about the potential impact of the reduced risk of cervical cancer among HPV-vaccinated women reduced the intention to participate among vaccinated women.
Objectives: To examine the effect of external application in pain compared to traditional method.
Design: A double-blind placebo-controlled clinical investigation.
Setting: A public hospital.
Participants: 168 LBP subjects.
Interventions: Assignment: (1) external IFT, (2) placebo external IFT, (3) traditional IFT and (4) placebo traditional IFT. Groups 1 and 3 received 20 min of IFT at 100 Hz and groups 2 and 4 received sham IFT.
Main outcome measures: Before and after IFT session, pain severity (VAS), pressure threshold (PPT), pain distribution and ROM were assessed.
Results: IFT changed all outcomes similarly. VAS and ROM improved statistically, P < 0.03. A trend of better VAS reduced with active IFTs.
Conclusions: No therapeutic difference between the two methods. 相似文献
Design: We conducted focus groups (FGs) with 17 GPs.
Setting: Norwegian primary health care.
Subjects: 17 GPs who attended a 5 d course on leadership in primary health care.
Results: Our study suggests that the GPs experience a need for more preparation and formal training for the leadership role, and that they experienced tensions between the clinical and leadership role. GPs recognized the need to take on leadership roles in primary care, but their lack of leadership training and credentials, and the way in which their practices were organized and financed were barriers towards their involvement.
Conclusions: GPs experience tensions between the clinical and leadership role and note a lack of leadership training and awareness. There is a need for a more structured educational and career path for GPs, in which doctors are offered training and preparation in advance.
- KEY POINTS
Little is known about doctors’ experiences and views about leadership in general practice and primary health care. Our study suggests that:
There is a lack of preparation and formal training for the leadership role.
GPs experience tensions between the clinical and leadership role.
GPs recognize leadership challenges at a system level and that doctors should take on leadership roles in primary health care.
Design: A cross-sectional population study.
Setting: The municipality of Naestved, Denmark.
Subjects: We studied 907 patients with type 2 diabetes identified from a random sample of 21,205 Danish citizens.
Main outcome measures: The proportion of patients who were not achieving goals for diabetes care based on their HbA1c, LDL-cholesterol, blood pressure, and lifestyle, and the proportion of patients who were treated with antihypertensive and cholesterol- and glucose-lowering medication.
Methods: We investigated the association of the socioeconomic factors such as age, gender, education, occupation, income, and civil status and attainment of treatment goals and pharmacotherapy in logistic regression analyses. We investigated effect modification of cardiovascular disease and kidney disease.
Results: Middle age (40–65 years), low education level (i.e. basic schooling), and low household income (i.e. less than 21,400 € per year) were associated with nonattainment of goals for diabetes care. The association of socioeconomic factors with attainment of individual treatment goals varied. Patients with low socioeconomic status were more often obese, physically inactive, smoking, and had elevated blood pressure. Socioeconomic factors were not associated with treatment goals for hyperglycemia. Socioeconomic factors were inconsistently associated with pharmacotherapy. There was no difference in contacts to general practitioners according to SES.
Conclusions: In a country with free access to health care, the socioeconomic factors such as middle age, low education, and low income were associated with nonattainment of goals for diabetes care.
- KEY POINTS
Middle age, low education, and low income were associated with nonattainment of goals for diabetes care, especially for lifestyle goals.
Patients with low socioeconomic status were more often obese, physically inactive, smoking, and had elevated blood pressure.
Association of socioeconomic factors with pharmacotherapy was inconsistent.
Purpose: To determine whether young adults with transversal upper limb reduction deficiency (tULRD) have experienced limitations in various domains of participation during transition to adulthood and how they dealt with these limitations.
Participants: Fifteen participants (mean age 21.4 years) with tULRD.
Methods: A qualitative study was performed using a semi-structured interview based on the Rotterdam Transition Profile to identify the limitations experienced in participation domains.
Results: Almost all the participants reported difficulties in finding a suitable study or job. Most young adults were convinced they were suitable for almost any study or job, but their teachers and potential employers were more reserved. Few difficulties were reported on the domains leisure activities, intimate relationships/sexuality, housing/housekeeping and transportation. Participants preferred to develop their own strategies for dealing with limitations. Various aids, adaptations and prostheses were used to overcome limitations. Rehabilitation teams were infrequently consulted for advice in solving transitional problems.
Conclusion: Young adults with tULRD experience limitations mainly in choosing and finding a suitable study or job. Rehabilitation teams may play a more extensive role in supporting individuals with transitional problems.
- Implications for rehabilitation
Most young adults with transversal upper limb reduction deficiency (tULRD) experience limitations in study and job selection during transition to adulthood, but they do not consult the rehabilitation team.
Assessment of abilities in relation to job interests and practicing job specific bimanual activities may be helpful for young adults with a tULRD.
How the rehabilitation teams can meet the needs of young adults with tULRD during transitional phases, when autonomy is of growing importance, should be investigated further.
The utility of a dedicated clinical test is dependent on the diagnostic accuracy values and the quality of the study in which the test was examined. Scales allow a summative scoring of bias within a study. At present, there are no scales advocated to measure the bias of diagnostic accuracy studies.
Objective:
The objective of this study was to create a new diagnostic accuracy quality scale (DAQS) that provides a quantitative summary of the methodological quality of studies evaluating clinical tests and measures.
Design:
The study used a four-round Delphi survey designed to create, revise, and develop consensus for a quality scale.
Methods:
The four-round Delphi involved a work team and a respondent group of experts. An initial round among the work team created a working document, which was then modified and revised, with opportunities to create new items threaded in the second round. Rounds III and IV involved voting on the importance of each of the proposed items and consensus development from the respondent group. Consensus for the selection of an item required a 75% approval for the importance of that item.
Results:
Sixteen individuals with a variety of research/professional backgrounds made up the respondent group. Modification and revision of the initial work team instrument created a scale with 21 items that reflected potential areas of methodological bias.
Limitations:
The new scale needs validation through weighted assessment. In addition, there was a large proportion of physical therapist/researchers on the work team and the respondent group.
Conclusions:
Systematic reviews allow summation of evidence for clinical tests and scales are essential to critique the quality of the articles included in the review. The DAQS may serve this role for diagnostic accuracy studies. 相似文献
Objectives: To examine whether real time feedback can be used to influence manual wheelchair propulsion biomechanics.
Review methods: Clinical trials and case series comparing the use of real time feedback against no feedback were included. A general review was performed and methodological quality assessed by two independent practitioners using the Downs and Black checklist. The review was completed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta Analyses (PRISMA) guidelines.
Results: Six papers met the inclusion criteria. Selected studies involved 123 participants and analysed the effect of visual and, in one case, haptic feedback. Across the studies it was shown that participants were able to achieve significant changes in propulsion biomechanics, when provided with real time feedback. However, the effect of targeting a single propulsion variable might lead to unwanted alterations in other parameters. Methodological assessment identified weaknesses in external validity.
Conclusions: Visual feedback could be used to consistently increase push arc and decrease push rate, and may be the best focus for feedback training. Further investigation is required to assess such intervention during outdoor propulsion.
- Implications for Rehabilitation
Upper limb pain and injuries are common secondary disorders that negatively affect wheelchair users’ physical activity and quality of life.
Clinical guidelines suggest that manual wheelchair users should aim to propel with a semi-circular pattern with low a push rate and large push arc in the range in order to minimise upper limbs’ loading.
Real time visual and haptic feedback are effective tools for improving propulsion biomechanics in both complete novices and experienced manual wheelchair users.
Method: We evaluated components of the therapeutic intervention, from the patients’ and the therapists’ points of view in a clinical feasibility study at a rehabilitation centre. We also assessed the integration of ART as an adjunct therapy for the clinical rehabilitation of subacute patients at two different hospitals.
Results: The results showed that the combination and application of the Berlin Protocol for Mirror Therapy together with ART was feasible for clinical use. This combination was integrated into the therapeutic plan of subacute stroke patients at the two clinical locations where the second part of this research was conducted.
Conclusions: Our findings pave the way for using technology to provide mirror therapy in clinical settings and show potential for the more effective use of inpatient time and enhanced recoveries for patients.
- Implications for Rehabilitation
Computerised Mirror Therapy is feasible for clinical use
Augmented Reflection Technology can be integrated as an adjunctive therapeutic intervention for subacute stroke patients in an inpatient setting
Virtual Rehabilitation devices such as Augmented Reflection Technology have considerable potential to enhance stroke rehabilitation
Design: Total population-based case–control study.
Setting and subjects: 4562 cancer patients and 17,979 controls matched by age, sex, and primary care unit. Data were collected from the Swedish Cancer Register and the Regional Healthcare Database.
Method: We identified cancer patients in the Västra Götaland Region of Sweden diagnosed in 2011 with prostate, breast, colorectal, lung, gynaecological, and skin cancers including malignant melanoma. We studied the symptoms and diagnoses identified by diagnostic codes during a diagnostic interval of 12 months before the cancer diagnosis.
Main outcome measures: Consultation frequency, symptom density by cancer type, prevalence and odds ratios (OR) for the diagnostic codes in the cancer population as a whole.
Results: The diagnostic codes with the highest OR were unspecified lump in breast, neoplasm of uncertain behaviour, and abnormal serum enzyme levels. The codes with the highest prevalence were hyperplasia of prostate, other skin changes and abdominal and pelvic pain. The frequency of diagnostic codes and consultations in primary care rose in tandem 50 days before diagnosis for breast and gynaecological cancer, 60 days for malignant melanoma and skin cancer, 80 days for prostate cancer and 100 days for colorectal and lung cancer.
Conclusion: Eighty-seven percent of patients with the most common cancers consulted a general practitioner (GP) a year before their diagnosis. An increase in consultation frequency and presentation of any symptom should raise the GP’s suspicion of cancer.
Key Points
Knowledge about the prevalence of early symptoms and other clinical signs in cancer patients in primary care remains insufficient.
Eighty-seven percent of the patients with the seven most common cancers consulted a general practitioner 12 months prior to cancer diagnosis.
Both the frequency of consultation and the number of symptoms and diseases expressed in diagnostic codes rose in tandem 50–100 days before the cancer diagnosis.
Unless it is caused by a previously known disease, an increased consultation rate for any symptom should result in a swift investigation or referral from primary care to confirm or exclude cancer.
Design: Population-based questionnaire study.
Setting: Central Denmark Region with approximately 1.3 million inhabitants.
Subjects: All 843 active GPs in the Central Denmark Region were sent a questionnaire by mail.
Main outcome measures: Responses to 18 items concerning four aspects: provision of EOL care to patients with different diagnosis, confidence with being a key worker, organisation of EOL care and EOL skills (medical and psychosocial).
Results: In total, 573 (68%) GPs responded. Of these, 85% often/always offered EOL care to cancer patients, which was twice as often as to patients with non-malignancies (34–40%). Moreover, 76% felt confident about being a key worker, 60% had a proactive approach, and 58% talked to their patients about dying. Only 9% kept a register of patients with EOL needs, and 19% had specific EOL procedures. GP confidence with own EOL skills varied; from 55% feeling confident using terminal medications to 90% feeling confident treating nausea/vomiting. Increasing GP age was associated with increased confidence about being a key worker and provision of EOL care to patients with non-malignancies. In rural areas, GPs were more confident about administering medicine subcutaneously than in urban areas.
Conclusion: We found considerable diversity in self-reported EOL care competences. Interventions should focus on increasing GPs’ provision of EOL care to patients with non-malignancies, promoting better EOL care concerning organisation and symptom management.
- KEY POINTS
GPs are pivotal in end-of-life (EOL) care, but their involvement has been questioned. Hence, GPs’ perceived competencies were explored.
GPs were twice as likely to provide EOL care for patients with cancer than for patients with non-malignancies.
EOL care was lacking clear organisation in general practice in terms of registering palliative patients and having specific EOL procedures.
GPs were generally least confident with their skills in terminal medical treatment, for example, using medicine administered subcutaneously.
Design: Secondary analysis of cross-sectional data from the 2014 Commonwealth Fund International Health Policy Survey of Older Adults.
Setting: 11 western countries.
Subjects: Community-dwelling adults, aged 55 or older.
Main outcome measure: Assessment of goals and priorities.
Results: The final sample size consisted of 17,222 respondents, 54% of whom reported an assessment of their goals and priorities (AGP) by healthcare professionals. In logistic regression model 1, which was used to analyse the entire population, the determinants found to have moderate to large effects on the likelihood of AGP were information exchange on stress, diet or exercise, or both. Country (living in Sweden) and continuity of care (no regular professional or organisation) had moderate to large negative effects on the likelihood of AGP. In model 2, which focussed on respondents who experienced continuity of care, country and information exchange on stress and lifestyle were the main determinants of AGP, with comparable odds ratios to model 1. Furthermore, a professional asking questions also increased the likelihood of AGP.
Conclusions: Continuity of care and information exchange is associated with a higher probability of AGP, while people living in Sweden are less likely to experience these assessments. Further study is required to determine whether increasing information exchange and professionals asking more questions may improve goal setting with older patients.
- Key points
A patient goal-oriented approach can be beneficial for older patients with chronic conditions or multimorbidity; however, discussing goals with these patients is not a common practice.
The likelihood of discussing goals varies by country, occurring most commonly in the USA, and least often in Sweden.
Country-level differences in continuity of care and questions asked by a regularly visited professional affect the goal discussion probability.
Patient characteristics, including age, have less impact than expected on the likelihood of sharing goals.
Design: Cross-sectional method comparison study.
Setting: From April 2014 to February 2015, we included patients coming to the general practice clinic “Lægerne Sløjfen”, Aalborg, Denmark for a routine ECG. Patients with severe dementia, mental illness or poor ECG readings were excluded. After oral and written informed consent an ECG and PEM recordings were obtained simultaneously. The PEM recordings were analyzed by two general practitioners (GPs) in training and ECG recordings were evaluated by a senior GP and a cardiologist. Both the PEM and the ECG recordings were analysed blinded.
Subjects: Ninety-three patients were included and four were excluded due to poor ECG readings.
Main outcome measures: The sensitivity and specificity of PEM compared to a standard 12-lead ECG.
Results: Eighty-nine of the 93 (95.7%) patients had ECGs of a satisfactory technical quality and were included in the study. The sensitivity of diagnosing AF by PEM recordings was 86.7% and the specificity was 98.7% when compared to a 12-lead ECG. According to the cardiologist, the misclassification of three PEM recordings were due to interpretation errors and not related to the PEM recording per se.
Conclusions: The inexpensive portable PEM device recording diagnosed AF with a high sensitivity and specificity.
- KEY POINTS
Simple ECG monitors could be useful to identify atrial fibrillation and thereby lead to a better prevention of stroke.
The PEM device was easy to use and 95.7% of the recordings were technically acceptable for detecting atrial fibrillation.
The PEM device has a high sensitivity and specificity in detecting atrial fibrillation compared to a standard 12-lead ECG.
Further studies should evaluate the clinical usefulness of the PEM device, e.g. to detect intermittent atrial fibrillation.
Pain Pattern Classification (PPC) and Directional Preference (DP) have been shown to be predictive of health care outcomes and serve to guide orthopedic clinical decision making. We conducted a prospective, observational cohort study to verify the association between PPC, DP, and clinical outcomes.
Methods:
Clinical outcome measures including pain intensity and disability were completed at first examination and follow-up by 335 patients. A Pearson’s chi-squared test was used to determine differences in prevalence rates for the categorical variables, and two-sample t-tests were used to determine differences in rates for the continuous variables. A Tukey’s range test was used to determine differences in follow-up pain intensity and disability for neck pain dual-classification schemes.
Results:
The prevalence of DP was 82.4%. The prevalence of CEN, Non-CEN, and Non-Classifiable (NC) was 15.2%, 42.1%, and 25.1%, respectively. The prevalence of DP was lowest for patients with sub-acute symptoms and who were <45 years old. Patients classified as DP CEN had, on average 2.62 NDI units less than patients classified as Non-DP. Patients classified as DP CEN had, on average, 0.90 pain intensity units less than patients classified as Non-DP at follow-up. Patients who demonstrated DP CEN did not have clinically significant lower pain intensity or disability at follow-up than patients who demonstrated Non-DP.
Discussion:
The results of this investigation need to be interpreted with caution with respect to the study design and it’s subsequent strengths and limitations.
Level of Evidence:
1b. 相似文献
Methods: Eye movements were recorded from 10 control participants and 8 chronic stroke participants during a visual orienting task (Experiment 1) and a series of reaching tasks (Experiment 2). Stroke participants completed the reaching tasks using (i) their less impaired upper limb, (ii) their more impaired upper limb without support, and (iii) their more impaired upper limb, with support (SaeboMAS gravitational support and/or electrical stimulation). Participants were tested individually and completed both experiments in the same session.
Results: Oculomotor control and the coordination between the upper limb and the oculomotor system were found to be intact in stroke participants when no limb movements were required, or when the less impaired upper limb was used. However, when the more impaired upper limb was used, success and accuracy in reaching decreased and patterns of eye movements changed, with an observed increase in eye movements to the limb itself. With upper limb support, patterns of hand-eye coordination were found to more closely resemble those of the control group.
Conclusion: Deficits in upper limb motor systems result in changes in patterns of eye movement behavior during reaching tasks. These changes in eye movement behavior can be modulated by providing upper limb support.
- Implications for Rehabilitation
Deficits in upper limb motor systems can result in changes in patterns of eye movement behavior during reaching tasks.
Upper limb support can reduce deficits in hand-eye coordination.
Stroke rehabilitation outcomes should consider motor and oculomotor performance.