Effectiveness of Technology-Based Distance Physical Rehabilitation Interventions for Improving Physical Functioning in Stroke: A Systematic Review and Meta-analysis of Randomized Controlled Trials

ObjectiveTo study the effectiveness of technology-based distance physical rehabilitation interventions on physical functioning in stroke.Data SourcesA systematic literature search was conducted in 6 databases from January 2000 to May 2018.Study SelectionInclusion criteria applied the patient, intervention, comparison, outcome, study design framework as follows: (P) stroke; (I) technology-based distance physical rehabilitation interventions; (C) any comparison without the use of technology; (O) physical functioning; (S) randomized controlled trials (RCTs). The search identified in total 693 studies, and the screening of 162 full-text studies revealed 13 eligible studies.Data ExtractionThe studies were screened using the Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines and assessed for methodological quality and quality of evidence. Meta-analysis was performed if applicable.Data SynthesisA total of 13 studies were included, and online video monitoring was the most used technology. Seven outcomes of physical functioning were identified—activities of daily living (ADL), upper extremity functioning, lower extremity functioning, balance, walking, physical activity, and participation. A meta-analysis of 6 RCTs indicated that technology-based distance physical rehabilitation had a similar effect on ADL (standard mean difference 0.06; 95% confidence interval: ?0.22 to 0.35, P=.67) compared to the combination of traditional treatments (usual care, similar and other treatment). Similar results were obtained for other outcomes, except inconsistent findings were noted for walking. Methodological quality of the studies and quality of evidence were considered low.ConclusionsThe findings suggest that the effectiveness of technology-based distance physical rehabilitation interventions on physical functioning might be similar compared to traditional treatments in stroke. Further research should be performed to confirm the effectiveness of technology-based distance physical rehabilitation interventions for improving physical functioning of persons with stroke.     

Growth hormone and cortisol secretion after propranolol--glucagon testing in the adult

Pituitary HGH response to propranolol-glucagon stimulation in a group of obese subjects (n = 45), patients with primary hypothyroidism (n = 13), and patients with hypopituitarism (n = 15) was compared to the response observed in normal subjects (n = 40). In normal and obese subjects, the magnitude of the HGH response to the same stimulus was compared with the results obtained with the insulin tolerance test. In addition, the cortisol response to propranolol-glucagon stimulation in normal subjects (n = 19) was compared to that obtained after insulin hypoglycemia. In the group of normal subjects, a positive HGH response after the propranolol-glucagon test (i.e., a peak value ≥ 9 ng/ml) was found in 38 of the 40 subjects tested. The mean HGH peak value (24.5 ± 2.1 ng/ml) was significantly lower than that (41.1 ± 2.8 ng/ml) on insulin testing (p < 0.001). In 45 overtly obese subjects, a mean peak value of 11.0 ± 1.3 ng/ml was reached, a significantly blunted response as compared to the group of normal subjects (p < 0.001). Again the HGH peak after propranolol-glucagon stimulation was significantly lower than the mean HGH response on insulin testing (18.7 ± 1.6 ng/ml) in a comparable group of obese individuals (p < 0.0025). A consistently blunted HGH response was observed in all the patients with pituitary insufficiency and in ten out of 13 patients with unsubstituted primary myxedema. The increase in plasma cortisol levels after propranolol-glucagon stimulation in normal subjects was comparable to the response after insulin hypoglycemia. It is concluded that the propranolol-glucagon test is a safe and reliable procedure, although normal “nonresponders” do exist, and that it represents a somewhat weaker stimulus for HGH release by the pituitary than postinsulin hypoglycemia. As plasma cortisol levels rise consistently, the test can also be used for the evaluation of the pituitary-adrenal axis.     

Graves’ disease,multinodular goiter and subclinical hyperthyroidism

Subclinical hyperthyroidism is a common clinical entity, defined by serum TSH below the reference range, with normal FT4 and FT3 levels in an asymptomatic patient. Whether or not subclinical hyperthyroidism should be treated remains a matter of debate. Cross-sectional and longitudinal population-based studies demonstrate association of subclinical hyperthyroidism with risk of atrial fibrillation and osteoporosis, and with cardiovascular and all-cause mortality. However, there are no randomized clinical trials addressing whether long-term health outcomes are improved by treating subclinical hyperthyroidism; in the absence of evidence one way or the other, it seems appropriate to use decision trees taking account of TSH concentration and presence of risk factors (age > 65 years or post-menopause, osteoporosis and cardiac disease).     

Low back pain, disability and back pain myths in a community sample: prevalence and interrelationships.

This study investigated the prevalence of back pain, disability, and, of most importance, the presence of misconceptions about low back pain (LBP), its diagnosis and treatment in a bicultural community sample (Belgium). Using the Graded Chronic Pain Scale [Pain 50 (1992) 133] persons were classified according to pain intensity and disability in five subgroups. The interrelationship between LBP beliefs and these five subgroups was also investigated. In our sample (n=1624) the 6-month prevalence of low back pain was 41.8%. Only in 8.2% back pain was disabling. Misconceptions about back pain were widespread, even in the group reporting no back pain. The least misconceptions were found to exist in participants with mild LBP without disability. It is suggested that recovery from an episode of acute low back pain is an active process that involves a correction of beliefs about harm, about the need to restrict physical activities and about medical diagnosis and cure. Finally, it is argued that community actions may be useful to correct LBP myths in order to prevent the development of long-term disability due to LBP.     

“It is not the fading candle that one expects”: general practitioners’ perspectives on life-preserving versus “letting go” decision-making in end-of-life home care

Background Many general practitioners (GPs) are willing to provide end-of-life (EoL) home care for their patients. International research on GPs’ approach to care in patients’ final weeks of life showed a combination of palliative measures with life-preserving actions.

Aim To explore the GP’s perspective on life-preserving versus “letting go” decision-making in EoL home care.

Design Qualitative analysis of semi-structured interviews with 52 Belgian GPs involved in EoL home care.

Results Nearly all GPs adopted a palliative approach and an accepting attitude towards death. The erratic course of terminal illness can challenge this approach. Disruptive medical events threaten the prospect of a peaceful end-phase and death at home and force the GP either to maintain the patient’s (quality of) life for the time being or to recognize the event as a step to life closure and “letting the patient go”. Making the “right” decision was very difficult. Influencing factors included: the nature and time of the crisis, a patient’s clinical condition at the event itself, a GP’s level of determination in deciding and negotiating “letting go” and the patient’s/family’s wishes and preparedness regarding this death. Hospitalization was often a way out.

Conclusions GPs regard alternation between palliation and life-preservation as part of palliative care. They feel uncertain about their mandate in deciding and negotiating the final step to life closure. A shortage of knowledge of (acute) palliative medicine as one cause of difficulties in letting-go decisions may be underestimated. Sharing all these professional responsibilities with the specialist palliative home care teams would lighten a GP’s burden considerably.

• Key Points

• A late transition from a life-preserving mindset to one of “letting go” has been reported as a reason why physicians resort to life-preserving actions in an end-of-life (EoL) context. We investigated GPs’ perspectives on this matter.

• Not all GPs involved in EoL home care adopt a “letting go” mindset. For those who do, this mindset is challenged by the erratic course of terminal illness.

• GPs prioritize the quality of the remaining life and the serenity of the dying process, which is threatened by disruptive medical events.

• Making the “right” decision is difficult. GPs feel uncertain about their own role and responsibility in deciding and negotiating the final step to life closure.