Barbara R. Lucas

Prevalence of fetal alcohol syndrome in a population-based sample of children living in remote Australia: The Lililwan Project

Aboriginal leaders concerned about high rates of alcohol use in pregnancy invited researchers to determine the prevalence of fetal alcohol syndrome (FAS) and partial fetal alcohol syndrome (pFAS) in their communities.

The Lililwan Project: study protocol for a population-based active case ascertainment study of the prevalence of fetal alcohol spectrum disorders (FASD) in remote Australian Aboriginal communities

Introduction Anecdotal reports suggest that high-risk drinking in pregnancy is common in some remote Australian communities. Alcohol is teratogenic and may cause a range of lifelong conditions termed ‘fetal alcohol spectrum disorders’ (FASD). Australia has few diagnostic services for FASD, and prevalence of these neurodevelopmental disorders remains unknown. In 2009, Aboriginal leaders in the remote Fitzroy Valley in North Western Australia identified FASD as a community priority and initiated the Lililwani Project in partnership with leading research organisations. This project will establish the prevalence of FASD and other health and developmental problems in school-aged children residing in the Fitzroy Valley, providing data to inform FASD prevention and management. Methods and analysis This is a population-based active case ascertainment study of all children born in 2002 and 2003 and residing in the Fitzroy Valley. Participants will be identified from the Fitzroy Valley Population Project and Communicare databases. Parents/carers will be interviewed using a standardised diagnostic questionnaire modified for local language and cultural requirements to determine the demographics, antenatal exposures, birth outcomes, education and psychosocial status of each child. A comprehensive interdisciplinary health and neurodevelopmental assessment will be performed using tests and operational definitions adapted for the local context. Internationally recognised diagnostic criteria will be applied to determine FASD prevalence. Relationships between pregnancy exposures and early life trauma, neurodevelopmental, health and education outcomes will be evaluated using regression analysis. Results will be reported according to STROBE guidelines for observational studies. Ethics and dissemination Ethics approval has been granted by the University of Sydney Human Research Ethics Committee, the Western Australian Aboriginal Health Information and Ethics Committee, the Western Australian Country Health Service Board Research Ethics Committee and the Kimberley Aboriginal Health Planning Forum Research Sub-committee. Results will be disseminated widely through peer-reviewed manuscripts, reports, conference presentations and the media.

Gross Motor Deficits in Children Prenatally Exposed to Alcohol: A Meta-analysis

BACKGROUND AND OBJECTIVES: Gross motor (GM) deficits are often reported in children with prenatal alcohol exposure (PAE), but their prevalence and the domains affected are not clear. The objective of this review was to characterize GM impairment in children with a diagnosis of fetal alcohol spectrum disorder (FASD) or “moderate” to “heavy” maternal alcohol intake. METHODS: A systematic review with meta-analysis was conducted. Medline, Embase, Allied and Complementary Medicine Database, Cumulative Index to Nursing and Allied Health Literature, PsycINFO, PEDro, and Google Scholar databases were searched. Published observational studies including children aged 0 to ≤18 years with (1) an FASD diagnosis or moderate to heavy PAE, or a mother with confirmed alcohol dependency or binge drinking during pregnancy, and (2) GM outcomes obtained by using a standardized assessment tool. Data were extracted regarding participants, exposure, diagnosis, and outcomes by using a standardized protocol. Methodological quality was evaluated by using Strengthening the Reporting of Observational Studies in Epidemiology guidelines. RESULTS: The search recovered 2881 articles of which 14 met the systematic review inclusion criteria. The subjects’ mean age ranged from 3 days to 13 years. Study limitations included failure to report cutoffs for impairment, nonstandardized reporting of PAE, and small sample sizes. The meta-analysis pooled results (n = 10) revealed a significant association between a diagnosis of FASD or moderate to heavy PAE and GM impairment (odds ratio: 2.9; 95% confidence interval: 2.1–4.0). GM deficits were found in balance, coordination, and ball skills. There was insufficient data to determine prevalence. CONCLUSIONS: The significant results suggest evaluation of GM proficiency should be a standard component of multidisciplinary FASD diagnostic services.

Prenatal alcohol exposure, FASD, and child behavior: a meta-analysis

CONTEXT: Fetal alcohol spectrum disorders (FASD) and prenatal alcohol exposure (PAE) are associated with behavioral difficulties, although there are no published systematic reviews that summarize and critique the literature. OBJECTIVE: To describe the behavioral characteristics of children with PAE and/or FASD, assessed using the Achenbach System of Empirically Based Assessments (ASEBA) for school-aged children with parent, teacher, and youth (self-report) forms. DATA SOURCES: Electronic literature databases, reference lists, hand-searches. STUDY SELECTION: peer-reviewed observational studies. DATA EXTRACTION: Study appraisal and data extraction were undertaken by 2 independent assessors. Meta-analyses were performed for parent-rated Internalizing, Externalizing, and Total problems scales. All other ASEBA scales were summarized qualitatively. RESULTS: Included were 23 articles; 16 were used in meta-analyses. Pooled results showed higher Total (mean difference 12.1, 95% confidence interval [95% CI] 7.7–16.5), Internalizing (6.3, 95% CI 3.1–9.5), and Externalizing problems scores (12.5, 95% CI 7.9–17.0) in FASD than No FASD; and greater odds of scoring in the “Clinical” range in FASD. Pooled results demonstrated higher problem scores in children with PAE (P > .05). Qualitative summaries of other scales from parents, teachers, and self-report show poorer behavior ratings in children with FASD and PAE on composite Problem and Competence scores and many Syndrome subscales. LIMITATIONS: Findings were restricted to behaviors assessed using the ASEBA. The published literature was limited, often with only 1 study reporting on a particular scale. CONCLUSIONS: Meta-analysis reveals that FASD and PAE are associated with problematic behavior in many, but not all domains. This clearly affects families, and should be considered in clinical practice by providers.

Dynamic splints do not reduce contracture following distal radial fracture: a randomised controlled trial

QUESTION Do dynamic splints reduce contracture following distal radial fracture? DESIGN Assessor-blinded, randomised controlled trial. PARTICIPANTS Forty outpatients with contracture following distal radial fracture. INTERVENTION The control group received routine care consisting of exercises and advice for 8 weeks. In addition to routine care, during the day the experimental group received a dynamic splint, which stretched the wrist into extension but allowed intermittent movement. OUTCOME MEASURES The primary outcomes were passive wrist extension and the Patient Rated Hand Wrist Evaluation (PRHWE). The secondary outcomes were active wrist extension, flexion, radial deviation, and ulnar deviation, and the performance and satisfaction items of the Canadian Occupational Performance Measure (COPM). All outcomes were measured at commencement, at the end of 8 weeks of treatment, and at 12 weeks (ie, 1 month follow-up). RESULTS The mean between-group difference for passive wrist extension and PRHWE at 8 weeks were 4 deg (95% CI -4 to 12) and -2 points (95% CI -8 to 4), respectively. The corresponding values at 12 week follow-up were 6 deg (95% CI 1 to 12) and 2 points (95% CI -5 to 9). There were no sufficiently important between-group differences for any of the secondary outcome measures at 8 or 12 weeks. CONCLUSION It is unclear whether dynamic splints following distal radial fracture have therapeutic effects on passive wrist extension or PRHWE, but they clearly do not have any therapeutic effects on active wrist extension, flexion, radial or ulnar deviation, or on the performance or satisfaction items of the COPM. The ongoing use of dynamic splints following distal radial fracture is difficult to justify. TRIAL REGISTRATION ACTRN12608000309381.

Fine motor skills in children with prenatal alcohol exposure or fetal alcohol spectrum disorder.

Objective: Prenatal alcohol exposure (PAE) can cause fetal alcohol spectrum disorders (FASD) and associated neurodevelopmental impairments. It is uncertain which types of fine motor skills are most likely to be affected after PAE or which assessment tools are most appropriate to use in FASD diagnostic assessments. This systematic review examined which types of fine motor skills are impaired in children with PAE or FASD; which fine motor assessments are appropriate for FASD diagnosis; and whether fine motor impairments are evident at both “low” and “high” PAE levels. Methods: A systematic review of relevant databases was undertaken using key terms. Relevant studies were extracted using a standardized form, and methodological quality was rated using a critical appraisal tool. Results: Twenty-four studies met inclusion criteria. Complex fine motor skills, such as visual-motor integration, were more frequently impaired than basic fine motor skills, such as grip strength. Assessment tools that specifically assessed fine motor skills more consistently identified impairments than those which assessed fine motor skills as part of a generalized neurodevelopmental assessment. Fine motor impairments were associated with “moderate” to “high” PAE levels. Few studies reported fine motor skills of children with “low” PAE levels, so the effect of lower PAE levels on fine motor skills remains uncertain. Conclusions: Comprehensive assessment of a range of fine motor skills in children with PAE is important to ensure an accurate FASD diagnosis and develop appropriate therapeutic interventions for children with PAE-related fine motor impairments.

Targeting care: tailoring nonsurgical management according to clinical presentation.

International evidence-based guidelines recommend a multitude of nonsurgical treatment options for the management of osteoarthritis. This article summarizes the evidence available for patient characteristics that have been analyzed as potential predictors of response to nonsurgical interventions for patients with hip and knee osteoarthritis. The specific variables targeted for this review include body mass index, psychological factors, muscle strength, tibiofemoral alignment, radiographic changes, and signs of inflammation. Several studies provide moderate to good evidence of potential predictors of response to nonsurgical treatments, and areas for future research are illuminated.

Prevalence and profile of Neurodevelopment and Fetal Alcohol Spectrum Disorder (FASD) amongst Australian Aboriginal children living in remote communities.

BACKGROUND Despite multiple risk factors for neurodevelopmental vulnerability, few studies have assessed neurodevelopmental performance of Australian Aboriginal children. An important risk factor for neurodevelopmental vulnerability is prenatal alcohol exposure (PAE), which places children at risk for Fetal Alcohol Spectrum Disorder (FASD). AIMS This study assesses neurodevelopment outcomes in a population of Australian Aboriginal children with and without PAE. METHODS AND PROCEDURES Children born in 2002/2003, and living in the Fitzroy Valley, Western Australia between April 2010 and November 2011, were eligible (N=134). Sociodemographic and antenatal data, including PAE, were collected by interview with 127/134 (95%) consenting parents/caregivers. Maternal/child medical records were reviewed. Neurodevelopment was assessed by clinicians blinded to PAE in 108/134 (81%) children and diagnoses on the FASD spectrum were assigned. OUTCOMES AND RESULTS Neurodevelopmental disorder was documented in 34/108 children (314.8 per 1000). Any diagnosis on the FASD spectrum was made in 21/108 (194.4 per 1000) children (95% CI=131.0-279.0). CONCLUSIONS AND IMPLICATIONS Neurodevelopmental impairment with or without PAE is highly prevalent among children in the Fitzroy Valley. Rates of diagnoses on the FASD spectrum are among the highest worldwide. Early intervention services are needed to support developmentally vulnerable children in remote communities.

An app with remote support achieves better adherence to home exercise programs than paper handouts in people with musculoskeletal conditions: a randomised trial

QUESTION Do people with musculoskeletal conditions better adhere to their home exercise programs when these are provided to them on an app with remote support compared to paper handouts? DESIGN Randomised, parallel-group trial with intention-to-treat analysis. PARTICIPANTS Eighty participants with upper or lower limb musculoskeletal conditions were recruited to the trial. Each participant was prescribed a 4-week home exercise program by a physiotherapist at a tertiary teaching hospital in Australia. Participants were randomly assigned via a computer-generated concealed block randomisation procedure to either intervention (n=40) or control (n=40) groups. INTERVENTION Participants in the intervention group received their home exercise programs on an app linked to the freely available website www.physiotherapyexercises.com. They also received supplementary phone calls and motivational text messages. Participants in the control group received their home exercise programs as a paper handout. OUTCOME MEASURES Blinded assessors collected outcome measures at baseline and 4 weeks. The primary outcome was self-reported exercise adherence. There were five secondary outcomes, which captured functional performance, disability, patient satisfaction, perceptions of treatment effectiveness, and different aspects of adherence. RESULTS Outcomes were available on 77 participants. The mean between-group difference for self-reported exercise adherence at 4 weeks was 1.3/11 points (95% CI 0.2 to 2.3), favouring the intervention group. The mean between-group difference for function was 0.9/11 points (95% CI 0.1 to 1.7) on the Patient-Specific Functional Scale, also favouring the intervention group. There were no significant between-group differences for the remaining outcomes. CONCLUSION People with musculoskeletal conditions adhere better to their home exercise programs when the programs are provided on an app with remote support compared to paper handouts; however, the clinical importance of this added adherence is unclear. TRIAL REGISTRATION ACTRN12616000066482. [Lambert TE, Harvey LA, Avdalis C, Chen LW, Jeyalingam S, Pratt CA, Tatum HJ, Bowden JL, Lucas BR (2017) An app with remote support achieves better adherence to home exercise programs than paper handouts in people with musculoskeletal conditions: a randomised trial. Journal of Physiotherapy 63: 161-167].

Does Clinical Presentation Predict Response to a Nonsurgical Chronic Disease Management Program for Endstage Hip and Knee Osteoarthritis

Objective. To identify baseline characteristics of participants who will respond favorably following 6 months of participation in a chronic disease management program for hip and knee osteoarthritis (OA). Methods. This prospective cohort study assessed 559 participants at baseline and following 6 months of participation in the Osteoarthritis Chronic Care Program. Response was defined as the minimal clinically important difference of an 18% and 9-point absolute improvement in the Western Ontario and McMaster Universities Arthritis Index global score. Multivariate logistic regression modeling was used to identify predictors of response. Results. Complete data were available for 308 participants. Those who withdrew within the study period were imputed as nonresponders. Three variables were independently associated with response: signal joint (knee vs hip), sex, and high level of comorbidity. Index joint and sex were significant in the multivariate model, but the model was not a sensitive predictor of response. Conclusion. Strong predictors of response to a chronic disease management program for hip and knee OA were not identified. The significant predictors that were found should be considered in future studies.