C.A.M. van Bennekom

How many people return to work after acquired brain injury?: A systematic review

Primary objective: To investigate how many people return to work (RTW) after acquiring brain injury (ABI) due to traumatic or non-traumatic causes. Secondary objectives were to investigate the differences in outcome between traumatic and non-traumatic causes, the development of RTW over time and whether or not people return to their former job. Methods: A systematic literature search (1992–2008) was performed using terms of ABI and RTW. The methodological quality of the studies was determined. An overall estimation of percentage RTW 1 and 2 years post-injury was calculated by data pooling. Main outcomes and results: Finally, 49 studies were included. Within 2 years post-injury, 39.3% of the subjects with non-traumatic ABI returned to work. Among people with traumatic ABI, 40.7% returned to work after 1 year and 40.8% after 2 years. No effect of cause or time since injury was found. Some people with traumatic ABI who returned to work were not able to sustain their job over time. Changes of occupation and job demands are common among people with ABI. Conclusions: About 40% of the people with traumatic or non-traumatic ABI are able to return to work after 1 or 2 years. Among those with acquired traumatic brain injury a substantial proportion of the subjects were either not able to return to their former work or unable to return permanently.

Physical capacity and walking ability after lower limb amputation: a systematic review

Objective: To review the influence of physical capacity on regaining walking ability and the development of walking ability after lower limb amputation. Design: A systematic search of literature was performed. The quality of all relevant studies was evaluated according to a checklist for statistical review of general papers. Subjects: Lower limb amputees. Main measures: Physical capacity (expressed by aerobic capacity, anaerobic capacity, muscle force, flexibility and balance) and walking ability (expressed by the walking velocity and symmetry). Results: A total of 48 studies that complied with the inclusion criteria were selected. From these studies there is strong evidence for deterioration of two aspects of physical capacity (muscle strength and balance) and of two aspects of walking ability (walking velocity and symmetry) after lower limb amputation. Strong evidence was found for a relation between balance and walking ability. Conclusion: Strong evidence was only found for a relation between balance and walking ability. Evidence about a relation between other elements of physical capacity and walking ability was insufficient. Training of physical capacity as well as walking ability during rehabilitation following lower limb amputation should not be discouraged since several parameters have been shown to be reduced after amputation, although their relation to regaining walking ability and to the development of walking ability remains unclear.

Rehabilitation Activities Profile: the ICIDH as a framework for a problem-oriented assessment method in rehabilitation medicine

The Rehabilitation Activities Profile (RAP) is an ICIDH-based assessment method that covers the domains of communication, mobility, personal care, occupation, and relationships. Disabilities and handicaps in these domains are assessed on four-point Likert scales for severity. Problems perceived by the patient associated with these disabilities or handicaps are also assessed on four-point Likert scales for severity. High scores on perceived problems represent a patients priorities. Information is gathered through a semi-structured interview with the patient; proxies and observations can be used as additional sources of information. Assessment can be performed at two levels. The first level is a global one, serving as a screening device. If disabilities or handicaps are identified, the second level provides for an in-depth assessment of those specific disabilities and handicaps as well as the related perceived problems. The method is designed to assist screening, goal-setting, and outcome evaluation of individual patients.

Prognostic factors of return to work after acquired brain injury: A systematic review

Primary objective: To provide insight into the prognostic and non-prognostic factors of return to work (RTW) in people with traumatic and non-traumatic acquired brain injury (ABI) who were working before injury. Methods: A systematic literature search (1992–2008) was performed, including terms for ABI, RTW and prognostic factors. The methodological quality of the studies was determined. Evidence was classified as strong (positive, negative or no), weak or inconsistent. Main outcomes and results: Following classification of the studies, 22 studies were included. Strong evidence was found that ‘gender’ and ‘anatomic location’ were not associated with RTW after non-traumatic ABI and that both ‘injury severity’ (classified by the Glascow Coma Scale) and ‘suffering from depression’ or ‘anxiety’ were not associated with RTW after traumatic ABI. In addition strong evidence was found for the negative prognostic value on RTW of the ‘inpatient length of stay’, after traumatic ABI. Weak evidence was found for the three trainable/treatable factors ‘ability to perform activities of daily living’, ‘residual physical deficits/higher disability level’ and ‘number of associated injuries’. Conclusion: Strong evidence was found that six variables either had no association or a negative association with RTW. It is recommended to focus in rehabilitation on the factors for which weak evidence was found but that are trainable/treatable with the goal of improving the process of vocational rehabilitation.

Mind your step: Metabolic energy cost while walking an enforced gait pattern

The energy cost of walking could be attributed to energy related to the walking movement and energy related to balance control. In order to differentiate between both components we investigated the energy cost of walking an enforced step pattern, thereby perturbing balance while the walking movement is preserved. Nine healthy subjects walked three times at comfortable walking speed on an instrumented treadmill. The first trial consisted of unconstrained walking. In the next two trials, subject walked while following a step pattern projected on the treadmill. The steps projected were either composed of the averaged step characteristics (periodic trial), or were an exact copy including the variability of the steps taken while walking unconstrained (variable trial). Metabolic energy cost was assessed and center of pressure profiles were analyzed to determine task performance, and to gain insight into the balance control strategies applied. Results showed that the metabolic energy cost was significantly higher in both the periodic and variable trial (8% and 13%, respectively) compared to unconstrained walking. The variation in center of pressure trajectories during single limb support was higher when a gait pattern was enforced, indicating a more active ankle strategy. The increased metabolic energy cost could originate from increased preparatory muscle activation to ensure proper foot placement and a more active ankle strategy to control for lateral balance. These results entail that metabolic energy cost of walking can be influenced significantly by control strategies that do not necessary alter global gait characteristics.

Obstructive sleep apnea is related to impaired cognitive and functional status after stroke

STUDY OBJECTIVES Obstructive sleep apnea (OSA) is a common sleep disorder in stroke patients and is associated with prolonged hospitalization, decreased functional outcome, and recurrent stroke. Research on the effect of OSA on cognitive functioning following stroke is scarce. The primary objective of this study was to compare stroke patients with and without OSA on cognitive and functional status upon admission to inpatient rehabilitation. DESIGN Case-control study. SETTING AND PATIENTS 147 stroke patients admitted to a neurorehabilitation unit. INTERVENTIONS N/A. MEASUREMENTS All patients underwent sleep examination for diagnosis of OSA. We assessed cognitive status by neuropsychological examination and functional status by two neurological scales and a measure of functional independence. RESULTS We included 80 stroke patients with OSA and 67 stroke patients without OSA. OSA patients were older and had a higher body mass index than patients without OSA. OSA patients performed worse on tests of attention, executive functioning, visuoperception, psychomotor ability, and intelligence than those without OSA. No differences were found for vigilance, memory, and language. OSA patients had a worse neurological status, lower functional independence scores, and a longer period of hospitalization in the neurorehabilitation unit than the patients without OSA. OSA status was not associated with stroke type or classification. CONCLUSIONS Obstructive sleep apnea (OSA) is associated with a lower cognitive and functional status in patients admitted for stroke rehabilitation. This underlines the importance of OSA as a probable prognostic factor, and calls for well-designed randomized controlled trials to study its treatability.

Usability of gait analysis in the alignment of trans-tibial prostheses: a clinical study.

The purpose of the study was to investigate which systematic effects of prosthetic misalignment could be observed with the use of the SYBAR system. The alignment of the prosthesis of five well-trained unilateral trans-tibial amputees was changed 158 in magnitude in varus, valgus, flexion, extension, endorotation, exorotation, dorsal flexion, and plantar flexion. Subjects walked over a distance of 8 m at a self-selected walking speed with the alignment of the prosthesis as it was at the start of the experiment (reference) and with each changed alignment. Two video cameras (frontal and sagittal) and a force plate of the SYBAR system (Noldus Information Technology, The Netherlands) were used to capture gait characteristics of the subjects. Temporal and spatial characteristics, the magnitude and timing of the ground reaction force (GRF), and the external joint moments were derived from these data. Despite the substantial perturbations to prosthetic alignment, only a few effects were observed in the temporal and spatial characteristics of gait, the magnitude and timing of the GRF, and the external joint moments. Only the pattern of the ground reaction force in the mediolateral direction and the joint moment around the ankle in the frontal plane during terminal stance showed a systematic effect when the alignment was set into varus and valgus or exorotation. It was concluded that using the SYBAR system in this study revealed little effect of perturbations in prosthetic alignment, for this group of patients, and for the selected parameters. It was questioned whether this is due to the relatively low resolution of the SYBAR system or the capacity of the well-trained subjects to compensate for the disturbance in alignment. It was suggested that the usability of the SYBAR system in clinical settings should be further explored.

Stay Focused! The Effects of Internal and External Focus of Attention on Movement Automaticity in Patients with Stroke

Dual-task performance is often impaired after stroke. This may be resolved by enhancing patients’ automaticity of movement. This study sets out to test the constrained action hypothesis, which holds that automaticity of movement is enhanced by triggering an external focus (on movement effects), rather than an internal focus (on movement execution). Thirty-nine individuals with chronic, unilateral stroke performed a one-leg-stepping task with both legs in single- and dual-task conditions. Attentional focus was manipulated with instructions. Motor performance (movement speed), movement automaticity (fluency of movement), and dual-task performance (dual-task costs) were assessed. The effects of focus on movement speed, single- and dual-task movement fluency, and dual-task costs were analysed with generalized estimating equations. Results showed that, overall, single-task performance was unaffected by focus (p = .341). Regarding movement fluency, no main effects of focus were found in single- or dual-task conditions (p’s ≥ .13). However, focus by leg interactions suggested that an external focus reduced movement fluency of the paretic leg compared to an internal focus (single-task conditions: p = .068; dual-task conditions: p = .084). An external focus also tended to result in inferior dual-task performance (β = -2.38, p = .065). Finally, a near-significant interaction (β = 2.36, p = .055) suggested that dual-task performance was more constrained by patients’ attentional capacity in external focus conditions. We conclude that, compared to an internal focus, an external focus did not result in more automated movements in chronic stroke patients. Contrary to expectations, trends were found for enhanced automaticity with an internal focus. These findings might be due to patients’ strong preference to use an internal focus in daily life. Future work needs to establish the more permanent effects of learning with different attentional foci on re-automating motor control after stroke.

Introducing an innovative method in team conferences

An innovative method to structure multidisciplinary team conferences in rehabilitation medicine was developed: Rehabilitation Activities Profile report system (RAP-TEAM). Experiences with introduction of RAP-TEAM and the study of its effects on the satisfaction of professionals are described. RAP-TEAM was introduced in three teams. RAP-TEAM did not influence the satisfaction of professionals in two teams; satisfaction in the third team even decreased. Nevertheless, professionals report more benefits than disadvantages of RAP-TEAM. Several possible explanations for these results and the methodological problems with this kind of evaluation study are discussed. The most important explanation is that introduction of an innovative method should be allowed sufficient time before it could become effective. Recommendations for a successful introduction of innovative changes are made. All people concerned must be aware that a process of change is not simple, and needs the full attention of all.

Is Implicit Motor Learning Preserved after Stroke? A Systematic Review with Meta-Analysis

Many stroke patients experience difficulty with performing dual-tasks. A promising intervention to target this issue is implicit motor learning, as it should enhance patients’ automaticity of movement. Yet, although it is often thought that implicit motor learning is preserved post-stroke, evidence for this claim has not been systematically analysed yet. Therefore, we systematically reviewed whether implicit motor learning is preserved post-stroke, and whether patients benefit more from implicit than from explicit motor learning. We comprehensively searched conventional (MEDLINE, Cochrane, Embase, PEDro, PsycINFO) and grey literature databases (BIOSIS, Web of Science, OpenGrey, British Library, trial registries) for relevant reports. Two independent reviewers screened reports, extracted data, and performed a risk of bias assessment. Overall, we included 20 out of the 2177 identified reports that allow for a succinct evaluation of implicit motor learning. Of these, only 1 study investigated learning on a relatively complex, whole-body (balance board) task. All 19 other studies concerned variants of the serial-reaction time paradigm, with most of these focusing on learning with the unaffected hand (N = 13) rather than the affected hand or both hands (both: N = 4). Four of the 20 studies compared explicit and implicit motor learning post-stroke. Meta-analyses suggest that patients with stroke can learn implicitly with their unaffected side (mean difference (MD) = 69 ms, 95% CI[45.1, 92.9], p < .00001), but not with their affected side (standardized MD = -.11, 95% CI[-.45, .25], p = .56). Finally, implicit motor learning seemed equally effective as explicit motor learning post-stroke (SMD = -.54, 95% CI[-1.37, .29], p = .20). However, overall, the high risk of bias, small samples, and limited clinical relevance of most studies make it impossible to draw reliable conclusions regarding the effect of implicit motor learning strategies post-stroke. High quality studies with larger samples are warranted to test implicit motor learning in clinically relevant contexts.