Caroline Cabral Robinson

Effects of Electrical Stimulation in Spastic Muscles After Stroke Systematic Review and Meta-Analysis of Randomized Controlled Trials

Background and Purpose— Neuromuscular electric stimulation (NMES) has been used to reduce spasticity and improve range of motion in patients with stroke. However, contradictory results have been reported by clinical trials. A systematic review of randomized clinical trials was conducted to assess the effect of treatment with NMES with or without association to another therapy on spastic muscles after stroke compared with placebo or another intervention. Methods— We searched the following electronic databases (from inception to February 2015): Medline (PubMed), EMBASE, Cochrane Central Register of Controlled Trials and Physiotherapy Evidence Database (PEDro). Two independent reviewers assessed the eligibility of studies based on predefined inclusion criteria (application of electric stimulation on the lower or upper extremities, regardless of NMES dosage, and comparison with a control group which was not exposed to electric stimulation), excluding studies with <3 days of intervention. The primary outcome extracted was spasticity, assessed by the Modified Ashworth Scale, and the secondary outcome extracted was range of motion, assessed by Goniometer. Results— Of the total of 5066 titles, 29 randomized clinical trials were included with 940 subjects. NMES provided reductions in spasticity (−0.30 [95% confidence interval, −0.58 to −0.03], n=14 randomized clinical trials) and increase in range of motion when compared with control group (2.87 [95% confidence interval, 1.18–4.56], n=13 randomized clinical trials) after stroke. Conclusions— NMES combined with other intervention modalities can be considered as a treatment option that provides improvements in spasticity and range of motion in patients after stroke. Clinical Trial Registration Information— URL: http://www.crd.york.ac.uk/PROSPERO. Unique identifier: CRD42014008946.

Effectiveness and Safety of an Extended ICU Visitation Model for Delirium Prevention: A Before and After Study.

Objectives: To evaluate the effect of an extended visitation model compared with a restricted visitation model on the occurrence of delirium among ICU patients. Design: Prospective single-center before and after study. Setting: Thirty-one–bed medical-surgical ICU. Patients: All patients greater than or equal to 18 years old with expected length of stay greater than or equal to 24 hours consecutively admitted to the ICU from May 2015 to November 2015. Interventions: Change of visitation policy from a restricted visitation model (4.5u2009hr/d) to an extended visitation model (12u2009hr/d). Measurements and Main Results: Two hundred eighty-six patients were enrolled (141 restricted visitation model, 145 extended visitation model). The primary outcome was the cumulative incidence of delirium, assessed bid using the confusion assessment method for the ICU. Predefined secondary outcomes included duration of delirium/coma; any ICU-acquired infection; ICU-acquired bloodstream infection, pneumonia, and urinary tract infection; all-cause ICU mortality; and length of ICU stay. The median duration of visits increased from 133 minutes (interquartile range, 97.7–162.0) in restricted visitation model to 245 minutes (interquartile range, 175.0–272.0) in extended visitation model (p < 0.001). Fourteen patients (9.6%) developed delirium in extended visitation model compared with 29 (20.5%) in restricted visitation model (adjusted relative risk, 0.50; 95% CI, 0.26–0.95). In comparison with restricted visitation model patients, extended visitation model patients had shorter length of delirium/coma (1.5 d [interquartile range, 1.0–3.0] vs 3.0 d [interquartile range, 2.5–5.0]; p = 0.03) and ICU stay (3.0 d [interquartile range, 2.0–4.0] vs 4.0 d [interquartile range, 2.0–6.0]; p = 0.04). The rate of ICU-acquired infections and all-cause ICU mortality did not differ significantly between the two study groups. Conclusions: In this medical-surgical ICU, an extended visitation model was associated with reduced occurrence of delirium and shorter length of delirium/coma and ICU stay.

The effect of exercise therapy on knee adduction moment in individuals with knee osteoarthritis: A systematic review.

BACKGROUNDnExercise therapy is an evidence-based intervention for the conservative management of knee osteoarthritis. It is hypothesized that exercise therapy could reduce the knee adduction moment. A systematic review was performed in order to verify the effects of exercise therapy on the knee adduction moment in individuals with knee osteoarthritis in studies that also assessed pain and physical function.nnnMETHODSnA comprehensive electronic search was performed on MEDLINE, Cochrane CENTRAL, EMBASE, Google scholar and OpenGrey. Inclusion criteria were randomized controlled trials with control or sham groups as comparator assessing pain, physical function, muscle strength and knee adduction moment during walking at self-selected speed in individuals with knee osteoarthritis that underwent a structured exercise therapy rehabilitation program. Two independent reviewers extracted the data and assessed risk of bias. For each study, knee adduction moment, pain and physical function outcomes were extracted. For each outcome, mean differences and 95% confidence intervals were calculated. Due to clinical heterogeneity among exercise therapy protocols, a descriptive analysis was chosen.nnnFINDINGSnThree studies, comprising 233 participants, were included. None of the studies showed significant differences between strengthening and control/sham groups in knee adduction moment. In regards to pain and physical function, the three studies demonstrated significant improvement in pain and two of them showed increased physical function following exercise therapy compared to controls. Muscle strength and torque significantly improved in all the three trials favoring the intervention group.nnnINTERPRETATIONnClinical benefits from exercise therapy were not associated with changes in the knee adduction moment. The lack of knee adduction moment reduction indicates that exercise therapy may not be protective in knee osteoarthritis from a joint loading point of view. Alterations in neuromuscular control, not captured by the knee adduction moment measurement, may contribute to alter dynamic joint loading following exercise therapy. To conclude, mechanisms other than the reduction in knee adduction moment might explain the clinical benefits of exercise therapy on knee osteoarthritis.

The effects of whole body vibration in patients with type 2 diabetes: a systematic review and meta-analysis of randomized controlled trials

Background: Whole body vibration (WBV) has been used to increase physical activity levels in patients with type 2 diabetes mellitus (T2DM). Objective: To carry out a systematic review of the effects of WBV on the glycemic control, cardiovascular risk factors, and physical and functional capacity of patients with T2DM. Method: MEDLINE, LILACS, PEDro, and Cochrane Central Register of Controlled Trials were searched up to June 1st, 2015. Randomized controlled trials investigating the effects of WBV, compared to control or other intervention, on blood glucose levels, blood and physical cardiovascular risk factors, and physical and functional capacity in adult individuals with T2DM. Two independent reviewers extracted the data regarding authors, year of publication, number of participants, gender, age, WBV parameters and description of intervention, type of comparison, and mean and standard deviation of pre and post assessments. Results: Out of 585 potentially eligible articles, two studies (reported in four manuscripts) were considered eligible. WBV interventions provided a significant reduction of 25.7 ml/dl (95% CI:-45.3 to -6.1; I2: 19%) in 12 hours fasting blood glucose compared with no intervention. Improvements in glycated hemoglobin, cardiovascular risk factors, and physical and functional capacity were found only at 12 weeks after WBV intervention in comparison with no intervention. Conclusion: WBV combined with exercise seems to improve glycemic control slightly in patients with T2DM in an exposure-dependent way. Large and well-designed trials are still needed to establish the efficacy and understand whether the effects were attributed to vibration, exercise, or a combination of both.

Global Postural Reeducation for patients with musculoskeletal conditions: a systematic review of randomized controlled trials.

ABSTRACT Objectives To systematically review randomized controlled trials that assessed the effects of Global Postural Reeducation (GPR) on patient-reported outcomes in conditions of the musculoskeletal system. Method An electronic search of MEDLINE (via PubMed), EMBASE, Cochrane CENTRAL, and SciELO was performed from their inception to June 2015. Randomized controlled trials that analyzed pain and patient-reported outcomes were included in this review. The Cochrane Collaboration’s Risk of Bias Tool was used to evaluate risk of bias, and the quality of evidence was rated following the GRADE approach. There were no language restrictions. Results Eleven trials were included totaling 383 patients. Overall, the trials had high risk of bias. GPR was superior to no treatment but not to other forms of treatment for pain and disability. No placebo-controlled trials were found. Conclusion GPR is not superior to other treatments; however, it is superior to no treatment. Due to the lack of studies, it is unknown if GPR is better than placebo. The quality of the available evidence ranges from low to very low, therefore future studies may change the effect estimates of GPR in musculoskeletal conditions.

Effects of monochromatic infrared phototherapy in patients with diabetic peripheral neuropathy: a systematic review and meta-analysis of randomized controlled trials

Highlights • MIRE is an adjunctive phototherapy source approved by FDA to improve blood perfusion and reduce pain.• MIRE was associated with a modest short-term improvement in plantar tactile sensitivity, not sustained over time.• MIRE resulted in a less decrease in pain relief, possibly associated with initial improvement in plantar sensitivity.• Current quality of evidence is low and further studies are likely to change the estimated effect.

More than the tip of the iceberg: association between disabilities and inability to attend a clinic-based post-ICU follow-up and how it may impact on health inequalities

Regis Goulart Rosa, Renata Kochhann, Paula Berto, Livia Biason, Juçara Gasparetto Maccari, Patrícia De Leon, Francine Dutra, Sâmia Faria da Silva, Daniel Sganzerla, Daniel Schneider, Paulo Ricardo Cardoso, Frederico Klein Gomes, Vitória Homem Machado, Gregory Medeiros, Tulio Frederico Tonietto, Luciana Tagliari, Mariana Mattioni, Luisa Anzolin, Maicon Oliveira, Juliana Mara Stormovski de Andrade, Maicon Falavigna, Caroline Cabral Robinson and Cassiano Teixeira

Study protocol to assess the effectiveness and safety of a flexible family visitation model for delirium prevention in adult intensive care units: a cluster-randomised, crossover trial (The ICU Visits Study)

Introduction Flexible intensive care unit (ICU) visiting hours have been proposed as a means to improve patient-centred and family-centred care. However, randomised trials evaluating the effects of flexible family visitation models (FFVMs) are scarce. This study aims to compare the effectiveness and safety of an FFVM versus a restrictive family visitation model (RFVM) on delirium prevention among ICU patients, as well as to analyse its potential effects on family members and ICU professionals. Methods and analysis A cluster-randomised crossover trial involving adult ICU patients, family members and ICU professionals will be conducted. Forty medical-surgical Brazilian ICUs with RFVMs (<4.5u2009hours/day) will be randomly assigned to either an RFVM (visits according to local policies) or an FFVM (visitation during 12 consecutive hours per day) group at a 1:1 ratio. After enrolment and follow-up of 25 patients, each ICU will be switched over to the other visitation model, until 25 more patients per site are enrolled and followed. The primary outcome will be the cumulative incidence of delirium among ICU patients, measured twice a day using the Confusion Assessment Method for the ICU. Secondary outcome measures will include daily hazard of delirium, ventilator-free days, any ICU-acquired infections, ICU length of stay and hospital mortality among the patients; symptoms of anxiety and depression and satisfaction among the family members; and prevalence of burnout symptoms among the ICU professionals. Tertiary outcomes will include need for antipsychotic agents and/or mechanical restraints, coma-free days, unplanned loss of invasive devices and ICU-acquired pneumonia, urinary tract infection or bloodstream infection among the patients; self-perception of involvement in patient care among the family members; and satisfaction among the ICU professionals. Ethics and dissemination The study protocol has been approved by the research ethics committee of all participant institutions. We aim to disseminate the findings through conferences and peer-reviewed journals. Trial registration NCT02932358.

Effects of monochromatic infrared energy in patients with diabetic peripheral neuropathy: a meta-analysis of randomized clinical trials

Objective Summarize the effect of MIRE in plantar sensitivity and neuropathic pain in patients with DPN trough a systematic review of randomized clinical trials. Materials and methods MEDLINE, EMBASE, Cochrane Central and Google Scholar were searched for studies published up to May 2015. Two independent reviewers assessed study eligibility based on predefined criteria and performed data extraction. Results of plantar sensitivity were in standard mean difference, and pain were in mean difference, with 95% of confidence intervals. Statistical heterogeneity was assessed by Cochran’s Q test and inconsistency I2 test. A p value ≤ 0.05 was statistically significant. Meta-analysis was performed on RevMan 5.3.