Narkeesh Arumugam

Effectiveness and cost-effectiveness of telephone-based support versus usual care for treatment of pressure ulcers in people with spinal cord injury in low-income and middle-income countries: study protocol for a 12-week randomised controlled trial

Introduction Pressure ulcers are a common and severe complication of spinal cord injury, particularly in low-income and middle-income countries where people often need to manage pressure ulcers alone and at home. Telephone-based support may help people in these situations to manage their pressure ulcers. The aim of this study is to determine the effectiveness and cost-effectiveness of telephone-based support to help people with spinal cord injury manage pressure ulcers at home in India and Bangladesh. Methods and analysis A multicentre (3 sites), prospective, assessor-blinded, parallel, randomised controlled trial will be undertaken. 120 participants with pressure ulcers on the sacrum, ischial tuberosity or greater trochanter of the femur secondary to spinal cord injury will be randomly assigned to a Control or Intervention group. Participants in the Control group will receive usual community care. That is, they will manage their pressure ulcers on their own at home but will be free to access whatever healthcare support they can. Participants in the Intervention group will also manage their pressure ulcers at home and will also be free to access whatever healthcare support they can, but in addition they will receive weekly telephone-based support and advice for 12 weeks (15–25 min/week). The primary outcome is the size of the pressure ulcer at 12 weeks. 13 secondary outcomes will be measured reflecting other aspects of pressure ulcer resolution, depression, quality of life, participation and satisfaction with healthcare provision. An economic evaluation will be run in parallel and will include a cost-effectiveness and a cost-utility analysis. Ethics and dissemination Ethical approval was obtained from the Institutional Ethics Committee at each site. The results of this study will be disseminated through publications and presented at national and international conferences. Trial registration number ACTRN12613001225707.

The California tri-pull taping method in the treatment of shoulder subluxation after stroke: A randomized clinical trial

Background: Shoulder subluxation is a frequent occurrence in individuals following a stroke. Although various methods of treatment are available, none of them address all possible consequences of the subluxation pain, limited range of motion, the subluxation, and decreased functional use of the arm. Aims: The purpose of this study was to evaluate the effectiveness of California tri-pull taping (CTPT) method on shoulder subluxation, pain, active shoulder flexion, and upper limb functional recovery after stroke. Materials and Methods: This was a randomized control study on 30 participants. All participants received conventional neurorehabilitation 5 days a week over 6 weeks. Half of the participants also received the CTPT. Pre- and post-assessment scores were taken on all participants for the amount of shoulder subluxation, pain, active shoulder flexion, and functional recovery. Results: The CTPT method demonstrated a significant reduction of pain in the treatment group from baseline, a significant improvement in active shoulder flexion and a significant improvement in proximal arm function as measured on the proximal subscale on the Fugl-Meyer upper extremity functional Scale but not the distal or total Fugl-Meyer subscales. Shoulder subluxation was not statistically significant. Conclusions: The CTPT method is an effective treatment for the hemiplegic subluxed shoulder.

Telephone-based management of pressure ulcers in people with spinal cord injury in low- and middle-income countries: a randomised controlled trial.

Study design:A multicentre, prospective, assessor-blinded, parallel randomised controlled trial.Objectives:The objective of the trial was to determine the effectiveness of telephone-based management of pressure ulcers in people with spinal cord injury (SCI) in low- and middle-income countries.Methods:One hundred and twenty people with SCI living in the community were recruited through three hospitals in India and Bangladesh between November 2013 and March 2016. Participants had sustained an SCI >3 months prior and had a pressure ulcer. Participants were randomly allocated (1:1) to a control or intervention group. Participants in the control group received no intervention. Participants in the intervention group received weekly advice by telephone for 12 weeks about the management of their pressure ulcers from a trained health-care professional. Outcomes were measured by a blinded assessor at baseline and 12 weeks. There was one primary outcome, namely, the size of the pressure ulcer and 13 secondary outcomes.Results:The mean between-group difference for the size of the pressure ulcer at 12 weeks was 2.3 cm2 (95% confidence interval −0.3 to 4.9; favouring the intervention group). Eight of the 13 secondary outcomes were statistically significant.Conclusion:The results of our primary outcome (that is, size of pressure ulcer) do not provide conclusive evidence that people with SCI can be supported at home to manage their pressure ulcers through regular telephone-based advice. However, the results from the secondary outcomes are sufficiently positive to provide hope that this simple intervention may provide some relief from this insidious problem in the future.

Motor cognitive processing speed estimation among the primary schoolchildren by deriving prediction formula: A cross-sectional study

Objectives: Motor cognitive processing speed (MCPS) is often reported in terms of reaction time. In spite of being a significant indicator of function, behavior, and performance, MCPS is rarely used in clinics and schools to identify kids with slowed motor cognitive processing. The reason behind this is the lack of availability of convenient formula to estimate MCPS. Thereby, the aim of this study is to estimate the MCPS in the primary schoolchildren. Materials and Methods: Two hundred and four primary schoolchildren, aged 6–12 years, were recruited by the cluster sampling method for this cross-sectional study. MCPS was estimated by the ruler drop method (RDM). By this method, a metallic stainless steel ruler was suspended vertically such that 5 cm graduation of the lower was aligned between the web space of the childs hand, and the child was asked to catch the moving ruler as quickly as possible, once released from the examiners hand. Distance the ruler traveled was recorded and converted into time, which is the MCPS. Multiple regression analysis of variables was performed to determine the influence of independent variables on MCPS. Results: Mean MCPS of the entire sample of 204 primary schoolchildren is 230.01 ms ± 26.5 standard deviation (95% confidence interval; 226.4–233.7 ms) that ranged from 162.9 to 321.6 ms. By stepwise regression analysis, we derived the regression equation, MCPS (ms) = 279.625–5.495 × age, with 41.3% (R = 0.413) predictability and 17.1% (R2 = 0.171 and adjusted R2 = 0.166) variability. Conclusion: MCPS prediction formula through RDM in the primary schoolchildren has been established.

Reaction time norms as measured by ruler drop method in school-going South Asian children: A cross-sectional study

This study aimed to estimate normative range for reaction time using ruler drop method for school-going South Asian children between 6 and 12 years of age. A cross-sectional study was used to evaluate the reaction time for 204 children. Normal values for each age group were obtained. The results of multiple linear regressions showed a decrease in the reaction time values with age, and a significant change occurring between six and eight years of age. No difference in reaction time was obtained between boys and girls. Ruler drop method is an easy to use test and the results of this study provide a normative data for age groups 6-12 years ranging from 214.2ms to 248.8ms. These values can serve as a reference to screen children with delayed reaction time.

Effect of surface spinal stimulation on autonomic nervous system in the patients with spinal cord injury

Background: The Autonomic Nervous System (ANS) plays a key role in the regulation of many physiological processes, mediated by supraspinal control from centers in the central nervous system. Spinal cord injury (SCI) decreases the ability to sympathetically control blood pressure and to regulate body temperature. Bladder dysfunction has been reported as a serious medical complication following SCI. The purpose of study is to find the effect of surface spinal stimulation on autonomic nervous system i.e., bladder function, skin resistance, and skin temperature. Materials and Methods: Five traumatic spinal cord injury subjects were selected for experimental pilot study; surface spinal stimulation for 45 minute period applied to the skin in T11-L2 area, with a carrier frequency of 2500Hz and modulated to beats frequency of 20Hz. Stimulation amplitude was raised to cause sensory stimulation. The pre- and post-stimulation values using the values of urodynamics testing, galvanic skin response, and infra-red thermometer compared in same patients and results were obtained. Results: Result of the present study indicates that four of five subjects demonstrate a decrease in the infused fluid volume, improved bladder sensation, but shown no effect over the bladder capacity. The skin resistance of the right lower limb was increased post-stimulation, but the improvement was not significant, and skin temperature of thigh and foreleg improved significantly. Conclusion: According to our results, surface spinal stimulation was effective to improve non-reflexive bladder, skin resistance and skin temperature, but further research is needed.

Multi-directional reach test in South Asian children: Normative reference scores from 5 year to 12 years old

Multi-directional reach test (MRT) emerged as a valid and reliable assessment tool for balance evaluation among elderly. The normative reference scores have been established in adults and elderly people, but they were not yet established for children. Hence, we aimed at establishing the normative reference scores of MRT among the school going children aged between 5 and 12 years. Children (N = 194; 124 males, 70 females) were recruited by the stratified random sampling for the normative study. MRT was performed by the custom made, multi-directional reach estimator. MRE device consists of three adjustable wooden frames with two metallic rulers each of 600 mm. Children were asked to reach maximum distance in forward reach (FR), backward reach (BR), right lateral reach (RLR) and left lateral reach (LLR) directions to obtain their maximum reaching ability. The mean of three readings were used to report the normative reference scores of MRT. Median age, height, weight and body mass index (BMI) were 8.5 years, 1240 mm, 27 kg and 17.24 kg/m2 respectively. The normative reference scores [median (95% confidence Interval, CI)] of MRT among the children aged 5-12 years old were FR [169.7 mm (CI, 166.1-183.3 mm)], BR [77.7 mm (CI, 78.0-85.5 mm)], RLR [122.0 mm (119.6-130.9 mm)] and LLR [107.0 (105.8-119.3 mm)] respectively.

Effectiveness of Activity-Based Therapy in Comparison with Surface Spinal Stimulation in People with Traumatic Incomplete Spinal Cord Injury for Activation of Central Pattern Generator for Locomotion: Study Protocol for a 24-Week Randomized Controlled Trial

Study Design A multi-centric randomized controlled trial to be conducted at two sites, department of phyhysiotherapypy, Punjabi University, Patiala and rehabilitation department, Indian Spinal Injury Centre, New Delhi, India. Purpose To determine the effectiveness of activity-based therapy in comparison with surface spinal stimulation (SSS) in traumatic incomplete spinal cord injury (SCI) with special reference to locomotion—a central pattern generator controlled function. Overview of Literature A major goal for many patients after SCI is to regain the function of locomotion. It is crucial that rehabilitation strives to maximize locomotor ability and functional recovery after SCI. Experimental evidence of improvement in stepping and motor control after activity-based training in animal models and human SCI has been translated into clinical neuro-rehabilitation. Methods Control group participants will undertake an intensive 24-week duration thrice weekly program of activity-based therapy. In addition to this the participants in experimental group will also receive a session of 45 minutes of SSS on thrice weekly basis. The primary analysis for our study will be at 24 weeks. Linear regression will be used to determine the mean between-group differences and 95% confidence interval for all continuous outcomes using baseline scores and group allocation as covariates. Results The primary outcome measure is improvement in the level of walking index for SCI-II. The secondary outcome measures are modified Ashworth scale, Penn spasm frequency score, spinal cord independence measure-III, SCI functional ambulation inventory, Hoffman’s reflex, somatosensory evoked potential, and American Spinal Injury Association Impairment Scale scores. Conclusions An insight into training-induced mechanisms will be of great importance to fine tune such combined treatments and vindicate their efficacy in restoration of locomotion and functional activities in individuals with SCI.

Effect of physical exercises on attention, motor skill and physical fitness in children with attention deficit hyperactivity disorder: a systematic review

Children with attention deficit hyperactivity disorder (ADHD) are educated in classrooms along with typically developing children. Those with ADHD, however, find it difficult to participate in routine educational and recreational activities as they encounter problems associated with behaviour, attention, motor skills and physical endurance. Traditionally, the management of children with ADHD has focussed primarily on problems with cognition and has been heavily dependent on pharmaceutical interventions and, to a lesser extent, on non-pharmaceutical measures. More recently, experts have increasingly advocated the use of exercises in alleviating symptoms associated with ADHD. The primary objective of this review was to summarize research that examined the role of exercises on deficits related to attention, motor skills and fitness in children with ADHD. A search of the available literature was conducted using a combination of relevant key words in the following databases: PubMed, MEDLINE, Google Scholar, Embase and Cochrane review. The search filtered 3016 studies of potential relevance, of which 2087 were excluded after screening titles and abstracts as per the inclusion criteria. Thirty-four (34) studies were analysed in greater depth, and 16 were excluded after detailed consideration as they did not match the inclusion (PEDro score > 4) and exclusion criteria. Three (3) additional studies were excluded as they lacked exercise prescription details such as intensity, duration and frequency of exercise. Finally, 15 studies were analysed with a focus on the effects of physical exercises on attention, hyperactive behaviour, motor skills and physical fitness in ADHD children. Overall, the studies reviewed were of moderate-to-high quality and reported benefits of a variety of exercise programmes in improving motor skills, physical fitness, attention and social behaviour in children with ADHD. However, there was limited information regarding school-based programmes, the effects of structured exercise programmes independently or in combination with cognitive-based therapies, and the long-term benefits of exercises in alleviating behavioural problems in these children.

Cost-effectiveness analysis of telephone-based support for the management of pressure ulcers in people with spinal cord injury in India and Bangladesh

Objective:To determine from a societal perspective the cost-effectiveness and cost-utility of telephone-based support for management of pressure ulcers.Study design:Cost-effectiveness and cost-utility analysis of a randomised clinical trial.Setting:Tertiary centre in India and Bangladesh.Methods:An economic evaluation was conducted alongside a randomised clinical trial comparing 12 weeks of telephone-based support (intervention group) with usual care (control group). The analyses evaluated costs and health outcomes in terms of cm2 reduction of pressure ulcers size and quality-adjusted life years (QALYs) gained. All costs were in Indian Rupees (INR) and then converted to US dollars (USD).Results:The mean (95% confidence interval) between-group difference for the reduction in size of pressure ulcers was 0.53 (−3.12 to 4.32) cm2, favouring the intervention group. The corresponding QALYs were 0.027 (0.004–0.051), favouring the intervention group. The mean total cost per participant in the intervention group was INR 43 781 (USD 2460) compared to INR 42 561 (USD 2391) for the control group. The per participant cost of delivering the intervention was INR 2110 (USD 119). The incremental cost-effectiveness ratio was INR 2306 (USD 130) per additional cm2 reduction in the size of the pressure ulcer and INR 44 915 (USD 2523) per QALY gained.Conclusion:In terms of QALYs, telephone-based support to help people manage pressure ulcers at home provides good value for money and has an 87% probability of being cost-effective, based on 3 times gross domestic product. Sensitivity analyses were performed using the overall cost data with and without productivity costs, and did not alter this conclusion.