Olive Lennon

A pilot randomized controlled trial to evaluate the benefit of the cardiac rehabilitation paradigm for the non-acute ischaemic stroke population

Objective: To evaluate risk factor reduction and health-related quality of life following a 10-week cardiac rehabilitation programme in non-acute ischaemic stroke subjects. Design: Single-blinded randomized control trial. Setting: Outpatient rehabilitation. Subjects: Forty-eight community-dwelling ischaemic stroke patients (38 independently mobile, 9 requiring assistance, 1 non-ambulatory) were randomly assigned to intervention or control groups by concealed allocation. Intervention: The trial consisted of a 10-week schedule with measures taken at weeks 1 and 10. Both groups continued usual care (excluding aerobic exercise); intervention subjects attended 16 cycle ergometry sessions of aerobic-training intensity and two stress-management classes. Main outcome measures: Cardiac risk score (CRS); VO2 (mL O2/kg per minute) and Borg Rate of Perceived Exertion (RPE) assessed during a standardized ergometry test; Hospital Anxiety and Depression Scale (HADS); Frenchay Activity Index; Fasting Lipid Profiles and Resting Blood Pressure. Results: Group comparison with independent t-tests showed significantly greater improvement at follow-up by intervention subjects than controls in VO2 (intervention 10.6 ±1.6 to 12.0 ± 2.2, control 11.1 ±1.8 to 11.1 ±1.9 t=4.734, P<0.001) and CRS (intervention 13.4 ±10.1 to 12.4 ±10.5, control 9.4 ±6.7 to 15.0 ±6.1 t=-2.537, P<0.05). RPE rating decreased in intervention subjects (13.4 ±12.2 to 12.4 ±2.0) and increased in controls (13.8 ±1.8 to 14.4 ±1.6); Mann—Whitney U (U = 173.5, P<0.05). Within-group comparison showed significant decrease in the HADS depression subscale in the intervention group alone (5.1 ±3.4 to 3.0 ±2.8) (Wilcoxon signed ranks test Z=-3.278, P<0.001). Conclusion: Preliminary findings suggest non-acute ischaemic stroke patients can improve their cardiovascular fitness and reduce their CRS with a cardiac rehabilitation programme. The intervention was associated with improvement in self-reported depression.

Lifestyle interventions for secondary disease prevention in stroke and transient ischaemic attack: a systematic review:

Background and purpose Secondary prevention in ischaemic stroke and transient ischaemic attack (TIA) is dominated by pharmacological interventions with evidence for non-pharmacological interventions being less robust. This systematic review and meta-analysis examines the impact of lifestyle interventions on secondary prevention in stroke or TIA. Methods A systematic literature search was performed. Randomised controlled trials (RCTs) examining the effectiveness of intervention packages incorporating any key component of health education/promotion/counselling on lifestyle and/or aerobic exercise compared to usual care ± a sham intervention in participants with ischaemic stroke or TIA were included. Outcomes of interest were mortality, cardiovascular disease (CVD) event rates, cardiovascular risk factors including blood pressure, lipid profiles and physical activity participation. Methodological quality was assessed. Statistical analyses determining treatment effect were conducted using Cochrane Review Manager Software. Results Seventeen RCTs were included. Data pooled from eight studies with a total of 2478 patients, demonstrated no effect in favour of lifestyle interventions compared to routine or sham interventions on mortality (risk ratio (RR) = 1.13 (95% confidence interval (CI), 0.85–1.52), I2 = 0%). Data relating to CVD events were pooled from four studies (1013 patients), demonstrated non-significant findings (RR = 1.16 (95% CI, 0.80--1.71), I2 = 0%). Similar results were reported for total cholesterol. Physical activity participation demonstrated significant improvement [SMD 0.24 (95% CI, 0.08–0.41), l2 = 47%]. Blood pressure reductions were noted but were non-significant when corrected for multimodal packages including enhanced pharmacotherapy compliance. Conclusions There is currently insufficient high quality research to support lifestyle interventions post-stroke or TIA on mortality, CVD event rates and cardio-metabolic risk factor profiles. Promising blood pressure reductions were noted in multimodal interventions which addressed lifestyle.

Cardiac rehabilitation adapted to transient ischaemic attack and stroke (CRAFTS): a randomised controlled trial

BackgroundCoronary Heart Disease and Cerebrovascular Disease share many predisposing, modifiable risk factors (hypertension, abnormal blood lipids and lipoproteins, cigarette smoking, physical inactivity, obesity and diabetes mellitus). Lifestyle interventions and pharmacological therapy are recognised as the cornerstones of secondary prevention. Cochrane review has proven the benefits of programmes incorporating exercise and lifestyle counselling in the cardiac disease population. A Cochrane review highlighted as priority, the need to establish feasibility and efficacy of exercise based interventions for Cerebrovascular Disease.MethodsA single blind randomised controlled trial is proposed to examine a primary care cardiac rehabilitation programme for adults post transient ischemic attack (TIA) and stroke in effecting a positive change in the primary outcome measures of cardiac risk scores derived from Blood Pressure, lipid profile, smoking and diabetic status and lifestyle factors of habitual smoking, exercise and healthy eating participation. Secondary outcomes of interest include health related quality of life as measured by the Hospital Anxiety and Depression Scale, the Stroke Specific Quality of Life scale and WONCA COOP Functional Health Status charts and cardiovascular fitness as measured by a sub-maximal fitness test.A total of 144 patients, over 18 years of age with confirmed diagnosis of ischaemic stroke or TIA, will be recruited from Dublin community stroke services and two tertiary T.I.A clinics. Exclusion criteria will include oxygen dependence, unstable cardiac conditions, uncontrolled diabetes, major medical conditions, claudication, febrile illness, pregnancy or cognitive impairment. Participants will be block-statified, randomly allocated to one of two groups using a pre-prepared computer generated randomisation schedule. Both groups will receive a two hour education class on risk reduction post stroke. The intervention group will receive a 10 week programme of supervised aerobic exercises (twice weekly) and individually tailored brief intervention lifestyle counselling. Both groups will be tested on week one and week ten of the programme. Follow-up at 1 year will assess longer term benefits. Analysis will test for significant changes in the key variables indicated.DiscussionApplication of the Cardiac Rehabilitation paradigm to patients with ischaemic stroke or TIA has not been explored despite the obvious overlap in aetiology. It is hoped the anticipated improvement in vascular risk factors and fitness resulting from such a programme will enhance health and social gain in this population.Trial RegistrationCurrent Controlled Trials ISCTRN90272638.

Neuropathic pain prevalence following spinal cord injury: A systematic review and meta-analysis

Following spinal cord injury (SCI), chronic pain is a common secondary complication with neuropathic pain (NP) cited as one of the most distressing and debilitating conditions leading to poor quality of life, depression and sleep disturbances. Neuropathic pain presenting at or below the level of injury is largely refractory to current pharmacological and physical treatments. No consensus on the prevalence of NP post SCI currently exists, hence this systematic review was undertaken. The review comprised three phases: a methodological assessment of databases [PubMed, Embase, Web of Knowledge, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane Library and Physiotherapy Evidence Database (PEDro)] identifying potential papers and screening for inclusion criteria by two independent reviewers; data extraction; and finally rating of internal validity and strength of the evidence, using a published valid and reliable scale. Meta‐analysis estimated pooled point prevalence rates using a random effects model. In total, 17 studies involving 2529 patients were included in the review. Overall point prevalence rates for NP were established at 53% (38.58–67.47); 19% (13.26–26.39) for at‐level NP and 27% (19.89–34.61) for below‐level NP, with high heterogeneity noted (I2 = 84–93%). Prevalence rates for NP following SCI are high. Future studies should include established definitions, classification systems and assessment tools for NP at defined time points post SCI to follow the trajectory of this problem across the lifespan and include indices of sleep, mood and interference to allow for appropriate, optimal and timely NP management for each patient.

Feasibility, criterion validity and retest reliability of exercise testing using the Astrand-rhyming test protocol with an adaptive ergometer in stroke patients

Purpose: (i) to establish feasibility of the Astrand-Rhyming submaximal protocol using the adaptive ergometer in healthy participants, (ii) to test feasibility of this protocol in stroke patients, (iii) to identify clinical characteristics of stroke patients which limit testing, (iv) to establish criterion validity of V·O2 steady state ergometry data against the gold standard open-circuit spirometry measure and, lastly, (v) to test–retest reliability of the data generated by the test protocol. Methods: A descriptive, cross sectional study design was implemented. Ten healthy participants (5 men, mean age 32 ± 6.6 y) and 20 chronic stroke patients (14 men, mean age 61.0 ± 11.6 y; mean months since stroke, 65.6 ± 34.4 y) took part in this study. Independent t-tests, Mann Whitney U tests and chi-square test identified characteristics of those who failed to successfully complete the protocol. Interclass correlation coefficients (ICCs) tested criterion validity and test–retest reliability. Results: No adverse events occurred. All healthy participants (100%) complied with the test protocol and estimation of V·O2max. 90% of stroke patients completed the test, with V·O2max estimated in 35% (7 / 20) stroke patients. Age and beta-blocker medication demonstrated statistical significance as barriers to the test protocol at p = 0.04 and p = 0.03, respectively. Criterion validity established by comparison with breath-by-breath gas analysis was excellent (ICC 0.93). Retest reliability of V·O2max, steady-state V·O2 and oxygen pulse had ICCs of 0.94, 0.96 and 0.97, respectively. Conclusions: The Astrand-Rhyming test protocol and MOTOmed Viva2 adaptive ergometer were feasible in healthy participants. The protocol was not feasible for V·O2max estimation for the majority of stroke patients based on heart rate response. The adapted steady state VO2 measures used however were feasible and had strong relationship to actual VO2 consumption. Criterion validity and retest reliability of test data were excellent. Implications for Rehabilitation Maximal fitness test protocols exclude disabled populations including many stroke patients. The Astrand Rhyming submaximal test protocol using an adaptive ergometer was a feasible tool for estimating VO2 max in healthy subjects. The Astrand Rhyming submaximal test protocol based on heart rate response to exercise was not feasible for estimating VO2 max in the majority of stroke patients despite the use of adaptive equipment.

Reliability and Validity of COOP/WONCA Functional Health Status Charts for Stroke Patients in Primary Care

Dartmouth Coop Functional Health Assessment/World Organization of National Colleges, Academies and Academic Association of General Practitioners (COOP/WONCA) functional health assessment charts depict levels of function/well being along 5-point ordinal scales in 6 domains. Responses, illustrated by drawings, make these charts a suitable tool for the stroke population, given the high prevalence (20%) of language impairment in this population. This study examined the validity and reliability of COOP/WONCA charts for community-dwelling stroke survivors. A total of 55 participants in this cross-sectional study completed COOP/WONCA Charts, Hospital Anxiety and Depression Scale (HAD), Stroke Specific Quality of Life Scale (SSQoL), EuroQoL EQ-5D and visual analogue scale (VAS), International Physical Activity Questionnaire (IPAQ), and Astrand-Rhyming submaximal oxygen volume (VO₂) fitness test. Spearmans correlation coefficient was used to test criterion validity, Cronbachs α was used to test internal validity, and the Mann-Whitney U tested discriminative validity. A subgroup (n = 30) completed COOP/WONCA charts 2 days later, and test-retest reliability (Kendalls τ-b statistic) analysis was conducted. Good agreement was observed between COOP/WONCA physical fitness chart, VO₂, and IPAQ (ρ = -0.438, P = .001; ρ = -0.497, P < .001), COOP/WONCA feelings chart and HAD anxiety and depression scores (ρ = 0.498, P < .001; ρ = 0.494, P < .001), COOP/WONCA overall health chart and EuroQol EQ-5D VAS (ρ = -0.535; P < .001), and COOP/WONCA daily activity and social activity charts and SSQoL (ρ = -0.371, P = .005; ρ = -0.463, P < .001). Cronbachs α (0.72) reflected good internal consistency among COOP/WONCA scales. Discriminative ability for independent ambulation and clinical depression was demonstrated (U = 103.5, P < .001; U = 156, P = .015). Test-retest reliability in each domain except Changes in Health was significant at P < .05 (Kendalls τ-b, 0.344-0.653). Our data indicate that the COOP/WONCA Functional Health charts demonstrate good validity and overall reliability for use with stroke patients in primary care.

An evaluation of neuromuscular electrical stimulation in critical care using the ICF framework: a systematic review and meta‐analysis

To review, in conformance with the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses guidelines, the totality of evidence for the use of neuromuscular electrical stimulation (NMES) in the critical care setting, when compared with usual care, under all domains of the World Health Organisation, International Classification of Functioning, Disability and Health (ICF) framework.

Can vestibular rehabilitation exercises help patients with concussion? A systematic review of efficacy, prescription and progression patterns

Objective Concussion symptoms normally resolve within 7–10 days but vertigo, dizziness and balance dysfunction persist in 10–30% of cases causing significant morbidity. This study systematically evaluated the evidence supporting the efficacy, prescription and progression patterns of vestibular rehabilitation therapy (VRT) in patients with concussion. Design Systematic Review, guided by PRISMA guidelines and presenting a best evidence synthesis. Data sources Electronic databases PubMed (1949 to May 2015), CINAHL (1982 to May 2015), EMBASE (1947 to May 2015), SPORTDiscus (1985 to May 2015), Web of Science (1945 to May 2015) and PEDRO (1999 to May 2015), supplemented by manual searches and grey literature. Eligibility criteria for study selection Article or abstract of original research, population of patients with concussion/mild traumatic brain injury (mTBI) with vestibular symptoms, interventions detailing VRT, measurement of outcomes pre-VRT/post-VRT. Study type was not specified. Results Following a double review of abstract and full-text articles, 10 studies met the inclusion criteria: randomised controlled trial (n=2), uncontrolled studies (n=3) and case studies (n=5). 4 studies evaluated VRT as a single intervention. 6 studies incorporated VRT in multimodal interventions (including manual therapy, strength training, occupational tasks, counselling or medication). 9 studies reported improvement in outcomes but level I evidence from only 1 study was found that demonstrated increased rates (OR 3.91; 95% CI 1.34 to 11.34; p=0.002) of medical clearance for return to sport within 8 weeks, when VRT (combined with cervical therapy) was compared with usual care. Heterogeneity in study type and outcomes precluded meta-analysis. Habituation and adaptation exercises were employed in 8 studies and balance exercises in 9 studies. Prescription and progression patterns lacked standardisation. Conclusions Current evidence for optimal prescription and efficacy of VRT in patients with mTBI/concussion is limited. Available evidence, although weak, shows promise in this population. Further high-level studies evaluating the effects of VRT in patients with mTBI/concussion with vestibular and/or balance dysfunction are required.

Pain profiles in a community dwelling population following spinal cord injury: a national survey

Context: While as many as 60% of patients with spinal cord injury (SCI) develop chronic pain, limited data currently exists on the prevalence and profile of pain post-SCI in community dwelling populations. Study Design: A cross-sectional population survey. Setting: Primary care. Participants: Community dwelling adults with SCI. Methods: Following ethical approval members registered to a national SCI database (n=1,574) were surveyed. The survey included demographic and SCI characteristics items, the International Spinal Cord Injury Pain Basic Data Set (version 1) the Douleur Neuropathique 4 questionnaire (interview) and questions relating to health care utilisation. Data were entered into the Statistical Package for the Social Sciences (version 20) Significance was set P < 0.05 for between group comparisons. Results: In total 643 (41%) surveys were returned with 458 (71%) respondents experiencing pain in the previous week. Neuropathic pain (NP) was indicated in 236 (37%) of responses and nociceptive pain in 206 (32%) Common treatments for pain included medications n=347 (76%) massage n=133 (29%) and heat n=115 (25%). Respondents with NP reported higher pain intensities and increased healthcare service utilisation (P= < 0.001) when compared to those with nociceptive pain presentations. A higher proportion of females than males reported pain (P = 0.003) and NP (P = 0.001) and those unemployed presented with greater NP profiles compared with those in education or employment (P = 0.006). Conclusion: Pain, in particular NP post SCI interferes with daily life, increases health service utilisation and remains refractory to current management strategies. Increased availability of multi-disciplinary pain management and further research into management strategies is warranted.

“I've Actually Changed How I Live”—Patients' Long-Term Perceptions of a Cognitive Behavioral Pain Management Program

Objective. To determine patients’ perceptions regarding cognitive behavioral pain management programs, and to determine what, if any, strategies learned on the program patients continue to use long-term to manage their pain. Design. A qualitative, focus-group based study. Setting. An outpatient multidisciplinary pain management program in a university teaching hospital. Patients. Patients with chronic pain who had previously completed a 4-week cognitive behavioral pain management program (2001–2014). Methods. Sixteen patients attended one of four focus groups. A battery of semi-structured questions explored their perceptions of the cognitive behavioral program, and which strategies they found useful and continued to use long-term to manage their pain. Results. Six key themes emerged: 1) universal long-term positive feedback on the utility of the program; 2) the program facilitated long-term changes in daily life; 3) participants now considered themselves as the “new me”; 4) request for more updates on emerging new treatments/pain knowledge; 5) recognizing that the key to maximizing gain from the program was to be open, to listen, and accept; and 6) participants sharing pain management knowledge with others in pain. Conclusion. There was universal positive feedback for the pain management program. Despite the years since they participated in one, patients continue to use key strategies to effectively manage their pain (pacing, relaxation), embedding them in their daily lives to maximize their quality of life.