Rory J O'Connor

Cryoprobe Treatment: An Alternative to Phenol Injections for Painful Neuromas After Amputation

AJR 2008; 191:W313 0361–803X/08/1916–W313

An Instrumented Walking Aid to Assess and Retrain Gait

An instrumented walking aid, the iWA system, has been developed to measure kinematic and kinetic properties of walking aid (WA) use and deliver feedback to improve gait. The clinical requirements, technical specification and design of the system are developed through clinical collaboration. The development of the system is described, including hardware components and data analysis used to process the measured data for assessment. The system measurements are validated under controlled laboratory conditions. The iWA system is evaluated in a typical U.K. clinical environment by a participant in a rehabilitation session. The resultant data successfully capture the quality of the participants WA use and agree with clinical opinion, supporting the efficacy of this approach.

What reductions in dependency costs result from treatment in an inpatient neurological rehabilitation unit for people with stroke

This paper examines the reductions in care costs that result from inpatient multidisciplinary rehabilitation for younger people with acquired brain injury. Thirty-five consecutive patients admitted following a stroke over one year were recruited to this observational study. Physical ability, dependency and potential community care costs were measured on admission and discharge. Fifty-one community-dwelling patients were transferred to rehabilitation from acute medical wards in a large teaching hospital; 35 met the inclusion criteria. After a median of 59 days of rehabilitation, 29 patients were discharged home and six to nursing homes. Patients made highly significant gains in physical ability (median Barthel index 50 to 64; p < 0.001). Dependency decreased; median calculated costs for care were reduced from pounds 1900 to pounds 1100 per week, a saving of pounds 868 per week. Total annualised care costs reduced from pounds 3,358,056 to pounds 1,807,208, a potential saving of pounds 1,550,848. The median time to repay rehabilitation costs was 21 weeks. Savings occurred in those with moderate and severe disability and they have the potential to continue to accrue for over 12 years. Similar results will probably be found for rehabilitation in other forms of acquired brain injury.

A pilot single-blind multicentre randomized controlled trial to evaluate the potential benefits of computer-assisted arm rehabilitation gaming technology on the arm function of children with spastic cerebral palsy:

Objective: To evaluate the potential benefits of computer-assisted arm rehabilitation gaming technology on arm function of children with spastic cerebral palsy. Design: A single-blind randomized controlled trial design. Power calculations indicated that 58 children would be required to demonstrate a clinically important difference. Setting: Intervention was home-based; recruitment took place in regional spasticity clinics. Participants: A total of 15 children with cerebral palsy aged five to 12 years were recruited; eight to the device group. Interventions: Both study groups received ‘usual follow-up treatment’ following spasticity treatment with botulinum toxin; the intervention group also received a rehabilitation gaming device. Main measures: ABILHAND-kids and Canadian Occupational Performance Measure were performed by blinded assessors at baseline, six and 12 weeks. Results: An analysis of covariance showed no group differences in mean ABILHAND-kids scores between time points. A non-parametric analysis of variance on Canadian Occupational Performance Measure scores showed a statistically significant improvement across time points (χ2 (2,15) = 6.778, p = 0.031), but this improvement did not reach minimal clinically important difference. Mean daily device use was seven minutes. Recruitment did not reach target owing to unanticipated staff shortages in clinical services. Feedback from children and their families indicated that the games were not sufficiently engaging to promote sufficient use that was likely to result in functional benefits. Conclusion: This study suggests that computer-assisted arm rehabilitation gaming does not benefit arm function, but a Type II error cannot be ruled out.

DVT and pulmonary embolism after acute infection.

At fi rst glance, this study by Liam Smeeth and colleagues (April 1, p 1075) was impressive, making use of a database comprising “more than 20 million person-years of observation from 220 general practices”. The method used was laid out in an earlier paper on adverse events from vaccines. The authors of that paper reported on both the relative incidence and attributable risk associated with the vaccine. We were surprised that Smeeth and colleagues chose to report only the incidence risk ratio, despite apparently having data on unexposed cases (used in adjustment for the eff ects of age) which would give access to attributable risk rates. Surely this was a missed opportunity. A doubling of relative risk might mislead the unwary reader into considering thromboprophylaxis after any lower respiratory tract or urinary tract infection. This would be appropriate if, for example, the risk doubles from 10 in 100 to 20 in 100, but would not make clinical sense if, for example, the risk increased from one in a million to two in a million. Perhaps the existing data set would allow this aspect to be investigated? We declare that we have no confl ict of interest.

Employing the International Classification of Functioning, Disability and Health framework to capture user feedback in the design and testing stage of development of home-based arm rehabilitation technology.

ABSTRACT The purpose of this study was to evaluate the International Classification of Functioning, Disability and Health (ICF) as a framework to ensure that key aspects of user feedback are identified in the design and testing stages of development of a home-based upper limb rehabilitation system. Seventeen stroke survivors with residual upper limb weakness, and seven healthcare professionals with expertise in stroke rehabilitation, were enrolled in the user-centered design process. Through semi-structured interviews, they provided feedback on the hardware, software and impact of a home-based rehabilitation device to facilitate self-managed arm exercise. Members of the multidisciplinary clinical and engineering research team, based on previous experience and existing literature in user-centred design, developed the topic list for the interviews. Meaningful concepts were extracted from participants’ interviews based on existing ICF linking rules and matched to categories within the ICF Comprehensive Core Set for stroke. Most of the interview concepts (except personal factors) matched the existing ICF Comprehensive Core Set categories. Personal factors that emerged from interviews e.g. gender, age, interest, compliance, motivation, choice and convenience that might determine device usability are yet to be categorised within the ICF framework and hence could not be matched to a specific Core Set category.

Development of a parent‐reported questionnaire evaluating upper limb activity limitation in children with cerebral palsy

Abstract Background and purpose Upper limb activity measures for children with cerebral palsy have a number of limitations, for example, lack of validity and poor responsiveness. To overcome these limitations, we developed the Childrens Arm Rehabilitation Measure (ChARM), a parent‐reported questionnaire validated for children with cerebral palsy aged 5–16 years. This paper describes both the development of the ChARM items and response categories and its psychometric testing and further refinement using the Rasch measurement model. Methods To generate valid items for the ChARM, we collected goals of therapy specifically developed by therapists, children with cerebral palsy, and their parents for improving activity limitation of the upper limb. The activities, which were the focus of these goals, formed the basis for the items. Therapists typically break an activity into natural stages for the purpose of improving activity performance, and these natural orders of achievement formed each items response options. Items underwent face validity testing with health care professionals, parents of children with cerebral palsy, academics, and lay persons. A Rasch analysis was performed on ChARM questionnaires completed by the parents of 170 children with cerebral palsy from 12 hospital paediatric services. The ChARM was amended, and the procedure repeated on 148 ChARMs (from childrens mean age: 10 years and 1 month; range: 4 years and 8 months to 16 years and 11 months; 85 males; Manual Ability Classification System Levels I = 9, II = 26, III = 48, IV = 45, and V = 18). Results The final 19‐item unidimensional questionnaire displayed fit to the Rasch model (chi‐square p = .18), excellent reliability (person separation index = 0.95, α = 0.95), and no floor or ceiling effects. Items showed no response bias for gender, distribution of impairment, age, or learning disability. Discussion The ChARM is a psychometrically sound measure of upper limb activity validated for children with cerebral palsy aged 5–16 years. The ChARM is freely available for use to clinicians and nonprofit organisations.

Care by companionship: a proposal for prescription friends

All clinicians are familiar with patients who are lonely, particularly at this time of the year. It has long been suspected that loneliness can affect health, and therefore wellbeing, with some evidence that loneliness is as significant a risk factor for poor health as obesity or smoking.1 Disabled people are especially vulnerable to loneliness because of their functional or psychological limitations combined with the inaccessibility of our society.2 If we are serious about promoting health and wellbeing for all patients, then what should we do to ameliorate the contribution of loneliness to poor health? We could combat loneliness through health promotion and greater cooperation with existing support organizations. But, maybe we should go further and prescribe friends? These would not only be beneficial to peoples health, but may also be economically viable. The medical benefits of companionship are increasingly recognized within medical and social care.3 The health differences between socially active and socially isolated people are as significant as those between non-obese and obese people, and non-smokers and smokers.4 Serum cortisol is higher in people who are lonely, contributing to the risk of vascular disease through increased blood pressure and increasing vulnerability to infections. The positive effect of friendship on wound healing is evident in people with good social contacts who demonstrate faster wound repair than those in social isolation.5 The benefits of friendship are psychological as well. The companionate function of friendship supports positive mental health and serves to support individuals during stressful life events. Loneliness is negatively correlated with happiness and perceived life satisfaction.6 Alcoholism, depression, psychosomatic illness and poor self-esteem are also more common among lonely people.7 Loneliness is a factor in poor sleep patterns and could contribute to the progression of dementia. Living a life of solitude can also contribute to a shorter life expectancy.8 Disability can have a profound impact on an individuals social intercourse and their experience of loneliness. A study of disabled people with a variety of conditions found that those with a physical impairment were significantly more likely to be lonely than those without impairments.2 So why are disabled people lonely? One could postulate that physical impairments can impact on an individuals dexterity, movement, hearing or vision and therefore makes meeting and communicating with others more difficult. Difficulties in communication may arise directly from cognitive or communication impairments and indirectly from displaced feelings, fear and anger.9 It has been suggested that the problem lies not with disabled people but with the organizational and architectural inaccessibility of our society, which is generally designed for non-disabled people. In addition, stigmatization may result from those impairments which produce a visible difference, for example, Downs syndrome or neurofibromatosis. We have identified three initiatives that could ameliorate the impact of loneliness on health, some of which have already been implemented successfully elsewhere. The Friends Can Be Good Medicine initiative in California has demonstrated that health promotion campaigns can influence positive relationship behaviour.10 Through media promotions, educational materials and community activities, members of the general public became more knowledgeable about the beneficial effects of friendship and had more relationship-minded intentions following the campaign. Such initiatives in the UK would prove beneficial to disabled people, as well as the general population which is increasingly socially isolated. Healthcare, social services and non-statutory organizations perform an invaluable job in providing social support. However, these supports are not always available, or are insufficient. A potential solution to loneliness would be to strengthen ties between doctors and support agencies so that particularly vulnerable people can be referred for support more easily. There is no reason why the NHS, with its organizational capacity could not help to coordinate links between disabled people and support agencies, remembering that health encompasses social and emotional as well as physical wellbeing. Finally, as one of us mused in clinic, ‘maybe the NHS should prescribe friends’. This is novel, but contentious for a number of reasons. First, friendship is supposed to be unconditional, voluntary and not a means to an end, such as financial reward. Second, it might be argued that lonely, disabled people need sustainable relationships in order to benefit from friendship. However, this service would provide friends and immediate companionship to those in desperate loneliness so that they felt more valued, and consequently developed the self-assurance to venture outside and forge their own relationships. The logic is much the same as prescribing anti-depressants to a patient who is depressed, not as a long-term cure, but to enable that individual to develop the strength required to address their underlying problems. A prescription friend may not perhaps generate a sustainable friendship, but it might empower a disabled person with the confidence to initiate his or her own supportive relationships. There is a theoretical basis and empirical evidence for the negative impact of loneliness on physical and mental health. Strong associations between loneliness and disability have also been highlighted, thereby making the health of disabled people a particular concern. We have briefly proposed three practical solutions in the form of health promotion, greater coordination between organizations and, more radically, prescription friends. By adopting such initiatives the much segregated population of disabled people could be helped to flourish through social intercourse with others, thereby reaping the health benefits of companionship.

Body Extension and the Law: Medical Devices, Intellectual Property, Prosthetics and Marginalisation (Again)

ABSTRACT This interdisciplinary paper, drawing on empirical and doctrinal research regarding artificial limbs and digital avatars, analyses two concepts which are argued to be core to the person – integrity and identity. From the perspective of a person who is a prosthetic user, the paper then evaluates the extent to which two legal regimes which are highly relevant to prosthetics, medical devices regulation (and its delivery) and intellectual property (and its power), engage with the person, integrity and identity with a focus on approaches taken to authority and control. The paper criticises the meaning which law generates regarding the person. It calls for new approaches to be taken by the legal regimes explored to the person, identity and integrity; and for a new multifaceted interdisciplinary driven approach to the person.

Struggling to be Fit : Identity, Integrity, and the Law

This interdisciplinary co-authored Analysis piece introduces identity and integrity, which are argued to sit at the core of the person. It analyses approaches taken to these concepts by legal regimes, particularly in the context of individuals using artificial limbs or digital avatars. The piece concludes that law engages with identity and integrity to a limited and incomplete extent; and that law is thus inadequate in its engagement with the person, and its meaning making in this respect. This piece draws on two interdisciplinary funded projects, funded by the Wellcome Trust and the Arts and Humanities Research Council.