Rose Galvin

Fixation of Ankle Syndesmotic Injuries Comparison of TightRope Fixation and Syndesmotic Screw Fixation for Accuracy of Syndesmotic Reduction

Background: Ankle syndesmotic injuries are complex and require anatomic reduction and fixation to restore the normal biomechanics of the ankle joint and prevent long-term complications. Purpose: The aim of this study is to compare the accuracy and maintenance of syndesmotic reduction using TightRope versus syndesmotic screw fixation. Study Design: Cohort study; Level of evidence, 2. Methods: This cohort study included consecutive patients treated for ankle syndesmotic diastases between July 2007 and June 2009. Single slice axial computed tomography (CT) scans of both the ankles together were performed at the level of syndesmosis, 1 cm above the tibial plafond. A greater than 2-mm widening of syndesmosis compared with the untreated contralateral ankle was considered significant malreduction. Clinical outcomes were measured using the American Orthopaedics Foot and Ankle Society (AOFAS) and Foot and Ankle Disability Index (FADI) scores. Results: Forty-six of 55 eligible patients participated in the study; 23 patients were in the TightRope group and 23 in the syndesmotic screw group. The average age was 42 years in the TightRope and 40 years in the syndesmotic screw group, and the mean follow-up time was 2.5 years (range, 1.5-3.5 years). The average width of normal syndesmosis was 4.03 ± 0.89 mm. In the TightRope group, the mean width of syndesmosis was 4.37 mm (SD, ±1.12 mm) (P = .30, t test) compared with 5.16 mm (SD, ±1.92 mm) in the syndesmotic screw group (P = .01, t test). Five of 23 ankles (21.7%) in the syndesmotic screw group had syndesmotic malreduction, whereas none of the TightRope group showed malreduction on CT scans (P = .04, Fisher exact test). Average time to full weightbearing was 8 weeks in the TightRope group and 9.1 weeks in the syndesmotic screw group. There was no significant difference between the TightRope and syndesmotic screw groups in mean postoperative AOFAS score (89.56 and 86.52, respectively) or FADI score (82.42 and 81.22, respectively). Regression analysis confirmed malreduction of syndesmosis as the only independent variable that affected the clinical outcome (regression coefficient, −12.39; t = −2.43; P = .02). Conclusion: The results of this study indicate that fixation with TightRope provides a more accurate method of syndesmotic stabilization compared with screw fixation. Syndesmotic malreduction is the most important independent predictor of clinical outcomes; therefore, care should be taken to reduce the syndesmosis accurately.

Effectiveness of acupuncture for nonspecific chronic low back pain: a systematic review and meta-analysis.

Study Design. A systematic review and meta-analysis of randomized controlled trials (RCTs). Objective. To evaluate the totality of evidence in relation to the effectiveness of acupuncture for nonspecific chronic low back pain (NSCLBP). Summary of Background Data. Acupuncture has become a popular alternative for treating clinical symptoms of NSCLBP. A number of RCTs have examined the effectiveness of acupuncture in the treatment of NSCLBP. Methods. A systematic literature search was completed without date or language restrictions up to May 2012. Studies included in the review were RCTs that examined all forms of acupuncture that adhered to the Traditional Acupuncture Theory for treating NSCLBP. Outcome measures included impairment, activity limitation, and participation restriction. The methodological quality of the studies was examined using the Cochrane risk of bias tool. Results. Thirty-two studies were included in the systematic review, of which 25 studies presented relevant data for the meta-analysis. Acupuncture had a clinically meaningful reduction in levels of self-reported pain (mean difference =−16.76 [95% confidence interval, −33.33 to −0.19], P = 0.05, I2 = 90%) when compared with sham, and improved function (standard mean difference =−0.94 [95% confidence interval, −1.41 to −0.47], P < 0.00, I2 = 78%) when compared with no treatment immediately postintervention. Levels of function also clinically improved when acupuncture in addition to usual care, or electroacupuncture was compared with usual care alone. When acupuncture was compared with medications (NSAIDs, muscle relaxants, and analgesics) and usual care, there were statistically significant differences between the control and the intervention groups but these differences were too small to be of any clinical significance. There was no evidence in support of acupuncture over transcutaneous electrical nerve stimulation. Conclusion. This systematic review demonstrates that acupuncture may have a favorable effect on self-reported pain and functional limitations on NSCLBP. However, the results should be interpreted in the context of the limitations identified, particularly in relation to the heterogeneity in the study characteristics and the low methodological quality in many of the included studies. Level of Evidence: 1

Family-Mediated Exercise Intervention (FAME) Evaluation of a Novel Form of Exercise Delivery After Stroke

Background and Purpose— Additional exercise therapy has been shown to have a positive impact on function after acute stroke and research is now focusing on methods to increase the amount of therapy that is delivered. This randomized controlled trial examined the impact of additional family-mediated exercise (FAME) therapy on outcome after acute stroke. Methods— Forty participants with acute stroke were randomly assigned to either a control group who received routine therapy with no formal input from their family members or a FAME group, who received routine therapy and additional lower limb FAME therapy for 8 weeks. The primary outcome measure used was the lower limb section of the Fugl-Meyer Assessment modified by Lindmark. Other measures of impairment, activity, and participation were completed at baseline, postintervention, and at a 3-month follow-up. Results— Statistically significant differences in favor of the FAME group were noted on all measures of impairment and activity postintervention (P<0.05). These improvements persisted at the 3-month follow-up but only walking was statistically significant (P<0.05). Participants in the FAME group were also significantly more integrated into their community at follow-up (P<0.05). Family members in the FAME group reported a significant decrease in their levels of caregiver strain at the follow-up when compared with those in the control group (P<0.01). Conclusions— This evidence-based FAME intervention can serve to optimize patient recovery and family involvement after acute stroke at the same time as being mindful of available resources.

Diagnostic accuracy of clinical tests for subacromial impingement syndrome: a systematic review and meta-analysis.

OBJECTIVE To examine the accuracy of clinical tests for diagnosing subacromial impingement syndrome (SIS). DATA SOURCES A systematic literature search was conducted in January 2011 to identify all studies that examined the diagnostic accuracy of clinical tests for SIS. The following search engines were used: Cochrane Library, EMBASE, Science Direct, and PubMed. STUDY SELECTION Two reviewers screened all articles. We included prospective or retrospective cohort studies that examined individuals with a painful shoulder, reported any clinical test for SIS, and used arthroscopy or open surgery as the reference standard. The search strategy yielded 1338 articles of which 1307 publications were excluded based on title/abstract. Sixteen of the remaining 31 articles were included. The PRISMA (preferred reporting items for systematic reviews and meta-analyses) guidelines were followed to conduct this review. DATA EXTRACTION The number of true positives, false positives, true negatives, and false negatives for each clinical test were extracted from relevant studies, and a 2×2 table was constructed. Studies were combined using a bivariate random-effects model. Heterogeneity was assessed using the variance of logit-transformed sensitivity and specificity. DATA SYNTHESIS Ten studies with 1684 patients are included in the meta-analysis. The Hawkins-Kennedy test, Neers sign, and empty can test are shown to be more useful for ruling out rather than ruling in SIS, with greater pooled sensitivity estimates (range, .69-.78) than specificity (range, .57-.62). A negative Neers sign reduces the probability of SIS from 45% to 14%. The drop arm test and lift-off test have higher pooled specificities (range, .92-.97) than sensitivities (range, .21-.42), indicating that they are more useful for ruling in SIS if the test is positive. CONCLUSIONS This systematic review quantifies the diagnostic accuracy of 5 clinical tests for SIS, in particular the lift-off test. Accurate diagnosis of SIS in clinical practice may serve to improve appropriate treatment and management of individuals with shoulder complaints.

The Impact of Increased Duration of Exercise Therapy on Functional Recovery Following Stroke — What Is the Evidence?

Abstract This article focuses on the impact of increased duration of exercise therapy on functional recovery after stroke. A comprehensive literature search using multiple databases was used to identify all relevant randomized controlled trials. Their quality was reviewed by two independent assessors, and a narrative systematic review and meta-analysis was completed. Methodological quality of all the 20 randomized controlled trials (RCTs) identified had a median of 6 points (range 5–8) on the 10-point PEDro scale. A meta-analysis was completed for studies that had a common outcome measure. For each outcome measure, the estimated effect size (ES) and the summary effect size (SES) were expressed as standardized mean differences (SMD). The results of the meta-analysis demonstrated that increased duration of exercise therapy time has a small but positive effect on activities of daily living as measured by the Barthel Index (SES 0.13; CI 0.01–0.25; Z = 2.15; p = .03) and that these improvements are maintained over a 6-month period (SES 0.15; CI 0.05–0.26; Z = 2.8; p = .00). Pooling reported differences in the various upper and lower extremity outcome measures demonstrated no significant SESs. However, the meta-analysis is supportive of the hypothesis that additional, focused exercise on the lower extremity has a favourable effect on lower extremity impairment and walking speed. The narrative review raises a number of issues that need to be considered in the development of future RCTs.

Addition of motivational interventions to exercise and traditional Physiotherapy: a review and meta-analysis

BACKGROUND Incontestable epidemiological trends indicate that, for the foreseeable future, mortality and morbidity will be dominated by an escalation in chronic lifestyle-related diseases. International guidelines recommend the implementation of evidence-based approaches to bring about health behaviour changes. Motivational interventions to increase adherence and physical activity are not part of traditional physiotherapy for any condition. OBJECTIVE To evaluate the evidence for the effectiveness of adding motivational interventions to traditional physiotherapy to increase physical activity and short- and long-term adherence to exercise prescriptions. DATA SOURCES A literature search of PubMed, EMBASE, Scopus, CINAHL, PsychINFO, AMED and Allied Health Evidence database using keywords and subject headings. STUDY SELECTION Only randomised controlled trials comparing two or more arms, with one arm focused on motivational interventions influencing exercise and one control arm, were included. The search identified 493 titles, of which 14 studies (comprising 1504 participants) were included. DATA EXTRACTION The principal investigator extracted data that were reviewed independently by another author. Methodological quality was assessed independently by two authors using the Cochrane Risk of Bias tool and the PEDro scale. Outcomes were measured at the level of impairment, activity limitation and participation restriction. The standardised mean difference between the control and intervention groups at follow-up time points was used as the mode of analysis. I2≤50% was used as the cut-off point for acceptable heterogeneity, above which a random effects model was applied. RESULTS Exercise attendance was measured in six studies (n=378), and the results indicate that there was no significant difference in exercise attendance between the groups (Random effects model, standardised mean difference 0.33, 95% confidence interval -0.03 to 0.68, I2 62%). Perceived self-efficacy results were pooled from six studies (n=722), and a significant difference was found between the groups in favour of the interventions (Fixed effects model, standardised mean difference 0.71, 95% confidence interval 0.55 to 0.87, I2 41%). The results for levels of activity limitation were pooled (n=550), and a significant difference was found between the groups in favour of the interventions (REM, standardised mean difference -0.37, 95% confidence interval -0.65 to -0.08, I(2) 61%). LIMITATIONS The majority of the included studies were of medium quality, and four studies were of low quality. Data were pooled from a wide variety of different populations and settings, increasing the assortment of study characteristics. CONCLUSIONS Motivational interventions can help adherence to exercise, have a positive effect on long-term exercise behaviour, improve self-efficacy and reduce levels of activity limitation. The optimal theory choice and the most beneficial length and type of intervention have not been defined, although all interventions showed benefits. There is a need to determine how practising physiotherapists currently optimise adherence, and their current levels of knowledge about motivational interventions. IMPLICATIONS OF KEY FINDINGS The results indicate that motivational interventions are successful for increasing healthy physical activity behaviour. Physiotherapists are ideally placed to take on this role, and motivational interventions must become part of physiotherapy practice.

Factors associated with community reintegration in the first year after stroke: a qualitative meta-synthesis.

Abstract Purpose: Although acute stroke care has improved survival, many individuals report dissatisfaction with community reintegration after stroke. The aim of this qualitative meta-synthesis was to examine the barriers and facilitators of community reintegration in the first year after stroke from the perspective of people with stroke. Methods: A systematic literature search was conducted. Papers that used qualitative methods to explore the experiences of individuals with stroke around community reintegration in the first year after stroke were included. Two reviewers independently assessed the methodological quality of papers. Themes, concepts and interpretations were extracted from each study, compared and meta-synthesised. Results: From the 18 included qualitative studies four themes related to community reintegration in the first year after stroke were identified: (i) the primary effects of stroke, (ii) personal factors, (iii) social factors and (iv) relationships with professionals. Conclusions: This review suggests that an individual’s perseverance, adaptability and ability to overcome emotional challenges can facilitate reintegration into the community despite persisting effects of their stroke. Appropriate support from family, friends, the broader community and healthcare professionals is important. Therapeutic activities should relate to meaningful activities and should be tailored to the individual stroke survivor. Implications for Rehabilitation: Stroke survivors feel that rehabilitation in familiar environments and therapeutic activities that reflect real-life could help their community re-integration. In addition to the physical sequelae of stroke, emotional consequences of stroke should be addressed during rehabilitation. Healthcare professionals can provide clear and locally relevant advice to facilitate aspects of community reintegration, including the return to driving and work.

Prognostic value of the ABCD2 clinical prediction rule: a systematic review and meta-analysis

OBJECTIVE The purpose of this systematic review with meta-analysis is to determine the predictive value of the ABCD ²at 7 and 90 days across three strata of risk. Background. The risk of stroke after transient ischaemic attack (TIA) is significant. The ABCD ²clinical prediction rule is designed to predict early risk of stroke after TIA. A number of independent validation studies have been conducted since the rule was derived. METHODS A systematic literature search was conducted to identify studies that validated the ABCD². The derived rule was used as a predictive model and applied to subsequent validation studies. Comparisons were made between observed and predicted number of strokes stratified by risk group: low (0-3 points), moderate (4-5 points) and high (6-7 points). Pooled results are presented as risk ratios (RRs) with 95% confidence intervals (CIs), in terms of over-prediction (RR > 1) or under-prediction (RR < 1) of stroke at 7 and 90 days. RESULTS We include 16 validation studies. Fourteen studies report 7-day stroke risk (n = 6282, 388 strokes). The ABCD² rule correctly predicts occurrence of stroke at 7 days across all three risk strata: low [RR 0.86, 95% CI (0.47-1.58), I² = 16%], moderate [RR 0.99, 95% CI (0.67-1.47), I² = 68%] and high [RR 0.84, 95% CI (0.6-1.19), I² = 46%]. Eleven studies report 90-day stroke risk (n = 6304). There is a non-significant trend towards over-prediction of stroke in all risk categories at 90 days. There are 426 strokes observed in contrast to a predicted 626 strokes. As the trichotomized ABCD² score increases, the risk of stroke increases (P < 0.01). There is no evidence of publication bias in these studies (P > 0.05). CONCLUSION The ABCD² is a useful CPR, particularly in relation to 7-day risk of stroke.

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.

To what extent are family members and friends involved in physiotherapy and the delivery of exercises to people with stroke

Purpose. To examine the views of people with stroke, their ‘family members/friends’ and physiotherapists on the role of the family in physiotherapy and the delivery of exercises following stroke. Methods. A self-report questionnaire was administered to 100 ‘family members/friends’ and 75 people with stroke. Two focus groups were conducted with 10 expert physiotherapists working in the area of stroke rehabilitation. Results. Family members of people with stroke are willing to participate in the delivery of unsupervised exercises in the hospital and the home setting (n = 91). Furthermore, this is also acceptable to people with stroke (n = 65) as an adjunct to routine physiotherapy. Physiotherapists highlighted a number of factors that influenced participation in physiotherapy such as; level of interest and motivation of the family (n = 5), availability (n = 3) and importance of education (n = 2). ‘Family members/friends’ identified reasons that would also limit participation such as work commitments (n = 24), lack of confidence (n = 20) and unsuitable treatment times (n = 13). The expert practitioners outlined a number of areas that family involvement can have an impact, such as treatment carry-over, assisting the family unit to cope on discharge and improving handling skills. Conclusions. Our study identifies an under-utilised role for ‘family members/friends’ in the rehabilitation of people with stroke. Family mediated exercises can maximise the carry-over outside formal physiotherapy giving patients the opportunity for informal practice. This study highlights the need to examine the value of a structured programme of exercises that can be delivered to people with stroke by their ‘family members/friends’.