Effectiveness of intensive physiotherapy for gait improvement in stroke: systematic review

Introduction: Stroke is one of the leading causes of functional disability worldwide. Approximately 80% of post-stroke subjects have motor changes. Improvement of gait pattern is one of the main objectives of physiotherapists intervention in these cases. The real challenge in the recovery of gait after stroke is to understand how the remaining neural networks can be modified, to be able to provide response strategies that compensate for the function of the affected structures. There is evidence that intensive training, including physiotherapy, positively influences neuroplasticity, improving mobility, pattern and gait velocity in post-stroke recovery. Objectives: Review and analyze in a systematic way the experimental studies (RCT) that evaluate the effects of Intensive Physiotherapy on gait improvement in poststroke subjects. Methodology: Were only included all RCT performed in humans, without any specific age, that had a clinical diagnosis of stroke at any stage of evolution, with sensorimotor deficits and functional gait changes. The databases used were: Pubmed, PEDro (Physiotherapy Evidence Database) and CENTRAL (Cochrane Center Register of Controlled Trials). Results: After the application of the criteria, there were 4 final studies that were included in the systematic review. 3 of the studies obtained a score of 8 on the PEDro scale and 1 obtained a score of 4. The fact that there is clinical and methodological heterogeneity in the studies evaluated, supports the realization of the current systematic narrative review, without meta-analysis. Discussion: Although the results obtained in the 4 studies are promising, it is important to note that the significant improvements that have been found, should be carefully considered since pilot studies with small samples, such as these, are not designed to test differences between groups, in terms of the effectiveness of the intervention applied. Conclusion: Intensive Physiotherapy seems to be safe and applicable in post-stroke subjects and there are indications that it is effective in improving gait, namely speed, travelled distance and spatiotemporal parameters. However, there is a need to develop more RCTs with larger samples and that evaluate the longterm resultsN/

Design and Development of Biofeedback Stick Technology (BfT) to Improve the Quality of Life of Walking Stick Users

Biomedical engineering has seen a rapid growth in recent times, where the aim to facilitate and equip humans with the latest technology has become widespread globally. From high-tech equipment ranging from CT scanners, MRI equipment, and laser treatments, to the design, creation, and implementation of artificial body parts, the field of biomedical engineering has significantly contributed to mankind. Biomedical engineering has facilitated many of the latest developments surrounding human mobility, with advancement in mobility aids improving human movement for people with compromised mobility either caused by an injury or health condition. A review of the literature indicated that mobility aids, especially walking sticks, and appropriate training for their use, are generally prescribed by allied health professionals (AHP) to walking stick users for rehabilitation and activities of daily living (ADL). However, feedback from AHP is limited to the clinical environment, leaving walking stick users vulnerable to falls and injuries due to incorrect usage. Hence, to mitigate the risk of falls and injuries, and to facilitate a routine appraisal of individual patient’s usage, a simple, portable, robust, and reliable tool was developed which provides the walking stick users with real-time feedback upon incorrect usage during their activities of daily living (ADL). This thesis aimed to design and develop a smart walking stick technology: Biofeedback stick technology (BfT). The design incorporates the approach of patient and public involvement (PPI) in the development of BfT to ensure that BfT was developed as per the requirements of walking stick users and AHP recommendations. The newly developed system was tested quantitatively for; validity, reliability, and reproducibility against gold standard equipment such as the 3D motion capture system, force plates, optical measurement system for orientation, weight bearing, and step count. The system was also tested qualitatively for its usability by conducting semi-informal interviews with AHPs and walking stick users. The results of these studies showed that the newly developed system has good accuracy, reported above 95% with a maximum inaccuracy of 1°. The data reported indicates good reproducibility. The angles, weight, and steps recorded by the system during experiments are within the values published in the literature. From these studies, it was concluded that, BfT has the potential to improve the lives of walking stick users and that, with few additional improvements, appropriate approval from relevant regulatory bodies, and robust clinical testing, the technology has a huge potential to carve its way to a commercial market

Firing properties of muscle spindles supplying the intrinsic muscles of the foot in unloaded and free-standing humans

Human posture and locomotion are dependent on the sensory apparatus – involving muscle spindles, cutaneous afferents and the vestibular system – that provides proprioception. In my previous work with my Bachelor of Medical Research, I investigated the relationship between galvanic vestibular stimulation and the sensitivity of muscle spindles of the long muscles of the leg. While that study showed no correlation between these systems it was limited by the lack of subject postural threat. In order to record from muscle spindles directly during unsupported free-standing, a new methodology for microneurographic recording from the posterior tibial nerve at the ankle was developed. For the first time, we have been able to identify the firing properties of muscle spindle endings in the small (intrinsic) muscles of the foot, as well as mechanoreceptors in the skin of the sole, while the participant is standing unsupported. This thesis presents this methodology along with the recordings made. In Study 1, the firing properties of 26 muscle spindles supplying the intrinsic muscles of the foot are described in unloaded conditions. Their responsiveness to stretch and related joint movements is shown to be similar to those in the short muscles in the hand and the long leg muscles. Only 27% were spontaneously active, of which there was no consistent resting firing rate or discharge variability. In Study 2, activity from 12 muscle spindles supplying the intrinsic foot muscles in unsupported free-standing conditions is described. In this group 50% were spontaneously firing and 67% had activity correlated with changes of centre of pressure recorded by a force plate, primarily (88%) along the anteroposterior axis. In Study 3, the activity of 28 multiunit cutaneous afferent recordings, as well as of 15 single-unit cutaneous afferents, supplying the sole of the foot in unsupported free standing is described. Activity of cutaneous afferents was found to be dependent on receptor type and location of receptive field. The data presented in this report is proof of this novel methodology’s suitability for detailed study into the sensory sources in the foot contributing to maintaining the upright posture

Somatosensory stimulation to improve lower-limb recovery after stroke

Introduction Increasing lower-limb sensation could improve walking post-stroke but evidence for this is limited. This thesis reports: 1) Review of published literature on somatosensory stimulation of the foot to enhance lower-limb function post-stroke. 2) Development of standardised intervention protocols for testing in a feasibility trial. 3) Feasibility trial of somatosensory stimulation interventions combined with functional activity. Methods 1) Systematic review with narrative synthesis of somatosensory stimulation to the foot to improve balance and gait post-stroke. 2) Modified Nominal Group Technique with experienced therapists, informed by literature, to develop and seek consensus on three standardised therapy protocols. a) lower-limb mobilization and tactile stimulation (MTS) b) textured insole wearing (TI) c) task-specific gait training (TSGT) 3) Mixed-methods, single-blind feasibility study explored: recruitment, participant characteristics, attrition, intervention and outcome measures acceptability (responses, feasibility, costs), sample size requirements, and participants’ experiences. Adults 42–112 days post-stroke were randomized to either TIs+TSGT or MTS+TSGT. Lower-limb sensorimotor and functional outcomes were measured pre-randomization, post-intervention, and one-month later. Participants’ experiences and acceptability of interventions and outcomes were explored in focus groups, with qualitative data analysed thematically. Quantitative feasibility outcomes were analysed using descriptive statistics, and within-group changes calculated. Results 1) Seventeen trials included in the review confirmed that evidence for somatosensory stimulation to improve lower-limb function post-stroke is limited. 2) Validated trial intervention protocols for MTS, TIs and TSGT were developed, with consensus. 3) Thirty-four stroke survivors were recruited and completed the trial, with acceptable recruitment (48.57%) and attrition (5.88%) rates. Feasibility of outcomes, costs, delivery and acceptability of interventions and outcome measures were confirmed. Potential response to treatment was noted. Conclusion Somatosensory stimulation of the foot post-stroke warrants investigation. Feasibility of a larger trial of somatosensory stimulation interventions was confirmed. Participant characteristics, response over time, and variance of outcome measures will inform a future larger trial

Pain : psychological measurement and treatment

This research was executed as three separate studies. Study 1 focused on the perception of pain and the semantic aspects of pain. Study 2 focused on the measurement of acute pain and mood states. Study 3 focused on the psychological treatment of cancer pain. In Study 1 a group of 66 Setswana-speaking adults were required to describe what they saw, what happened, and what would be the outcome with respect to three visually presented pain scenes using The Pain Apperception Test (PAT) A qualitative analysis of their responses shows that pain is experienced as an all encompassing experience affecting all aspects of their lives, such as the physical, emotional, social, and economic. This was found to be true, irrespective of gender and age with the exception of economic issues. A qualitative analysis of their responses to the Pain Eliciting Incidents Questionnaire (PEIQ) reveals that the Setswana pain descriptors are classifiable according to the three dimensions of pain namely, the sensory-discriminative, affective-motivational, and cognitive-evaluative. Sludy 2 applied the Profile of Mood States (POMS) preoperatively to a group of 58 female laparotomy (gynaecological) patients. These patients were also tested post-operatively with the Visual Analogue Scale (VAS) and the Wisconsin Brief Pain Questionnaire (WBPQ) as pain measures. The pain measures were taken at no medication and at the peak of medication. Factor analysis could not confirm the validity of the six POMS scales. These scales also did not show correlations with post-operative pain. Correlations between the pain measures showed acceptable reliability and validity of the VAS and the WBPQ. In Study 3 three groups of 15 cancer patients each, suffering from chronic pain, were treated over a period of two weeks with either cognitive behavioural therapy plus medication, reassurance therapy plus medication, or medication only. Comparison of before and after treatment pain measures showed that both cognitive behavioural therapy and reassurance therapy had a beneficial effect. Follow-up results three months later showed that the beneficial effect of reassurance therapy did not persist. Patients treated with cognitive behavioral therapy still showed the beneficial effects thereof.PsychologyD. Litt. et Phil. (Psychology

Exploring Racial Disparity in St. Louis City Fetal-Infant Death

The perinatal periods of risk (PPOR) methodology was used to analyze resident fetal and infant deaths in St. Louis City, Missouri, for the years 1999 - 2008. The PPOR approach is mapped into four periods: Maternal Health/Prematurity (MHP), Maternal Care (MC), Newborn Care (NC), and Infant Health (IF). Both Blacks and Whites experienced excess fetal-infant death within the MHP periods. Recognizing specific periods of increased risk provides key information to transform data into action. Findings allow childbirth educators, community members, and policy-makers to further explore barriers limiting maternal care

The Role of Ultrasound in the Lebanese Outreach Setting

A cross-sectional study was carried out on 669 patients to assess the role of introducing ultrasound into obstetrical outreach in Lebanon. Data were collected, and descriptive statistics were performed. Sonographic findings were compared using Chi-square tests between underserved Lebanese and Syrian refugee mothers. Ultrasound plays a significant role in properly dating pregnancies in addition to identifying at-risk fetuses and detecting placental abnormalities. Medical providers need to make sonographic evaluation in the Lebanese outreach obstetrical setting more available and more systematic in order to secure a safe outcome for underserved Lebanese and Syrian refugee mothers and offspring

Natural Labor Pain Management

There is a current trend toward natural pain management in labor, and pregnant women will seek the guidance of childbirth educators to make qualified decisions. The childbirth educator bases practice on the most current evidence; however, natural pain management in labor is not well studied. This paper offers information and current evidence as well as a story that illustrates the use of many natural or complementary and alternative medical therapies used in pain management during labor

A Review of Fatherhood Related Issues in the Country of Lebanon

Fatherhood issues in the country of Lebanon remain largely unexplored and undocumented. This review serves as a basis for fatherhood issues and presents a snapshot of the current situation with a background of some of the most related challenges affecting the issue of parenting in Lebanon. In addition, this review lays the background of how these challenges affect women of childbearing age who often end up raising their families on their own. Cultural and religious beliefs as well as factors relating to political influences in the Middle East region are discussed. The author concludes with a set of lessons learned