Investigating cognitive impairment, biopsychosocial barriers, and predictors of return to daily life among older stroke survivors

PurposeThe aim was to investigate the associations between cognitive impairment and biopsychosocial factors among older stroke survivors and predictors of poststroke return to daily life.Materials and methodsThis cross-sectional study involved 117 stroke survivors (61% men) with an average age of 77 years (range 65–91). The participants completed two questionnaires (Riksstroke and Short Form 36 questionnaires). The Montreal Cognitive Assessment (MoCA) was used to assess cognitive abilities. The International Classification of Functioning, Disability, and Health (ICF) framework guided the selection of biopsychosocial variables. We used Spearman’s correlation coefficient and multiple logistic regression in the analyses.ResultsThe average MoCA score was 21.7 points (range: 4–30, SD 5.6). The need for assistance from relatives and professionals, need for help with dressing and household chores, reliance on others for mobility, and reading and balance problems were correlated with more severe cognitive impairment (r = 0.20–0.33). Cognitive impairment, fatigue, and balance issues predicted an unfavorable return to daily life (odds ratio: 6.2–6.8).ConclusionThe study indicated that cognitive impairment is associated with difficulties in all ICF domains. Cognitive impairment, fatigue, and balance issues are associated with an unsuccessful return to daily life. Prioritizing these factors and screening for cognitive impairment with objective assessment tools may improve rehabilitation outcomes and enhance overall quality of life poststroke

Should weight-bearing activity be reduced during healing of plantar diabetic foot ulcers, even when using appropriate offloading devices?

Physical activity is an essential part of general health and diabetes management. However, recommending weight-bearing physical activity for people with plantar diabetic foot ulcers is controversial, even when gold standard offloading devices are used, as it is commonly thought to delay healing. We aimed to narratively review relevant studies investigating the relationship between plantar diabetic foot ulcer healing and weight-bearing activity, plantar pressure and device adherence. We defined relevant studies as those from two systematic reviews, along with those identified since using a similar updated Pubmed search strategy. We identified six studies. One study found that more daily steps were associated with worse ulcer healing, three found no significant association between steps and ulcer healing, and in two others the association was unclear. Thus, there is weak evidence for an inverse relationship between weight-bearing physical activity and plantar ulcer healing while utilizing offloading devices. We propose a Diabetic foot Offloading and Activity framework to guide future research to find the optimal balance between the positive and negative effects of weight-bearing activity in the context of foot ulcers. We hope such future studies will shed more conclusive light on the impact of weight-bearing activity on healing of plantar diabetic foot ulcers

A model of access combining triage with initial management reduced waiting time for community outpatient services: a stepped wedge cluster randomised controlled trial

BACKGROUND: Long waiting times are associated with public community outpatient health services. This trial aimed to determine if a new model of care based on evidence-based strategies that improved patient flow in two small pilot trials could be used to reduce waiting time across a variety of services. The key principle of the Specific Timely Appointments for Triage (STAT) model is that patients are booked directly into protected assessment appointments and triage is combined with initial management as an alternative to a waiting list and triage system. METHODS: A stepped wedge cluster randomised controlled trial was conducted between October 2015 and March 2017, involving 3116 patients at eight sites across a major Australian metropolitan health network. RESULTS: The intervention reduced waiting time to first appointment by 33.8% (IRR = 0.663, 95% CI 0.516 to 0.852, P = 0.001). Median waiting time decreased from a median of 42 days (IQR 19 to 86) in the control period to a median of 24 days (IQR 13 to 48) in the intervention period. A substantial reduction in variability was also noted. The model did not impact on most secondary outcomes, including time to second appointment, likelihood of discharge by 12 weeks and number of appointments provided, but was associated with a small increase in the rate of missed appointments. CONCLUSIONS: Broad-scale implementation of a model of access and triage that combined triage with initial management and actively managed the relationship between supply and demand achieved substantial reductions in waiting time without adversely impacting on other aspects of care. The reductions in waiting time are likely to have been driven, primarily, by substantial reductions for those patients previously considered low priority. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12615001016527 registration date: 29/09/2015

Risk för fotsår vid diabetes : Är objektiva riskfaktorer associerade med upplevd risk?

Foot ulcers are a common and difficult complication of diabetes, and can end with amputation of the foot. Although some patients fear amputation more than death, adherence to self-care to prevent ulceration is generally low. This raises the question about how people at risk of foot ulcerations perceive risks. The aim the thesis is to explore whether people with and without known risk factors for foot ulcerations (male gender, previous foot ulcer, and previous amputation) experience different levels of probability of developing foot ulcers the coming 12 months. A questionnaire was sent to 1230 patients at two prosthetics and orthotics clinics in Örebro and Gothenburg. 443 responses were included in the analysis. The association between each risk factor and perceived risk of foot ulcer was investigated with a Mann-Whitney test and Chi-square test. Subsequently, all risk factors were included in a multiple logistic regression analysis with perceived foot ulcer risk as the dependent variable. The Mann-Whitney test and Chi-square test showed that people with previous foot ulcers experienced significantly higher risk (p<0.05) than people without previous foot ulcers and people with amputation experienced higher risk than people without amputation. Gender was not significantly associated with perceived foot ulcer risk. In the logistic regression analysis, previous foot ulcer was significantly associated with higher perceived risk of future foot ulcers, while sex and amputation were not significant. Presumably, amputation was not significant in the logistic regression analysis because there was a strong association between previous foot ulcer and amputation. The model explained only 8,3 % of the variance in perceived foot ulcer risk, which indicates that there may be several other factors affecting perceived risk of foot ulcers. The lack of significant association between sex and perceived risk can be interpreted as an optimism bias among men and/or a pessimism bias among women, which would be interesting to investigate further in future research. Future studies should use more precise methods to measure subjective risk, measure the negative value of foot ulcers and investigate interventions to promote a more realistic perception of risk to promote self-care and reduce risk of foot ulcer.

Accuracy and precision of a technique to assess residual limb volume with a measuring-tape

Transtibial stump volume can change dramatically postoperatively and jeopardise prosthetic fitting. Differences between individuals make it hard to give general recommendations of when to fit with a definitive prosthesis. Measuring the stump volume on every patient could solve this, but most methods for volume assessments are too complicated for clinical use. The aim of this study was to evaluate accuracy and intra- and interrater precision of a method to estimate stump volume from circumferential measurements. The method approximates the stump as a number of cut cones and the tip as a sphere segment. Accuracy was evaluated theoretically on six scanned stump models in CAPOD software and manually on six stump models. Precision was evaluated by comparing measurements made by four CPOs on eight stumps. Measuring devices were a wooden rule and a metal circumference rule. The errors were estimated with intraclass correlation coefficient (ICC), where 0,85 was considered acceptable, and a clinical criterion that a volume error of ±5% was acceptable (5% corresponds to one stocking). The method was accurate on all models in theory but accurate on only four models in reality. The ICC was 0,95-1,00 for intrarater precision but only 0,76 for interrater precision. Intra- and interrater precision was unsatisfying when using clinical criteria. Variations between estimated tip heights and circumferences were causing the errors. The method needs to be developed and is not suitable for stumps with narrow ends. Using a longer rule (about 30 cm) with a set square end to assess tip heights is recommended to improve precision. Using a flexible measuring-tape (possible to disinfect) with a spring-loaded handle could improve precision of the circumferential measurements

Risk för fotsår vid diabetes : Är objektiva riskfaktorer associerade med upplevd risk?

Foot ulcers are a common and difficult complication of diabetes, and can end with amputation of the foot. Although some patients fear amputation more than death, adherence to self-care to prevent ulceration is generally low. This raises the question about how people at risk of foot ulcerations perceive risks. The aim the thesis is to explore whether people with and without known risk factors for foot ulcerations (male gender, previous foot ulcer, and previous amputation) experience different levels of probability of developing foot ulcers the coming 12 months. A questionnaire was sent to 1230 patients at two prosthetics and orthotics clinics in Örebro and Gothenburg. 443 responses were included in the analysis. The association between each risk factor and perceived risk of foot ulcer was investigated with a Mann-Whitney test and Chi-square test. Subsequently, all risk factors were included in a multiple logistic regression analysis with perceived foot ulcer risk as the dependent variable. The Mann-Whitney test and Chi-square test showed that people with previous foot ulcers experienced significantly higher risk (p<0.05) than people without previous foot ulcers and people with amputation experienced higher risk than people without amputation. Gender was not significantly associated with perceived foot ulcer risk. In the logistic regression analysis, previous foot ulcer was significantly associated with higher perceived risk of future foot ulcers, while sex and amputation were not significant. Presumably, amputation was not significant in the logistic regression analysis because there was a strong association between previous foot ulcer and amputation. The model explained only 8,3 % of the variance in perceived foot ulcer risk, which indicates that there may be several other factors affecting perceived risk of foot ulcers. The lack of significant association between sex and perceived risk can be interpreted as an optimism bias among men and/or a pessimism bias among women, which would be interesting to investigate further in future research. Future studies should use more precise methods to measure subjective risk, measure the negative value of foot ulcers and investigate interventions to promote a more realistic perception of risk to promote self-care and reduce risk of foot ulcer.

A model to facilitate implementation of the International Classification of Functioning, Disability and Health into prosthetics and orthotics

BACKGROUND: The International Classification of Functioning, Disability and Health is a classification of human functioning and disability and is based on a biopsychosocial model of health. As such, International Classification of Functioning, Disability and Health seems suitable as a basis for constructing models defining the clinical P&O process. The aim was to use International Classification of Functioning, Disability and Health to facilitate development of such a model. Proposed model: A model, the Prosthetic and Orthotic Process (POP) model, is proposed. The Prosthetic and Orthotic Process model is based on the concepts of the International Classification of Functioning, Disability and Health and comprises four steps in a cycle: (1) Assessment, including the medical history and physical examination of the patient. (2) Goals, specified on four levels including those related to participation, activity, body functions and structures and technical requirements of the device. (3) Intervention, in which the appropriate course of action is determined based on the specified goal and evidence-based practice. (4) Evaluation of outcomes, where the outcomes are assessed and compared to the corresponding goals. After the evaluation of goal fulfilment, the first cycle in the process is complete, and a broad evaluation is now made including overriding questions about the patient's satisfaction with the outcomes and the process. This evaluation will determine if the process should be ended or if another cycle in the process should be initiated. CONCLUSION: The Prosthetic and Orthotic Process model can provide a common understanding of the P&O process. Concepts of International Classification of Functioning, Disability and Health have been incorporated into the model to facilitate communication with other rehabilitation professionals and encourage a holistic and patient-centred approach in clinical practice. Clinical relevance The Prosthetic and Orthotic Process model can support the implementation of International Classification of Functioning, Disability and Health in P&O practice, thereby providing a common understanding of the P&O process and a common language to facilitate communication with other rehabilitation professionals

An innovative sealed shoe to off-load and heal diabetic forefoot ulcers – a feasibility study

Background: Non-removable knee-high devices are the gold standard to treat diabetic foot ulcers located on the plantar forefoot, but they immobilize the ankle, which restricts daily life activities and has negative effects on joint functioning. Objective: To investigate the feasibility of sealing a therapeutic shoe to off-load and heal diabetic forefoot ulcers. Design: A case series of seven men with type 2 diabetes and a metatarsal head ulcer were prescribed therapeutic shoes and custom-made insoles. The shoe was sealed with a plastic band. Off-loading was assessed with the F-scan pressure measurement system. Adherence to wearing the shoe was assessed with a temperature sensor and by documenting the status of the seal. Results: The off-loading was effective and all ulcers healed. Median time to healing was 56 days (range 8–160). Complications were secondary ulcer (n = 1) and plantar hematoma (n = 1). Five of seven participants did not disturb the seal. Conclusions: Sealing a therapeutic shoe is a feasible way to off-load and heal forefoot ulcers. A controlled trial is needed to compare the effectiveness and safety of a sealed shoe to other non-removable devices

Knee-high devices are gold in closing the foot ulcer gap : A review of offloading treatments to heal diabetic foot ulcers

Diabetic foot ulcers (DFU) are a leading cause of the global disease burden. Most DFUs are caused, and prolonged, by high plantar tissue stress under the insensate foot of a person with peripheral neuropathy. Multiple different offloading treatments have been used to try to reduce high plantar tissue stress and heal DFUs, including bedrest, casting, offloading devices, footwear, and surgical procedures. The best offloading treatments are those that balance the benefits of maximizing reductions in high plantar tissue stress, whilst reducing the risks of poor satisfaction, high costs and potential adverse events outcomes. This review aimed to summarize the best available evidence on the effects of offloading treatments to heal people with DFUs, plus review their use in clinical practice, the common barriers and solutions to using these treatments, and discuss promising emerging solutions that may improve offloading treatments in future. Findings demonstrate that knee-high offloading devices, non-removable or removable knee-high devices worn for all weight-bearing activities, are the gold standard offloading treatments to heal most patients with DFU, as they are much more effective, and typically safer, quicker, and cheaper to use compared with other offloading treatments. The effectiveness of offloading treatments also seems to increase when increased offloading mechanical features are incorporated within treatments, including customized insoles, rocker-bottom soles, controlled ankle motion, and higher cast walls. However, in clinical practice these gold standard knee-high offloading devices have low rates of prescription by clinicians and low rates of acceptance or adherence by patients. The common barriers resulting in this low use seem to surround historical misperceptions that are mostly dispelled by contemporary evidence. Further, research is now urgently required to close the implementation gap between the high-quality of supporting evidence and the low use of knee-high devices in clinical practice to reduce the high global disease burden of DFU in future.</p