A home physiotherapy service for stroke patients in Malta: constraints and recommendations. The process of setting up a home physiotherapy service for hospitalised stroke patients within the public health system in Malta - new knowledge contributing to a strategy document.

Home physiotherapy is a valid service option for the patient who was recently discharged from hospital after sustaining a stroke, as it enhances functional independence in friendly and familiar surroundings, as opposed to an outpatient clinic (Bader 2008). The aim of this study was to investigate the system responses to the planning and implementation of a home physiotherapy service as an innovation within the Maltese Public Health Service, uncovering barriers or constraints that influenced the introduction and development of state-run home physiotherapy in Malta. Method A qualitative approach was used for this research. A case study design was selected because it possessed contextual, descriptive and heuristic characteristics. Study participants planned and implemented the service using the available resources. Policy makers, physiotherapists, stroke patients and caregivers contributed to the study through their responses to, and experiences of, this service innovation. It was both an exploration and an opportunity to learn about service innovation from a Maltese perspective. A group of stakeholders were interviewed during the planning stage (Phase 1) of the home physiotherapy service. The main purpose of these interviews was to inform the design of the service. Another group of participants was interviewed in the active service stage (Phase 2) - at the beginning and at the end. The purpose here was to gather data from their direct experiences with home physiotherapy. Documents relevant to home rehabilitation were accessed and analysed hermeneutically. These included newspaper media, as it was considered a sensitive instrument to understand social context (Catalán Matamoros 2007; Davis 1990). Findings and discussion Data analysis identified categories of findings such as ¿barriers to the implementation of a new service¿, ¿attitudes to home physiotherapy¿ and ¿fragmented rehabilitation service¿. The category components were discussed and linked to the hermeneutical analysis of documents, offering a deeper understanding of the categories within the local context, and revealing a reinforcement of establishment-based health care. Conclusion The findings of this study provided an insight into the constraints that would appear if home physiotherapy, indeed home rehabilitation, were introduced by the Maltese Public Health Service. This research had an impact on the state physiotherapy services. Recommendations to help mitigate the constraints in an overarching manner were offered at the end of the thesis. To the international reader with experience in organised home physiotherapy, this study gives a glimpse into how issues that would seem trivial and obvious at first glance become significant challenges¿.challenges that the uninitiated would need to overcome

Person-centred care in rehabilitation : shall we explore?

The concept of person-centred care has developed over time due to significant changes in the interactions between patients and physicians in healthcare systems. Over the years, diverse healthcare professions involved in the care of patients have also evolved. It is useful to consider the global changes within patient care across time, that now includes social and cultural contexts.peer-reviewe

Health status of COPD patients undergoing pulmonary rehabilitation : a comparative responsiveness of the CAT and SGRQ

The authors would like to thank all the participants who participated in this study and the CEO of the state general hospital for his support.The St. George’s Respiratory Questionnaire (SGRQ) and chronic obstructive pulmonary disease (COPD) assessment test (CAT) are the measures used to assess health status. This study aims to examine the responsiveness of these tools by severity of dyspnoea category in patients with COPD. Forty-nine COPD patients who underwent a 12-week pulmonary rehabilitation (PR) programme were assessed at baseline, 12 weeks and at 28-week follow-up. Patients were categorized into two groups by severity of dyspnoea category (i.e. mild to moderate (modified Medical Research Council (mMRC) 1–2) and severe to very severe (mMRC 3–4)) using the mMRC dyspnoea scale. Effect size (ES) was computed as estimates of responsiveness. The SGRQ demonstrated greater responsiveness by total sample (SGRQ, ES = 0.87; CAT, ES = 0.75) and for the mMRC 3–4 category (SGRQ, ES = 0.91; CAT, ES = 0.76) on completion of PR. At 28-week follow-up, overall comparable responsiveness of the CAT and SGRQ was identified by total sample (SGRQ, ES = 0.75; CAT, ES = 0.74) and by severity of dyspnoea category. The symptom, impact and activity domains of the SGRQ showed good responsiveness, with greater ESs obtained overall for the mMRC 3–4 category. On completion of PR, the SGRQ demonstrates a greater responsiveness with COPD patients, especially in relation to the mMRC 3–4 category, while both the CAT and SGRQ show comparable responsiveness on follow-up.peer-reviewe

Nicotine dependence and the International Association for the Study of Pain neuropathic pain grade in patients with chronic low back pain and radicular pain : is there an association?

Background: This study investigated whether current smoking and a higher nicotine dependency were associated with chronic low back pain (LBP), lumbar related leg pain (sciatica) and/or radicular neuropathic pain.Methods: A cross-sectional study was conducted on 150 patients (mean age, 60.1 ± 13.1 yr). Demographic data, the International Association for the Study of Pain (IASP) neuropathic pain grade, STarT Back tool, and the Fagerström test were com- pleted. A control group (n = 50) was recruited.Results: There was a significant difference between current smokers and non- smokers in the chronic LBP group in the mean pain score (P = 0.025), total STarT Back score (P = 0.015), worst pain location (P = 0.020), most distal pain radiation (P = 0.042), and in the IASP neuropathic pain grade (P = 0.026). There was a significant difference in the mean Fagerström score between the four IASP neuropathic pain grades (P = 0.005). Current smoking yielded an odds ratio (OR) of 3.071 (P = 0.011) for developing chronic LBP and sciatica, and an OR of 4.028 (P = 0.002) for obtaining an IASP “definite/probable” neuropathic pain grade, for both cohorts. The likelihood for chronic LBP and sciatica increased by 40.9% (P = 0.007), while the likelihood for an IASP neuropathic grade of “definite/probable” increased by 50.8% (P = 0.002), for both cohorts, for every one unit increase in the Fagerström score.Conclusions: A current smoking status and higher nicotine dependence increase the odds for chronic LBP, sciatica and radicular neuropathic pain.peer-reviewe

Is chronic low back pain and radicular neuropathic pain associated with smoking and a higher nicotine dependence? A cross-sectional study using the DN4 and the Fagerström test for nicotine dependence

Objectives: To evaluate, if a current smoking status and a higher nicotine dependence were associated with chronic low back pain (LBP) and/or radicular neuropathic leg pain. Methods: The study was designed as a cross-sectional study on the first eligible consecutive 120 patients. Demographic data, pain intensity, worst pain location, most distal pain radiation, the DN4 questionnaire, STarT back tool, and the Fagerström test were collected during the initial examination. An age- and gender-matched control group (n=50), free from chronic LBP was recruited. Results: In the chronic pain group, there was a significant difference between smokers and lifetime non-smokers in the average pain intensity score (p=0.037), total DN4 score (p=0.002), STarT Back tool (p=0.006), worst pain location (p=0.023), and the most distal pain radiation (p=0.049). The mean total DN4 score increased with a corresponding increase in the number of cigarettes smoked daily (p=0.002). Current smokers had an OR of 3.071 (p=0.013) (95% CI 1.268–7.438) for developing chronic LBP and lumbar related leg pain and an OR of 6.484 (p<0.001) (95% CI 2.323–18.099) for developing chronic radicular neuropathic leg pain. For every one-unit increase in the Fagerström test score, the likelihood for chronic LBP and lumbar related leg pain increased by 40.71% (p=0.008) (95% CI 1.095–1.809) and for chronic radicular neuropathic leg pain increased by 71.3% (p<0.001) (95% CI 1.292–2.272). Conclusion: A current smoking status and a nicotine dependence were both independently associated with an increased risk for chronic LBP and/or chronic radicular neuropathic leg pain.peer-reviewe

Assessment tools for the admission of older adults to inpatient rehabilitation : a scoping review

(1) Objective: To identify the assessment tools and outcome measures used to assess older adults for inpatient rehabilitation. (2) Design: Scoping review. (3) Data sources: ProQuest, PEDro, PubMed, CINAHL Plus with full text (EBSCO), Cochrane Library and reference lists from included studies. (4) Review method: The inclusion of studies covering patients aged >60, focusing on rehabilitation assessments delivered in hospitals in community settings. Studies reporting on rehabilitation specifically designed for older adults—testing for at least one domain that affects rehabilitation or assessments for admission to inpatient rehabilitation—were also included. Results were described both quantitatively and narratively. (5) Results: 1404 articles were identified through selected databases and registers, and these articles underwent a filtering process intended to identify and remove any duplicates. This process reduced the number to 1186 articles. These, in turn, were screened for inclusion criteria, as a result of which 37 articles were included in the final review. The majority of assessments for geriatric rehabilitation were carried out by a multidisciplinary team. Multiple studies considered more than one domain during assessment, with a high percentage evaluating a specific outcome measure used in geriatric rehabilitation. The most common domains assessed were function, cognition and medical status—with communication, vision and pain being the least common. A total of 172 outcome measures were identified in this review, with MMSE, BI, FIM and CCI being the most frequent. (6) Conclusions: This review highlights the lack of standardised approaches in existing assessment processes. Generally, older-adult-rehabilitation assessments struggle to capture rehabilitation potential in a holistic manner. Hence, a predictive model of rehabilitation for assessing patients at the initial stages would be useful in planning a patient-specific programme aimed at maximising functional independence and, thus, quality of life.peer-reviewe

Systemic inflammation in COPD is not influenced by pulmonary rehabilitation

Purpose: Pulmonary rehabilitation is known to lead to improvements in exercise tolerance, health-related quality of life and help reduce symptoms. Exercise, one of the largest components of such an intervention, although of great benefit, can increase the inflammatory response related to chronic obstructive pulmonary disease, depending on intensity and duration. Through this study, the effects of a 12week, high-intensity PR programme on COPD inflammatory-related markers were investigated. Materials and methods: This study is a longitudinal, observational type of study. Sixty COPD patients were enrolled, 49 of which completed the programme. A 2-h high-intensity PR programme was delivered, twice weekly for 12 weeks. The following markers were assessed at baseline, 4, 8 and 12 weeks through rehabilitation – C-reactive protein, erythrocyte sedimentation rate, neutrophil, eosinophil counts, complete blood count, six-minute walk test and St. George’s Respiratory Questionnaire. Serum amyloid A levels were assessed at baseline, week 8 and 12 and exhaled NO at baseline and upon completion of the programme. Results: This 12-week PR programme resulted in no changes in the inflammatory markers but resulted in significant improvements in both the 6MW distance and health quality of life. Conclusions: Beneficial effects on functional and HRQoL measures resulted, which, however, appear unrelated to changes in the systemic inflammatory markers.peer-reviewe

Pulmonary rehabilitation in chronic obstructive pulmonary disease : outcomes in a 12 week programme

Objective. The optimal time-frame for pulmonary rehabilitation (PR) in patients diagnosed with chronic obstructive pulmonary disease (COPD) is still debated. A 12 week programme was designed looking at whether the benefits were reached at or before a 12 week period of PR for COPD patients. Method. Seventy-five patients (59 males, 16 females) aged 40 75 years were referred from the local general hospital in Malta. Baseline assessments were carried out on all patients 2 weeks before initiation of the programme. Sixty patients were eligible to start a twice-weekly, 12 week multidisciplinary programme delivered after the screening process. The Six-Minute Walk Test (6MWT), dyspnoea score using the Borg scale, spirometry testing, plethysmography, COPD Assessment Tool (CAT) score, St George's Respiratory Questionnaire (SGRQ) and Hospital and Anxiety scale score were monitored at 4 weekly intervals throughout the 12 weeks of PR for these COPD patients. Results. The 6MWT distance increased by a mean total of 132.45 m (p < 0.001) by 12 weeks, with the highest change recorded in the first 4 weeks for the milder COPD patients. Lung function test improvements were marginal. Borg scale readings at rest and following exertion decreased significantly from weeks 0 to 4 but remained fairly constant thereafter. The Body mass index, airway Obstruction, Dyspnoea, and Exercise capacity (BODE) index, SGRQ and CAT score values decreased significantly throughout the weeks irrespective of the initial Medical Research Council score. Anxiety scoring decreased significantly by 12 weeks, while the depression rating improved by 8 weeks. Conclusion. These findings show that 12 weeks of PR in this cohort of COPD patients resulted in clinically significant changes in functional outcome measures which are supported by statistically significant changes in health-related quality of life measures. In milder COPD cases, by 4 weeks of PR gains in exercise tolerance had already resulted. The more severe group required more time to obtain improvements. Therefore, hospitals could organize shorter PR programmes for larger numbers of patients with milder COPD.peer-reviewe

Serum amyloid A in chronic obstructive pulmonary disease

Introduction: Serum Amyloid A types 1 and 2 (SAA1, SAA2) are acute phase proteins elevated in inflammatory conditions. They are biomarkers of disease activity and participants in pathogenesis. Production is primarily hepatic, while pulmonary expression has also been reported in COPD. This project aimed to (i) study the cytokine-induced SAA transcriptional regulation in human airway related cells (ii) investigate temporal changes in serum SAA levels in stable COPD patients undergoing a 12-week pulmonary rehabilitation (PR) programme.peer-reviewe