Early supported discharge by caregiver-mediated exercises and e-health support after stroke - a proof of concept trial

Embargoed by publisher until 31 Dec 2016Background and Purpose—: This proof-of-concept trial investigated the effects of an 8-week program of caregiver-mediated exercises commenced in hospital combined with tele-rehabilitation services on patient self-reported mobility and caregiver burden. Methods—: Sixty-three hospitalized stroke patients (mean age 68.7, 64% female) were randomly allocated to an 8-week caregiver-mediated exercises program with e-health support or usual care. Primary outcome was the Stroke Impact Scale mobility domain. Secondary outcomes included length of stay, other Stroke Impact Scale domains, readmissions, motor impairment, strength, walking ability, balance, mobility, (extended) activities of daily living, psychosocial functioning, self-efficacy, quality of life, and fatigue. Additionally, caregiver’s self-reported fatigue, symptoms of anxiety, self-efficacy, and strain were assessed. Assessments were completed at baseline and at 8 and 12 weeks. Results—: Intention-to-treat analysis showed no between-group difference in Stroke Impact Scale mobility (P=0.6); however, carers reported less fatigue (4.6, confidence interval [CI] 95% 0.3–8.8; P=0.04) and higher self-efficacy (-3.3, CI 95% -5.7 to -0.9; P=0.01) at week 12. Per-protocol analysis, examining those who were discharged home with tele-rehabilitation demonstrated a trend toward improved mobility (-9.8, CI 95% -20.1 to 0.4; P=0.06), significantly improved extended activities of daily living scores at week 8 (-3.6, CI 95% -6.3 to -0.8; P=0.01) and week 12 (3.0, CI 95% -5.8 to -0.3; P=0.03), a 9-day shorter length of stay (P=0.046), and fewer readmissions over 12 months (P<0.05). Conclusions—: Caregiver-mediated exercises supported by tele-rehabilitation show promise to augment intensity of practice, resulting in improved patient-extended activities of daily living, reduced length of stay with fewer readmissions post stroke, and reduced levels of caregiver fatigue with increased feelings of self-efficacy. The current findings justify a larger definite phase III randomized controlled trial

Effects of a physiotherapy and occupational therapy intervention on mobility and activity in care home residents: a cluster randomised controlled trial

Objective To compare the clinical effectiveness of a programme of physiotherapy and occupational therapy with standard care in care home residents who have mobility limitations and are dependent in performing activities of daily living

Visual Field Dependence Is Associated with Reduced Postural Sway, Dizziness and Falls in Older People Attending a Falls Clinic.

Moving visual fields can have strong destabilising effects on balance, particularly when visually perceived motion does not correspond to postural movements. This study investigated relationships between visual field dependence (VFD), as assessed using the roll vection test, and reported dizziness, falls and sway under eyes open, eyes closed and optokinetic conditions. Ninety five falls clinic attendees undertook the roll vection test (i.e. attempted to align a rod to the vertical while exposed to a rotating visual field). Sway was assessed under different visual conditions by centre of pressure movement. Participants also completed questionnaires on space and motion discomfort, fear of falling, depression and anxiety. Thirty four (35.8%) participants exhibited VFD, i.e. had an error > 6.5º in the roll vection test. Compared to participants without VFD, participants with VFD demonstrated less movement of the centre of pressure across all visual conditions, were more likely to report space and motion discomfort and to have suffered more multiple falls in the past year. VFD was independent of fear of falling, anxiety and depression. VFD in a falls clinic population is associated with reduced sway possibly due to a stiffening strategy to maintain stance, dizziness symptoms and an increased risk of falls

Anabolic steroids for rehabilitation after hip fracture in older people

Copyright © 2014 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. This review is made available in accordance with Cochrane Database of Systematic Review's repositories policyBackground Hip fracture occurs predominantly in older people, many of whom are frail and undernourished. After hip fracture surgery and rehabilitation, most patients experience a decline in mobility and function. Anabolic steroids, the synthetic derivatives of the male hormone testosterone, have been used in combination with exercise to improve muscle mass and strength in athletes. They may have similar effects in older people who are recovering from hip fracture. Objectives To examine the effects (primarily in terms of functional outcome and adverse events) of anabolic steroids after surgical treatment of hip fracture in older people. Search methods We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (10 September 2013), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, 2013 Issue 8), MEDLINE (1946 to August Week 4 2013), EMBASE (1974 to 2013 Week 36), trial registers, conference proceedings, and reference lists of relevant articles. The search was run in September 2013. Selection criteria Randomised controlled trials of anabolic steroids given after hip fracture surgery, in inpatient or outpatient settings, to improve physical functioning in older patients with hip fracture. Data collection and analysis Two review authors independently selected trials (based on predefined inclusion criteria), extracted data and assessed each study's risk of bias. A third review author moderated disagreements. Only very limited pooling of data was possible. The primary outcomes were function (for example, independence in mobility and activities of daily living) and adverse events, including mortality

The effects of cognitive-linguistic interventions to treat aphasia in the first 90 days post-stroke: A systematic review

Background: Cognitive-linguistic interventions for aphasia are behavioural-based approaches to therapy that aim to treat language impairment skills post-acquired brain injury. The purpose of cognitive-linguistic intervention is to restore and rehabilitate language impairment skills through targeting phonologic, semantic and syntactic systems, which may support goals to improve everyday communication. Aims: The aim of this systematic review was to investigate the effects of cognitive-linguistic interventions on language processing for aphasia in the first 90 days post-stroke. Secondary aims include the investigation of the effects of these interventions on functional communication and quality of life. Methods: A systematic search was conducted across six databases. Twenty-one studies met the predefined eligibility criteria and were included in the review. Studies were rated for methodological quality and data extracted. A narrative synthesis was completed and conducted for all included studies. Four studies were suitable for meta-analysis. Main Contribution: Evidence for the effects of cognitive-linguistic intervention for aphasia in the first 90 days post-stroke is inconclusive. Intervention approaches included constraint-induced intervention, melodic intonation therapy and study specific cognitive-linguistic intervention. Multiple studies investigated the use of computers as a mode of intervention delivery or to increase the frequency of intervention or session duration. Improvement on language outcomes was associated with positive effects on functional communication, regardless of the specific intervention. There were mixed results for quality-of-life outcomes. Conclusions: Further research is required to guide aphasia intervention the first 90 days post stroke, a time critical period for recovery and rehabilitation. Research reports should include adequate description of participant characteristics and consistent use of intervention protocols and outcome measures. Providing a clear description of theoretical underpinnings and detailed information regarding the components of intervention will also facilitate future research synthesis

Physical activity coaching for adults with mobility limitations: protocol for the ComeBACK pragmatic hybrid effectiveness-implementation type 1 randomised controlled trial

INTRODUCTION: Mobility limitation is common and often results from neurological and musculoskeletal health conditions, ageing and/or physical inactivity. In consultation with consumers, clinicians and policymakers, we have developed two affordable and scalable intervention packages designed to enhance physical activity for adults with self-reported mobility limitations. Both are based on behaviour change theories and involve tailored advice from physiotherapists. METHODS AND ANALYSIS: This pragmatic hybrid effectiveness-implementation type 1 randomised control trial (n=600) will be undertaken among adults with self-reported mobility limitations. It aims to estimate the effects on physical activity of: (1) an enhanced 6-month intervention package (one face-to-face physiotherapy assessment, tailored physical activity plan, physical activity phone coaching from a physiotherapist, informational/motivational resources and activity monitors) compared with a less intensive 6-month intervention package (single session of tailored phone advice from a physiotherapist, tailored physical activity plan, unidirectional text messages, informational/motivational resources); (2) the enhanced intervention package compared with no intervention (6-month waiting list control group); and (3) the less intensive intervention package compared with no intervention (waiting list control group). The primary outcome will be average steps per day, measured with the StepWatch Activity Monitor over a 1-week period, 6 months after randomisation. Secondary outcomes include other physical activity measures, measures of health and functioning, individualised mobility goal attainment, mental well-being, quality of life, rate of falls, health utilisation and intervention evaluation. The hybrid effectiveness-implementation design (type 1) will be used to enable the collection of secondary implementation outcomes at the same time as the primary effectiveness outcome. An economic analysis will estimate the cost-effectiveness and cost-utility of the interventions compared with no intervention and to each other. ETHICS AND DISSEMINATION: Ethical approval has been obtained by Sydney Local Health District, Royal Prince Alfred Zone. Dissemination will be via publications, conferences, newsletters, talks and meetings with health managers. TRIAL REGISTRATION NUMBER: ACTRN12618001983291

Digitally enabled aged care and neurological rehabilitation to enhance outcomes with Activity and MObility UsiNg Technology (AMOUNT) in Australia: A randomised controlled trial

Background: Digitally enabled rehabilitation may lead to better outcomes but has not been tested in large pragmatic trials. We aimed to evaluate a tailored prescription of affordable digital devices in addition to usual care for people with mobility limitations admitted to aged care and neurological rehabilitation. Methods and findings: We conducted a pragmatic, outcome-assessor-blinded, parallel-group randomised trial in 3 Australian hospitals in Sydney and Adelaide recruiting adults 18 to 101 years old with mobility limitations undertaking aged care and neurological inpatient rehabilitation. Both the intervention and control groups received usual multidisciplinary inpatient and post-hospital rehabilitation care as determined by the treating rehabilitation clinicians. In addition to usual care, the intervention group used devices to target mobility and physical activity problems, individually prescribed by a physiotherapist according to an intervention protocol, including virtual reality video games, activity monitors, and handheld computer devices for 6 months in hospital and at home. Co-primary outcomes were mobility (performance-based Short Physical Performance Battery [SPPB]; continuous version; range 0 to 3; higher score indicates better mobility) and upright time as a proxy measure of physical activity (proportion of the day upright measured with activPAL) at 6 months. The dataset was analysed using intention-to-treat principles. The trial was prospectively registered with the Australian New Zealand Clinical Trials Registry (ACTRN12614000936628). Between 22 September 2014 and 10 November 2016, 300 patients (mean age 74 years, SD 14; 50% female; 54% neurological condition causing activity limitation) were randomly assigned to intervention (n = 149) or control (n = 151) using a secure online database (REDCap) to achieve allocation concealment. Six-month assessments were completed by 258 participants (129 intervention, 129 control). Intervention participants received on average 12 (SD 11) supervised inpatient sessions using 4 (SD 1) different devices and 15 (SD 5) physiotherapy contacts supporting device use after hospital discharge. Changes in mobility scores were higher in the intervention group compared to the control group from baseline (SPPB [continuous, 0–3] mean [SD]: intervention group, 1.5 [0.7]; control group, 1.5 [0.8]) to 6 months (SPPB [continuous, 0–3] mean [SD]: intervention group, 2.3 [0.6]; control group, 2.1 [0.8]; mean between-group difference 0.2 points, 95% CI 0.1 to 0.3; p = 0.006). However, there was no evidence of a difference between groups for upright time at 6 months (mean [SD] proportion of the day spent upright at 6 months: intervention group, 18.2 [9.8]; control group, 18.4 [10.2]; mean between-group difference −0.2, 95% CI −2.7 to 2.3; p = 0.87). Scores were higher in the intervention group compared to the control group across most secondary mobility outcomes, but there was no evidence of a difference between groups for most other secondary outcomes including self-reported balance confidence and quality of life. No adverse events were reported in the intervention group. Thirteen participants died while in the trial (intervention group: 9; control group: 4) due to unrelated causes, and there was no evidence of a difference between groups in fall rates (unadjusted incidence rate ratio 1.19, 95% CI 0.78 to 1.83; p = 0.43). Study limitations include 15%–19% loss to follow-up at 6 months on the co-primary outcomes, as anticipated; the number of secondary outcome measures in our trial, which may increase the risk of a type I error; and potential low statistical power to demonstrate significant between-group differences on important secondary patient-reported outcomes. Conclusions: In this study, we observed improved mobility in people with a wide range of health conditions making use of digitally enabled rehabilitation, whereas time spent upright was not impacted. Trial registration: The trial was prospectively registered with the Australian New Zealand Clinical Trials Register; ACTRN1261400093662

Market-dependent production set

A country’s production possibility frontier or PPF is defined as the boundary of its economy’s production set in the net output space for a given technology and fixed quantities of primary factors of production. In general equilibrium theory, exogenous changes in technology or primary-factor supplies alter equilibrium prices; however, government-policy induced domestic relative commodity price changes do not alter the shape of an economy’s production set. We show that, under international capital mobility, which is empirically significant, the shape of a country’s production set does, in fact, depend on market forces and this shape can be manipulated by government policy