Archives of physical medicine and rehabilitation最新文献

Objective: Repetitive transcranial magnetic stimulation (rTMS) is a promising approach in improving swallowing function after stroke. However, comparative efficacy of different rTMS protocols for poststroke dysphagia (PSD) remains unclear.

Data sources: PubMed, Embase, and Cochrane database were systematically searched for eligible random controlled trials (RCTs) from inception to August 30, 2024.

Study selection: RCTs comparing rTMS with control or head-to-head comparisons of 2 rTMS protocols in patients with PSD.

Data extraction: Data were extracted by 2 independent reviewers. A network meta-analysis combining direct and indirect evidence was conducted to assess the pooled findings of RCTs with standard mean difference (SMD) with 95% credible interval (CrI).

Data synthesis: Eighteen RCTs involving 760 participants (mean age of 62.4 [range 49.7-74.7] years; 45.7% women) were included. Pooled data showed that high frequency (HF)/ipsilesional hemisphere (ipsi-hemi) (SMD, -0.94; 95% CrI, -1.51 to -0.44), HF/bilateral hemisphere (bi-hemi) (SMD, -2.59; 95% CrI, -3.50 to -1.72), HF/ipsilesional cerebellar (ipsi-CRB) (SMD, -0.79; 95% CrI, -1.55 to -0.10), HF/bilateral cerebellar (bi-CRB) (SMD, -1.02; 95% CrI, -1.83 to -0.29), and HF/ipsi-hemi + low frequency (LF)/contralesional hemisphere (contra-hemi) (SMD, -2.72; 95% CrI, -4.12 to -1.41) rTMS all significantly improved swallowing function compared with control. For patients with acute stroke, HF/ipsi-hemi rTMS had a positive effect (SMD, -1.36; 95% CrI, -2.86 to -0.02); in subacute stage, HF/ipsi-hemi + LF/contra-hemi rTMS showed the best efficacy (SMD, -2.68; 95% CrI, -4.26 to -1.26). However, rTMS failed to improve swallowing function in chronic stage.

Conclusions: This network meta-analysis showed that most of the rTMS protocols (HF/ipsi-hemi, HF/bi-hemi, HF/ipsi-CRB, HF/bi-CRB, and HF/ipsi-hemi + LF/contra-hemi) may improve swallowing function in patients with PSD. The HF/ipsi-hemi rTMS had a positive effect in acute stage and the HF/ipsi-hemi + LF/contra-hemi protocol seemed to have the best efficacy when applied in subacute stroke.

Objective: To identify risk factors for dysphagia in individuals who sustained traumatic cervical SCI. The pathophysiologic mechanisms of dysphagia in individuals with traumatic cervical spinal cord injury (SCI) are not well understood yet. Several risk factors for developing dysphagia after SCI were postulated including mechanical ventilation, tracheostomy, age, female sex, anterior surgical approach, SCI severity, and multilevel spinal fusion.

Design: Retrospective analysis: Candidate explanatory variables, including injury severity, age, neurological level of injury, surgical approach, number of fused spinal segments, and tracheostomy including its type, were analyzed using univariate and multivariable statistical analyses.

Setting: We included patients, who were treated at the BG Trauma Center Murnau between 2013 and 2022.

Participants: Datasets of a total of 407 patients with traumatic cervical SCI were included.

Main outcome measures: Dysphagia prevalence and identification of associated risk factors.

Results: Our analysis included 407 individuals, of whom 22.6% had dysphagia. Tracheostomy and age were identified as the main risk factors for dysphagia after traumatic cervical SCI. Contrary to previous literature, injury severity, an anterior surgical approach, the type of tracheostomy, a higher neurological level of SCI, and multilevel spinal fusion did not show an increased risk after accounting for other factors.

Conclusions: Our study identifies age and tracheostomy as primary risk factors for dysphagia after SCI, allowing to identify patients at risk and inform early-stage clinical management.

Objective: To assess the available evidence of noninvasive or minimally invasive neuromodulation therapies in improving urodynamic outcomes, voiding diaries, and quality of life in patients with neurogenic lower urinary tract dysfunction (NLUTD) after spinal cord injury (SCI).

Data sources: A comprehensive search of 10 databases from inception until August 30, 2023, was conducted.

Study selection: Randomized controlled trials (RCTs) assessing the effects of conventional treatment (CT) and CT combined with sham stimulation, transcranial magnetic stimulation (TMS), sacral nerve magnetic stimulation (SNMS), TMS+SNMS, sacral pulsed electromagnetic field therapy (SPEMFT), sacral transcutaneous electrical nerve stimulation (STENS), sacral dermatomal transcutaneous electrical nerve stimulation, bladder & STENS, transcutaneous tibial nerve stimulation (TTNS), transcutaneous electrical acupoint stimulation, pelvic floor electrical stimulation, or pelvic floor biofeedback therapy on postvoid residual volume (PVR), maximum cystometric capacity (MCC), number of voids per 24 hours (V24), mean urine volume per micturition, (MUV), maximum urinary flow rate (Qmax), maximum detrusor pressure (MDP), maximum voiding volume, number of leakages per 24 hours (L24), lower urinary tract symptoms score, and SCI-quality of life (SCI-QoL) score in patients with NLUTD after SCI were included.

Data extraction: Two researchers independently extracted data on study characteristics and outcomes following the Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines. The Cochrane risk of bias tool (2.0) was used to assess the quality of RCTs.

Data synthesis: Fifty-two RCTs with 2884 participants were included. CT+TMS was able to remarkably decrease PVR (mean difference [MD], -132.14; 95% confidence interval [CI], -230.97 to -33.31) and increase MUV (MD, 147.79; 95% CI, 64.51-231.06). CT+SNMS ranked high in improving V24 (MD, 2.76; 95% CI, 1.26-4.25) and reducing L24 (MD, -2.73; 95% CI, -4.46 to -1.01); CT+TMS+SNMS maximized the reduction of SCI-QoL scores (MD, -1.52; 95% CI, -2.97 to -0.25) and ranked second in both reducing PVR and improving MCC; CT+SPEMFT had a significant advantage in improving MCC (MD, 83.31; 95% CI, 39.73-126.88) and increasing Qmax (MD, 5.91; 95% CI, 2.99-8.84). Improvement in MDP was highly ranked by CT+TTNS (MD, 9.46; 95% CI, 2.15-16.76).

Conclusions: CT combined with magnetic stimulation therapy provided more benefits than its combination with electrical stimulation. TMS+SNMS seemed to be a promising noninvasive neuromodulation technique in managing NLUTD after SCI. High-quality RCTs should be conducted in the future to validate these findings.

Objective(s): To investigate the relationship between impaired gliding in the anterior knee region and anterior knee pain (AKP) in patients after total knee arthroplasty (TKA).

Design: Cross-sectional study.

Setting: Orthopedic hospital.

Participants: Patients aged >60 years who underwent TKA between June and September 2023 without abnormal components or postoperative infections.

Interventions: Not applicable.

Main outcome measures: Ultrasonography visualized the anterior knee soft tissues (subcutaneous tissue [SC], patellar tendon [PT], and infra-patellar fat pad [IFP]) during maximal voluntary isometric knee extension. Particle image velocimetry analyzed the SC, PT, and IFP flow velocities, organized into time-series data. Correlation coefficients of flow velocity between the SC and PT and between the PT and IFP were calculated to define the gliding coefficient. We measured AKP during walking and stair ascent and descent. Furthermore, we investigated the correlations between gliding coefficients and AKP and identified factors contributing to AKP using multiple regression analysis. The relationship between gliding coefficients and patient-reported outcomes was explored.

Results: In total, 20 patients (mean age, 72.9years; postoperative period, 14.9weeks) were included. A significant positive correlation was observed between the SC-PT gliding coefficients and AKP. Multiple regression analysis identified the SC-PT gliding coefficient as a significant independent variable associated with AKP during stair descent. Additionally, the SC-PT gliding coefficients were found to have a significant negative correlation with patient-reported outcomes.

Conclusions: The impaired gliding between the SC and PT may contribute to AKP, specifically during stair descent. This finding suggests that soft tissue gliding plays a significant role in postoperative pain and activity limitations in patients who underwent TKA.

Objective(s): To examine whether a nationally representative population of older adults with communication disabilities (CDs) has a higher risk of mortality than older adults without these disabilities, independent of sociodemographic, health, and other disability characteristics.

Design: Retrospective, cohort study. We conducted a survival analysis using multivariable Cox proportional hazards regression, adjusting for sociodemographic, health, and other disability characteristics.

Setting: Annual data from the National Health and Aging Trends Study (Rounds 2011-2020).

Participants: A nationally representative sample of Medicare beneficiaries aged ≥65 years with and without any receptive or expressive communication difficulties.

Interventions: Not applicable.

Main outcome measures: Hazard ratios demonstrated the independent mortality risk by CD, over a 10-year period.

Results: The presence of CD was associated with an increased hazard of dying (hazard ratio, 2.79; 95% CI, 2.51-3.10). After adjustment, older adults with CD had a 1.46 times higher risk of death than those without CD (95% CI, 1.31-1.62).

Conclusions: Having a CD in older age increases mortality risk, independent of health, sociodemographic, and other disability characteristics. These findings warrant consideration of communication-specific mechanisms contributing to disparate mortality outcomes in older adulthood.

Objective: We aim to describe health care, vocational, and educational transitions in young adults with pediatric-onset disabilities and to examine the associations with social determinants of health and depressive symptoms.

Design: This cross-sectional study used multinomial and binary logistic regression to examine the associations of sociodemographic factors and depressive symptoms with health care, educational, and vocational transitions.

Setting: Participants were recruited from outpatient specialty clinics in a rehabilitation medicine department at a quaternary academic children's hospital.

Participants: Transition age adults with acquired brain injury (17), spina bifida (10), and neuromuscular disorders (28) participated in this study.

Interventions: Not applicable.

Main outcome measures: Participants provided information about their current health care utilization and educational/vocational status.

Results: Twenty-five percent of participants were unsure of their primary resource for preventative health care; this uncertainty was associated with White race/Hispanic ethnicity (P=.004) and public insurance (P=.02). When asked about their primary health care resource if they are sick or have an immediate health-related question, 18% identified the emergency department; this was significantly related to greater neighborhood disadvantage (P=.009). Considering current educational and vocational status, having a job while also going to school was associated with more self-reported depressive symptoms (P=.009) and younger age (P=.02).

Conclusions: Outcomes during the transition to adulthood are related to multiple factors, including race and ethnicity, public insurance, neighborhood disadvantage, and depressive symptoms. Targeted interventions to support health care, vocational, and educational transitions in the context of social determinants of health and mental health status are needed.

Objective: To measure the effect of a community-based peer-led eHealth manual wheelchair (MWC) skills training program on community participation, wheelchair skills capacity and performance, wheelchair-specific self-efficacy, and health-related quality of life.

Design: Randomized control trial with wait-list control group.

Setting: Community.

Participants: Community-dwelling MWC users aged 18 years or older who propel using both arms (N=50).

Interventions: The 4-week MWC skills training intervention was comprised of 3 virtual sessions with a peer trainer and a self-directed eHealth home training application delivered via a computer tablet. Peer trainers were experienced MWC users who had received structured training for intervention delivery. Participants were provided with required equipment and encouraged to involve a care provider during home training. Peer trainers tailored the program to life activities participants identified as relevant. The control group were placed on a 4-week no intervention wait-list (reflecting typical clinical practice) and after postintervention data collection were offered the training program.

Main outcome measures: The primary outcome was community participation measured by the Wheelchair Outcome Measure. Secondary outcomes included skill capacity and performance on the Wheelchair Skills Test-Questionnaire, self-efficacy on the Wheelchair Use Confidence Scale, and health-related quality of life on the Short-Form 36 Health Survey Enabled.

Results: The intention-to-treat (n=50) primary analysis revealed a statistically significant Time*Allocation interaction for community participation (mean P=.046 and η_p²=0.09), increasing by 24%. Per protocol (n=42) secondary analyses indicated significant improvements of 16.1% in the skill capacity (P=.004), 11.4% in self-efficacy (P=.017), and 7% relative improvement in quality of life (P=.012).

Conclusions: The findings indicate that an eHealth MWC training program incorporating peer and tablet application training components was effective in improving community participation, skill capacity, self-efficacy, and quality of life for a wide range of MWC users. An eHealth delivery format offers considerable potential from both an access and resource perspective.

Objective: To examine the correlations between individual characteristics among clients with stroke within public vocational rehabilitation (VR) and the employment outcome, as well as the utilization of VR services and their employment outcomes after VR services.

Design: Observational cohort study.

Setting: Nationwide VR data from the Rehabilitation Service Administration Case Service Report for fiscal year 2022.

Participants: Individuals with stroke as primary cause of disability.

Interventions: Not applicable.

Main outcome measures: Employment status and VR service types.

Results: Of those with stroke who received VR services (n=1793), 653 (36.4%) achieved a competitive employment outcome. Black clients were less likely to be competitively employed at closure than White clients, odds ratio (OR, 0.72; 95% CI, 0.56-0.92). Clients whose primary disability was auditory or communicative disabilities were more likely to be competitively employed at closure (OR, 2.25; 95% CI, 1.22-4.17). Regarding VR services, receiving distinct types of VR services significantly was associated with the competitive employment outcome for clients. Clients who received short-term job support services were 6.36 times more likely to be competitively employed at closure than those who did not receive the service (OR, 6.36; 95% CI, 4.28-9.46).

Conclusions: Our results found that race, types of primary disability, level of education, receipt of Supplemental Security Income/Social Security Disability Insurance and the length of the VR services were associated with obtaining or regaining employment among clients with stroke who received public VR services. In terms of VR service patterns, job support services, job placement assistance, rehabilitation technology supports, maintenance services, other services, and VR counseling and guidance were associated with competitive employment outcomes among individuals with stroke.

Objectives: (1) To replicate the assessment of the internal construct validity of the Coma Recovery Scale-Revised (CRS-R) within the Rasch Measurement Theory framework using a larger multicenter sample size and (2) to compare the different sets of item-level diagnostic criteria against the measurement ruler constructed from Rasch analysis to understand how those criteria relate to the overall level of persons' consciousness.

Design: Multicenter retrospective study.

Setting: Seven centers.

Participants: A total of 380 inpatients with a disorder of consciousness with one or more observations, for a total sample of 1460 observations.

Interventions: Not applicable.

Main outcome measure: CRS-R.

Results: We created 2 subsamples: a validation subsample of 1 randomized assessment per subject (N=380) and a confirmation subsample using the further available assessments per subject (N=347). The Rasch analyses, conducted on the validation subsample and replicated on the confirmation one, demonstrated adequate satisfaction of all the model's requirements, including monotonicity, unidimensionality, local independence, invariance (χ²_df=40.224; P=.020), and absence of significant differential item functioning across all person factors explored, including etiology. The reliability (Person Separation Index>0.870) was sufficient for individual person measurement, with the distinction of five Distinct Levels of Performance Ability. The CRS-R rulers based on the Rasch calibration allowed the visual comparison of the various sets of disorder of consciousness diagnostic criteria available, suggesting the possibility of a further refinement of these criteria.

Conclusions: This study improved the results of a previous Rasch analysis published in 2013. It delivered a new stable Rasch calibration of the CRS-R within the largest multicenter sample size available to date and without any differential item functioning by patient's etiology. The adopted measurement-based approach provided further insights into the diagnostic meaning of several score categories of the CRS-R, confirming previous findings and suggesting that "automatic motor response" (item: motor function) and "object recognition" (item: visual function) are likely to represent behavioral manifestations of MCS+ and eMCS, respectively.

Objectives: To investigate the acute (directly poststretching) and long-term (≥1 week of treatment) effects of stretching type, duration, and intensity on joint range of motion (ROM) and stiffness in ankle contractures.

Data sources: PubMed, Embase.com, Clarivate Analytics/Web of Science Core Collection, EBSCO/SPORTDiscus, and EBSCO/CINAHL were searched for studies published in English from inception until September 12, 2023.

Study selection: Fifty-five studies that met the inclusion criteria were included, covering observational, controlled and noncontrolled studies.

Data extraction: Pre- and post-treatment ankle ROM and stiffness, and stretching duration, intensity, and type were extracted from each eligible treatment group by 1 reviewer.

Data synthesis: Most studies did not quantify stretching intensity and its effect was not tested. For the acute effects on ROM, 15 effect sizes were obtained from 11 studies. ROM increased more after constant-torque (95% confidence interval [CI] [1.35, 2.15]) than after constant-angle (95% CI [0.44, 1.40] or dynamic stretching (95% CI [0.50, 1.01]), F=11.99, P=.004, I²=0%, and increased with duration (95% CI [0.00, 0.05]), F=5.12, P=.011, I²=55%. Acute effects on joint stiffness could not be assessed. For the long-term effects, 54 and 12 effect sizes were estimated from 44 and 10 studies, for ROM and stiffness, respectively. No effect of stretching duration on either outcome was found (F=0.32, P=.57, I²=78% and F=0.74, P=.409, I²=5%, respectively). No effect of stretching type on stiffness was found (F=0.02, P=.888, I²=0%). Not enough information was available to assess the long-term effects of stretch type.

Conclusions: We conclude that constant-torque stretching acutely increases ROM more than constant-angle and dynamic stretching. To assess if these superior acute effects result in more substantial adaptations over time, future long-term studies should define stretching type more clearly. Also, torque and angle during stretching should be recorded as measures of intensity in future studies.