Rehabilitation interventions for foot drop in neuromuscular disease.

BACKGROUND: "Foot drop" or "Floppy foot drop" is the term commonly used to describe weakness or contracture of the muscles around the ankle joint. It may arise from many neuromuscular diseases. OBJECTIVES: To conduct a systematic review of randomised trials of treatment for footdrop resulting from neuromuscular disease. SEARCH STRATEGY: We searched the Cochrane Neuromuscular Disease Group Trials Register (July 2005), MEDLINE (January 1966 to July 2005), EMBASE (January 1980 to July 2005), AMED (January 1985 to July 2005) and CINAHL databases (January 1982 to July 2005). SELECTION CRITERIA: Randomised and quasi-randomised trials of physical, orthotic and surgical treatments for footdrop resulting from lower motor neuron or muscle disease and related contractures were included. People with primary joint disease were excluded. Interventions included a 'wait and see' approach, physiotherapy, orthotics, surgery and pharmacological therapy. The primary outcome measure was ability to walk whilst secondary outcome measures included dorsiflexor torque and strength, measures of 'activity' and 'participation' and adverse effects. DATA COLLECTION AND ANALYSIS: Methodological quality was evaluated by two authors using the van Tulder criteria. Three studies with altogether 139 participants were included in the review. Heterogeneity of the studies precluded pooling the data. MAIN RESULTS: Early surgery did not significantly affect walking speed in a trial including 20 children with Duchenne muscular dystrophy. After one year, the mean difference (MD) of the 28 feet walking time was 0.00 seconds (95% confidence interval (CI) -0.83 to 0.83) and the MD of the 150 feet walking time was -2.88 seconds, (95% CI -8.18 to 2.42). In a trial with altogether 26 participants with Charcot-Marie-Tooth disease (hereditary motor and sensory neuropathy), long-term strength training significantly increased walking speed on a 6 metre timed walk (MD -0.70 seconds, 95% CI -1.17 to -0.23) but not on a 50 metre timed walk (MD -1.9 seconds, 95% CI -4.09 to 0.29). In a trial of a 24-week strength training programme in 28 participants with myotonic dystrophy, there was no significant change in walking speed on either a 6 or 50 metre walk. AUTHORS' CONCLUSIONS: Using the primary outcome of ability to walk, only one study demonstrated a positive effect and that was an exercise programme for people with Charcot-Marie-Tooth disease. Surgery was not significantly effective in children with Duchenne Muscular Dystrophy. More evidence generated by methodologically sound trials is required.

Multi-disciplinary rehabilitation for acquired brain injury in adults of working age.

BACKGROUND: Evidence from systematic reviews demonstrates that multi-disciplinary rehabilitation is effective in the stroke population, where older adults predominate. However, the evidence base for the effectiveness of rehabilitation following acquired brain injury (ABI) in younger adults is not yet established, perhaps because there are different methodological challenges. OBJECTIVES: To assess the effects of multi-disciplinary rehabilitation following ABI in adults, 16 to 65 years. To explore approaches that are effective in different settings and the outcomes that are affected. SEARCH STRATEGY: We used a wide range of sources including: Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (1966-2004), EMBASE (1988-2004), CINAHL (1983-2004), PsycLIT (1967-2004), AMED, the National Research Register 2004 and ISI Science Citation Index (1981-2004). SELECTION CRITERIA: Randomised controlled trials (RCTs) comparing multi-disciplinary rehabilitation with either routinely available local services or lower levels of intervention; or trials comparing intervention in different settings or at different levels of intensity. Quasi-randomised and quasi-experimental designs were also included, providing they met pre-defined methodological criteria. DATA COLLECTION AND ANALYSIS: Trials were selected by two authors independently, and their methodological quality rated, again by two independent authors. A third reviewer arbitrated when disagreements could not be resolved by discussion. A 'best evidence' synthesis was performed by attributing levels of evidence, based on methodological quality. Trials were sub-divided in terms of severity of ABI and the setting and type of rehabilitation offered. MAIN RESULTS: Ten trials were identified of good methodological quality and four of lower quality. Within the subgroup of predominantly mild brain injury, 'strong evidence' suggested that most patients make a good recovery with provision of appropriate information, without additional specific intervention. For moderate to severe injury, there is 'strong evidence' of benefit from formal intervention. For patients with moderate to severe ABI already in rehabilitation, there is strong evidence that more intensive programmes are associated with earlier functional gains, and 'moderate evidence' that continued outpatient therapy can help to sustain gains made in early post-acute rehabilitation. There is 'limited evidence' that specialist in-patient rehabilitation and specialist multi-disciplinary community rehabilitation may provide additional functional gains, but the studies serve to highlight the particular practical and ethical restraints on randomisation of severely affected individuals for whom there are no realistic alternatives to specialist intervention. AUTHORS' CONCLUSIONS: Problems following ABI vary; different services are required to suit the needs of patients with different problems. Patients presenting acutely to hospital with moderate to severe brain injury should be routinely followed up to assess their need for rehabilitation. Intensive intervention appears to lead to earlier gains. The balance between intensity and cost-effectiveness has yet to be determined. Patients discharged from in-patient rehabilitation should have access to out-patient or community-based services appropriate to their needs. Those with milder brain injury benefit from follow-up, and appropriate information and advice. Not all questions in rehabilitation can be addressed by traditional research methodologies. There are important questions still to be answered and future research should employ the most appropriate methodology.

Applications of functional assessment to musculoskeletal disability evaluation.

A review of the history of the disability determination for LBP suggests that the early focus upon disability as a direct "effect" of impairment has given way to an updated approach acknowledging the multitude of factors, many of which are subjective, that contribute to an individual's future return to work and disability status. In addition to the evaluation of the underlying impairment and pathology, physicians performing disability evaluations for LBP will be best served when they can assess the individual's functional status, and incorporate that information into their decision regarding the individual's current limitations and prognosis. As discussed above, many of the factors contributing to the evaluation of functional status, including pain, physical functioning, and affective status, are necessarily subjective. Nonetheless, the rehabilitation literature suggests that inclusion of this information into the disability determination using a patient-centered approach may provide the factors that are most potent with respect to patient prognosis and eventual return to work.

Lumbar spine range of motion as a measure of physical and functional impairment: an investigation of validity.

OBJECTIVE: To investigate the validity of the spinal range of motion models outlined in the second and fourth editions of the American Medical Association Guides to the evaluation of permanent impairment (AMA Guides), for assessing the percentage impairment in chronic low back pain patients. DESIGN: Cross-sectional validation study. SETTING: Outpatient department in the Rehabilitation Medicine Unit. SUBJECTS: A volunteer sample of 34 subjects participated in the study, 21 females and 13 males, with a mean age of 47.7 years (1 SD = 12.1) and 40.1 years (1 SD = 11.1), respectively. Subjects had chronic low back with or without leg pain of at least six months' duration. Subjects were recruited by medical practitioners and physiotherapists through the Rehabilitation Unit at the Essendon Campus of Royal Melbourne Hospital. MAIN OUTCOME MEASURES: Lower back range of motion measured with a long arm goniometer and a dual inclinometer, Waddell Physical Impairment Scale, Waddell Disability Index, Oswestry Disability Index. RESULTS: Both range of motion measurement methods demonstrated poor validity and do not bear any consistent relationship to the level of physical or functional impairment in subjects with chronic low back pain. CONCLUSIONS: There was no evidence for a relationship between low back range of motion and impairment, and thus it would appear illogical to evaluate impairment in chronic low back pain patients using a spinal range of motion model when aiming to measure or compensate disability.

Reliability of the American Medical Association guides' model for measuring spinal range of motion. Its implication for whole-person impairment rating.

STUDY DESIGN: Repeated measures design for intra- and interrater reliability. OBJECTIVES: To determine the intra- and interrater reliability of the lumbar spine range of motion measured with a dual inclinometer, and the thoracolumbar spine range of motion measured with a long-arm goniometer, as recommended in the American Medical Association Guides. SUMMARY OF BACKGROUND DATA: The American Medical Association Guides (2nd and 4th editions) recommend using measurements of thoracolumbar and lumbar range of movement, respectively, to estimate the percentage of permanent impairment in patients with chronic low back pain. However, the reliability of this method of estimating impairment has not been determined. METHODS: In all, 34 subjects participated in the study, 21 women with a mean age of 40.1 years (SD, +/- 11.1) and 13 men with a mean age of 47.7 years (SD, +/- 12.1). Measures of thoracolumbar flexion, extension, lateral flexion, and rotation were obtained with a long-arm goniometer. Lumbar flexion, extension, and lateral flexion were measured with a dual inclinometer. Measurements were taken by two examiners on one occasion and by one examiner on two occasions approximately 1 week apart. RESULTS: The results showed poor intra- and interrater reliability for all measurements taken with both instruments. Measurement error expressed in degrees showed that measurements taken by different raters exhibited systematic as well as random differences. As a result, subjects measured by two different examiners on the same day, with either instrument, could give impairment ratings ranging between 0% and 18% of the whole person (excluding rotation), in which percentage impairment is calculated using the average range of motion and the average systematic and random error in degrees for the group for each movement (flexion, extension, and lateral flexion). CONCLUSIONS: The poor reliability of the American Medical Association Guides' spinal range of motion model can result in marked variation in the percentage of whole-body impairment. These findings have implications for compensation bodies in Australia and other countries that use the American Medical Association Guides' procedure to estimate impairment in chronic low back pain patients.

Can we achieve accountability for long-term outcomes?

OBJECTIVE: To explore options for the development of a set of indicators to assess the long-term outcomes achieved by all people with a given disabling condition in a given population. DATA SOURCES: The review draws on empirical studies of predictive indicators, theoretical literature on long-term recovery processes, and literature from administrative science on the use of indicators in accountability systems. STUDY SELECTION: Studies were selected that explicitly sought to relate short-term and long-term outcomes or that explored the mediating factors in the relationship between impairment, disability, and handicap. DATA EXTRACTION: The focus of the review is on (1) empirical evidence of the relationship between short- and long-term outcomes, particularly in causal claims, and (2) theoretical analyses of the factors that mediate this relationship. DATA SYNTHESIS: Evidence is presented that certain outcome states can be considered thresholds that make the outcome usable and, hence, sustainable or that create the opportunity for further improvement. Such thresholds could meet the construct validity criteria necessary for measures that are to be used as indicators in an accountability system. The interaction between psychological and physical factors in setting thresholds means that both objective and subjective indicators are required in an indicator system. CONCLUSIONS: It may well be possible to develop a parsimonious set of population-based outcome indicators for people with disabilities. The key safeguards required are construct validity and the involvement of people with disabilities in both the development and use of the indicators.

Managing chronic back pain: impact of an interdisciplinary team approach.

OBJECTIVE: To evaluate the effectiveness of a six-week outpatient program in pain management for patients with chronic back pain. DESIGN: Retrospective review. SETTING: Rehabilitation Clinical Business Unit, Essendon campus of the Royal Melbourne Hospital. SUBJECTS: 138 consecutive patients who participated in the unit's Chronic Back Pain Programme between 1991 and 1993. INTERVENTION: Multidisciplinary program that promoted pain management rather than "cure", with two six-hour group sessions per week for six weeks. OUTCOME MEASURES: Patient assessments before the program and at program completion and at three months' follow-up, with the West Haven-Yale Multidimensional Pain Inventory (WHYMPI) and a four-minute walk test. RESULTS: At program completion, the WHYMPI showed significant decreases in the amount pain interfered with life and significant increases in patient sense of control and activity level. However, severity of pain remained the same. All these effects were maintained three months later. CONCLUSIONS: A brief outpatient program was effective in improving pain management in a group of chronic back pain sufferers. This seems a useful and relatively inexpensive option in managing this problematic group of patients.

Predicting hours of care needed.

This study investigated whether the number of hours of care needed by a person with disability could be predicted by his or her score on the Functional Independence Measure (FIM) or the Edinburgh Rehabilitation Status Scale (ERSS). Seventy-five subjects (age range, 19 to 65), from a variety of residential services, with neurological disabilities, were visited by an experienced observer to estimate the number of hours of care per week required, from whatever source, for the subject to manage adequately. A second observer, blind to the observations of the first, assessed the subjects' FIM and ERSS scores by interview with the subjects and their carers. Wide ranges of scores on both scales suggested that subjects with many different dependency levels were surveyed, confirmed by "required care hours" varying between 0 and 168 per week (median 18). Pearson's correlation coefficients were 0.36 for ERSS (p < 0.002) and -0.39 for FIM (p < 0.001). Analysis of the scattergrams identified three aberrant cases. Investigation of these showed they each had a high level of dependency due to supervision rather than physical care; exclusion of these cases resulted in much stronger correlations for the remaining 72 cases (ERSS, 0.61; FIM, -0.76). Both ERSS and FIM correlate well with hours of care required, but their association with hours of supervision is poor.

Variations in mortality of the coloured, white and Asian population groups in the RSA, 1978-1982. Part V. Hypertensive diseases.

An analysis was undertaken of mortality from hypertensive disease in the RSA between 1978 and 1982 among whites, coloureds and Asians. The age-specific mortality rates for each group are presented and comparisons are also made between these groups based on age-standardised mortality rates. As with a similar study undertaken for the period 1969-1971, marked variations are seen between the various population groups. The rates for Asians exceeded those for coloureds substantially, and both these groups had far higher rates than whites. These results demonstrate an interesting variation when compared with mortality from ischaemic heart disease and recent prevalence studies of hypertension. The possibility that this variation is due to better control of hypertension in whites or is a result of a different ratio of risk factors in each group studied is considered.

Variations in mortality of the coloured, white and Asian population groups in the RSA, 1978-1982. Part VI. Ischaemic heart disease.

An analysis of ischaemic heart disease (IHD) mortality for the period 1978-1982 showed markedly different rates for the Asian, white and coloured population groups in the RSA. Age-specific and age-standardised rates for Asians were in general considerably higher than those for whites, and did not show the marked decline with time observed in rates for whites. Although coloureds were seen to have considerably lower age-standardized rates than Asians or whites of the same sex, an increase in the age-standardised rates for coloured males over a 10-year period and a slight decrease among females suggested that rates for coloureds may be in the process of approaching those for the other groups. The observed decline in IHD rates among whites of both sexes suggests that preventable major risk factors may be coming under control, apparently to a greater extent in this group than among Asians or coloureds.

Variations in mortality of the coloured, white and Asian population groups in the RSA, 1978-1982. Part II. Cerebrovascular disease.

An analysis was undertaken of mortality from cerebrovascular disease in the RSA between 1978 and 1982 in whites, coloureds and Asians. This article details the age-specific mortality rates for each group and also comparisons between groups based on age-standardised mortality rates. Marked differences are seen between the various population groups, the rates for Asians and coloureds (particularly females) far exceeding that for whites. Comparison of these data with those published previously by Wyndham suggest that while mortality from this cause may be falling among whites and Asians, the rate is remaining relatively static in the coloured population.

Variations in mortality of the coloured white and Asian population groups in the RSA, 1978-1982. Part III. Rheumatic heart disease.

An analysis was undertaken of mortality from rheumatic heart disease in the RSA between 1978 and 1982 in whites, coloureds and Asians. This article details the age-specific mortality rates (MRs) for each group and also comparisons between groups based on age-standardised MRs. The rates for Asians and coloureds markedly exceed those for whites, particularly in the lower age groups (under 45 years).

Variations in mortality of the coloured, white and Asian population groups in the RSA, 1978-1982. Part I. All causes.

Previous reports, based largely on the 1970 census and the 8th revision of the International Classification of Diseases, (ICD-8) have suggested that marked differences in mortality exist between population groups in the RSA. In this article the ICD-9 classification of causes of death and 1980 census are used to assess whether the trends have continued through to the present time. Total mortality data in the RSA for whites, coloureds and Asians for the 5-year period 1978-1982 are presented. The 1980 national census provided the denominator population data. Annual age- and sex-specific mortality rates were higher for coloureds than for whites or Asians, the differences being most marked in childhood. There appears to have been little change in total standardised mortality rates among whites over the 5-year period, while increases have occurred among coloureds of both sexes and among Asian males. Analysis of proportional mortality stresses the relatively large proportion of deaths accounted for by external causes and infections among coloureds and by cardiovascular diseases among whites and Asians. There is an urgent need for the health services to take note of these data in order to provide for the varied needs of the population.

Community health service planning in the education of medical students.

Few medical students gain practical experience in practical epidemiology during their undergraduate years or understand how this science is a prerequisite to decision-making in the health services. In an attempt to overcome this deficit a group of clinical students was asked to measure the incidence of cerebrovascular disease in the Cape Peninsula over a relatively short period in order that rehabilitation facilities could be planned for affected patients. The exercise proved extremely fruitful for both the staff and the students. For the latter it not only met the objectives outlined above but also forced them to enter the community and so gain a perspective of all health services provided. We suggest that this technique, which can be applied to many topics, is a useful way of introducing students to these important concepts.

Protoporphyrinogen oxidase and porphobilinogen deaminase in variegate porphyria.

Two enzymes of the haem biosynthetic pathway were investigated in patients with variegate porphyria. Protoporphyrinogen oxidase in cultures of Epstein-Barr virus transformed lymphoblasts from twenty-seven patients showed a mean maximal velocity (Vmax) of 0.39 +/- 0.08+ nmol of protoporphyrin mg protein-1 h-1, a 52% reduction (P less than 0.001) from a non-porphyric control group (0.82 +/- 0.10). Km values (1.00 +/- 0.27 microM) did not differ significantly (P greater than 0.05) from control values in any of the patients. The mean Vmax of porphobilinogen deaminase in the cultures was 1.50 +/- 0.18 nmol of uroporphyrin mg protein-1 min-1, a 24% reduction (P less than 0.001) from controls (1.94 +/- 0.14). Mean porphobilinogen deaminase activity in the erythrocytes of twenty-one patients with variegate porphyria was 8.37 +/- 1.99 nmol of uroporphyrin 1 erythrocytes-1 s-1, a 28% reduction (P less than 0.001) from normal (11.98 +/- 2.11). The reduced activities of these two enzymes comply with the expression of variegate porphyria during its quiescent and acute phases.

The prevalence of locomotor disability and handicap in the Cape Peninsula. Part I. The coloured population of Bishop Lavis.

A door-to-door survey to identify the locomotor disabled was carried out on 33.35% of the so-called coloured population in a low socio-economic area of the Cape Peninsula (9112 people). The prevalence rate of locomotor disability was 11.2/1000. The main causes of disability were illness (44.1%) and trauma (41.2%); the former resulted mostly from cerebrovascular accidents (15.7%) and poliomyelitis (15.7%). Of the disabled persons 11.8% were 15 years of age or less, 57.8% between the ages of 16 and 59 years and 30.4% were more than 60 years. Of those in the working-age group 15% were employed. Few of the unemployed had hobbies or interests or had any contact with health or social services.