To What Extent is Walking Ability Associated with Participation in People after Stroke?

OBJECTIVES: This study aims to 1) identify the relation between walking ability and participation after stroke and 2) explore whether change in walking ability is associated with change in participation over time in community living-people after stroke. MATERIALS AND METHODS: Fifty-two people after stroke were assessed at baseline and after a 6-week gait training intervention. People were included between two weeks and six months after stroke. The Utrecht Scale for Evaluation of Rehabilitation-Participation was used to measure participation. Assessment of walking ability included the six-minute walking test for walking endurance, Timed-up & Go test for functional mobility, Mini Balance Evaluation Systems Test for dynamic balance, and total duration of walking activity per day to measure walking activity. RESULTS: At baseline, six-minute walking test, Timed-up & Go test, and Mini Balance Evaluation Systems Test were univariately associated with participation (P < 0.001). Backward multiple regression analysis showed that the Mini Balance Evaluation Systems Test independently explained 55.7% of the variance in participation at baseline. Over time, only change in the six-minute walking test was positively associated with change in participation (R2 = 0.087, P = 0.040). CONCLUSIONS: Cross-sectional associations showed that walking ability, and especially dynamic balance, contributes to participation after stroke. Dynamic balance, as underlying variable for walking, was an important independently related factor to participation after stroke which needs attention during rehabilitation. Longitudinally, improvement in walking endurance was significantly associated with improvement in participation, which indicates the relevance of training walking endurance to improve participation after stroke.

Effect of Virtual Reality Gait Training on Participation in Survivors of Subacute Stroke: A Randomized Controlled Trial.

OBJECTIVE: After stroke, people experience difficulties with walking that lead to restrictions in participation in daily life. The purpose of this study was to examine the effect of virtual reality gait training (VRT) compared to non-virtual reality gait training (non-VRT) on participation in community-living people after stroke. METHODS: In this assessor-blinded, randomized controlled trial with 2 parallel groups, people were included between 2 weeks and 6 months after stroke and randomly assigned to the VRT group or non-VRT group. Participants assigned to the VRT group received training on the Gait Real-time Analysis Interactive Lab (GRAIL), and participants assigned to the non-VRT group received treadmill training and functional gait exercises without virtual reality. Both training interventions consisted of 12 30-minute sessions during 6 weeks. The primary outcome was participation measured with the restrictions subscale of the Utrecht Scale for Evaluation of Rehabilitation-Participation (USER-P) 3 months postintervention. Secondary outcomes included subjective physical functioning, functional mobility, walking ability, dynamic balance, walking activity, fatigue, anxiety and depression, falls efficacy, and quality of life. RESULTS: Twenty-eight participants were randomly assigned to the VRT group and 27 to the non-VRT group, of whom 25 and 22 attended 75% or more of the training sessions, respectively. No significant differences between the groups were found over time for the USER-P restrictions subscale (1.23; 95% CI = -0.76 to 3.23) or secondary outcome measures. Patients' experiences with VRT were positive, and no serious adverse events were related to the interventions. CONCLUSIONS: The effect of VRT was not statistically different from non-VRT in improving participation in community-living people after stroke. IMPACT: Although outcomes were not statistically different, treadmill-based VRT was a safe and well-tolerated intervention that was positively rated by people after stroke. VR training might, therefore, be a valuable addition to stroke rehabilitation. LAY SUMMARY: VRT is feasible and was positively experienced by people after stroke. However, VRT was not more effective than non-VRT for improving walking ability and participation after stroke.

Perceived barriers and facilitators for gait-related participation in people after stroke: From a patients' perspective.

Background: An important focus of post-stroke physical therapy is to improve walking and walking capacity. However, many people after stroke experience difficulties with gait-related participation, which includes more than walking capacity alone. Gait-related participation involves walking with a participation goal and requires to deal with changes in the environment during walking and perform dual tasks, for example.Objective: To explore barriers and facilitators for gait-related participation from the perspective of people after stroke. This knowledge can contribute to the development of effective interventions to improve gait-related participation.Methods: Semi-structured interviews were conducted to investigate how people after stroke experience gait-related participation. Audio-recorded interviews were transcribed, anonymized, and analyzed thematically. Barriers and facilitators were categorized according to the International Classification of Functioning, Disability and Health (ICF) framework.Results: Twenty-one people after stroke participated. Median age was 65 years, median time since stroke 16 weeks. Barriers were reported in movement-related functions, cognitive functions, mobility, personal factors, and environmental factors. Facilitators were found on participation level and in personal and environmental factors, such as motivation and family support.Conclusion: People after stroke who were physically able to walk independently still described multiple barriers to gait-related participation in all components of the ICF framework.

Effectiveness of the Brains Ahead! Intervention: 6 Months Results of a Randomized Controlled Trial in School-Aged Children With Mild Traumatic Brain Injury.

OBJECTIVE: To examine the effectiveness of Brains Ahead!, a psychoeducational intervention aimed to prevent long-term problems with activities and participation in children after mild traumatic brain injury (mTBI). PARTICIPANTS: In total, 124 children, aged 6 to 18 years, diagnosed with mTBI and their caregivers. METHOD: After randomization, participants in the intervention group received a face-to-face psychoeducational session with written take-home information and follow-up telephone call(s). Participants in the control group received usual care, consisting of a concise information brochure. PRIMARY OUTCOME MEASURES: Activities and participation (Child and Adolescent Scale of Participation [CASP]). SECONDARY OUTCOMES: fatigue, postconcussive symptoms (PCSs), posttraumatic stress symptoms (PTSSs), and quality of life (QOL). RESULTS: Generalized Estimated Equation analyses showed that both groups improved over the first 6 months post-mTBI, but the intervention group did not differ significantly on the CASP. Mann-Whitney U tests showed that the intervention group reported significantly less fatigue, PCSs, and PTSSs and better QOL compared with the control group at 6 months post-MTBI. CONCLUSIONS: The Brains Ahead! intervention resulted in significant improvements compared with usual care in reducing fatigue, PCSs, and PTSSs and improving QOL. Lack of an effect on activities and participation may be due to the ceiling effect of the CASP.

Activities and Participation in the First 6 Months After Mild Traumatic Brain Injury in Children and Adolescents.

OBJECTIVE: To investigate the natural course of activities and participation of children up to 6 months after a mild traumatic brain injury (mTBI). METHODS: A prospective longitudinal cohort study with complete data sets of 231 children diagnosed with mTBI and their caregivers. MAIN MEASURES: Activities and participation assessed with the Child and Adolescent Scale of Participation (CASP) and the Children's Assessment of Participation and Enjoyment (CAPE) measured at 2 weeks, 3 months, and 6 months post-mTBI. Because of a ceiling effect, the primary outcome measure (CASP) was divided into deviant (not maximum score) or full functioning. RESULTS: Friedman's, Cochran's Q, and McNemar's tests (CASP) and repeated-measures analyses of variance (CAPE) showed significant increases in activities and participation between 2 weeks and 3 and 6 months after mTBI. Based on the parents' perspective, 67% of the children returned to full functioning at 6 months postinjury, with only 38% of the children describing themselves as functioning at their premorbid level. DISCUSSION: Findings indicate that most children return to maximum level of activities and participation over time after mTBI. In a substantial number of children, however, the level of activities and participation at 6 months postinjury is evaluated as lower than that of peers. The importance of investigating predictors for child and caregiver perspectives is emphasized.

Predictors of activities and participation six months after mild traumatic brain injury in children and adolescents.

OBJECTIVE: This study aimed to identify predictors of long-term consequences for activities and participation in children and adolescents with mild traumatic brain injury (mTBI). METHODS: A multicentre prospective longitudinal cohort study was conducted. The primary outcome measure was activities and participation measured with the Child and Adolescent Scale of Participation - CASP and completed by children (N = 156) and caregivers (N = 231) six months post-mTBI. The CASP items were categorized into home, community, school, and environment. Predictors were categorized according to the International Classification of Functioning, Disability and Health for Children and Youth. Predictors included pre-injury personal- and environmental factors, injury-related factors, symptoms, and resumption of activities in the first two weeks after mTBI. Univariate and multivariate logistic regression analyses were used to determine the predictive value of these factors. RESULTS: Results show that predictors differ across settings and perspectives (child or caregiver). Decreased activities and participation in children with mTBI can be predicted by adverse pre-injury behavioral functioning of the child (p < .000 - p = .038), adverse pre-injury family functioning (p = .001), lower parental SES (p = .038), more stress symptoms post-injury (p = .017 - p = .032), more post-concussive symptoms (p = .016 - p = .028) and less resumption of activities (p = .006 - p = .045). DISCUSSION: Pre-injury factors, more symptoms post-injury and less resumption of activities should be considered when children are screened for unfavorable outcomes. Additional factors may add to the prediction, but injury-related factors do not. It is recommended that future research explores psychosocial factors, such as coping styles, emotion-regulation, personality traits, social support, and other comorbid problems of both children and caregivers.

Virtual reality gait training versus non-virtual reality gait training for improving participation in subacute stroke survivors: study protocol of the ViRTAS randomized controlled trial.

BACKGROUND: A stroke often results in gait impairments, activity limitations and restricted participation in daily life. Virtual reality (VR) has shown to be beneficial for improving gait ability after stroke. Previous studies regarding VR focused mainly on improvements in functional outcomes. As participation in daily life is an important goal for rehabilitation after stroke, it is of importance to investigate if VR gait training improves participation. The primary aim of this study is to examine the effect of VR gait training on participation in community-living people after stroke. METHODS/DESIGN: The ViRTAS study comprises a single-blinded, randomized controlled trial with two parallel groups. Fifty people between 2 weeks and 6 months after stroke, who experience constraints with walking in daily life, are randomly assigned to the virtual reality gait training (VRT) group or the non-virtual reality gait training (non-VRT) group. Both training interventions consist of 12 30-min sessions in an outpatient rehabilitation clinic during 6 weeks. Assessments are performed at baseline, post intervention and 3 months post intervention. The primary outcome is participation measured with the Utrecht Scale for Evaluation of Rehabilitation-Participation (USER-P). Secondary outcomes are subjective physical functioning, functional mobility, walking ability, walking activity, fatigue, anxiety and depression, falls efficacy and quality of life. DISCUSSION: The results of the study provide insight into the effect of VR gait training on participation after stroke. TRIAL REGISTRATION: Netherlands National Trial Register, Identifier NTR6215 . Registered on 3 February 2017.

Central activation, metabolites, and calcium handling during fatigue with repeated maximal isometric contractions in human muscle.

PURPOSE: To determine the roles of calcium (Ca2+) handling by sarcoplasmic reticulum (SR) and central activation impairment (i.e., central fatigue) during fatigue with repeated maximal voluntary isometric contractions (MVC) in human muscles. METHODS: Contractile performance was assessed during 3 min of repeated MVCs (7-s contraction, 3-s rest, n = 17). In ten participants, in vitro SR Ca2+-handling, metabolites, and fibre-type composition were quantified in biopsy samples from quadriceps muscle, along with plasma venous [K+]. In 11 participants, central fatigue was compared using tetanic stimulation superimposed on MVC in quadriceps and adductor pollicis muscles. RESULTS: The decline of peak MVC force with fatigue was similar for both muscles. Fatigue resistance correlated directly with % type I fibre area in quadriceps (r = 0.77, P = 0.009). The maximal rate of ryanodine-induced Ca2+-release and Ca2+-uptake fell by 31 ± 26 and 28 ± 13%, respectively. The tetanic force depression was correlated with the combined reduction of ATP and PCr, and increase of lactate (r = 0.77, P = 0.009). Plasma venous [K+] increased from 4.0 ± 0.3 to 5.4 ± 0.8 mM over 1-3-min exercise. Central fatigue occurred during the early contractions in the quadriceps in 7 out of 17 participants (central activation ratio fell from 0.98 ± 0.05 to 0.86 ± 0.11 at 1 min), but dwindled at exercise cessation. Central fatigue was seldom apparent in adductor pollicis. CONCLUSIONS: Fatigue with repeated MVC in human limb muscles mainly involves peripheral aspects which include impaired SR Ca2+-handling and we speculate that anaerobic metabolite changes are involved. A faster early force loss in quadriceps muscle with some participants is attributed to central fatigue.

Long-term prognosis of acute lateral ankle ligamentous sprains: high incidence of recurrences and residual symptoms.

BACKGROUND: Acute lateral ankle ligamentous sprains (ALALS) are common injuries. This injury does not always have a favourable long-term outcome. Studies reporting the prognosis of ALALS after functional treatment are scarce. OBJECTIVE: To determine the prognosis of functionally treated ALALS, in terms of recurrent ALALS and residual symptoms. STUDY DESIGN: Retrospective cohort study. SETTING: Patients were recruited from 20 family practices, nine physical therapy practices, the emergency departments of a regional hospital and a university hospital. PATIENTS: Adult patients with an ALALS caused by an inversion trauma were invited to participate in this study 2.5-5 years after their initial injury. INDEPENDENT VARIABLES: Functional treatment of the initial ALALS. MAIN OUTCOME MEASURES: Acute lateral ankle ligamentous sprain recurrences and residual symptoms. RESULTS: A total of 44 patients were included, with an average follow-up period after the initial ankle sprain of 204 weeks (range 150-274 weeks). Eight patients (18.1%) had reinjured their ankle. Explicit pain around the ankle joint at physical examination was experienced by 45.5%. Clinical symptoms of anterior ankle impingement were present in 25% (all athletes), with radiologically confirmed tibiotalar osteophyte bone formation in 82% of them. CONCLUSIONS: A large proportion of patients with ALALS experience recurrences and persistent symptoms after their initial ankle injury. The high percentage of patients with anterior ankle impingement syndromes illustrates the need for early assessment of this impairment in patients with persistent complaints.

Activities and participation of children and adolescents after mild traumatic brain injury and the effectiveness of an early intervention (Brains Ahead!): study protocol for a cohort study with a nested randomised controlled trial.

BACKGROUND: Approximately 20 % of children and adolescents who have sustained mild traumatic brain injuries may experience long-term consequences, including cognitive problems, post-traumatic stress symptoms and reduced load-bearing capacity. The underestimation and belated recognition of these long-term consequences may lead to chronic and disruptive problems, such as participation problems in school and in social relationships. The aim of this study is to examine the level of activities and participation of children and adolescents up to 6 months after a mild traumatic brain injury and to identify possible outcome predictors. Another aim is to investigate the effectiveness of an early psychoeducational intervention and compare the results with those obtained with usual care. METHODS/DESIGN: This paper presents the Brains Ahead! study design, a randomised controlled trial nested within a multicentre, longitudinal, prospective cohort study. The eligible participants include children and adolescents between 6 and 18 years of age who have experienced a mild traumatic brain injury within the last 2 weeks. The cohort study will include 500 children and adolescents with a mild traumatic brain injury and their caregivers. A subset of 140 participants and their caregivers will be included in the randomised controlled trial. Participants in the randomised controlled trial will be randomly assigned to either the psychoeducational intervention group or the usual care control group. The psychoeducational intervention involves one face-to-face contact and one phone contact with the interventionist, during which the consequences of mild traumatic brain injury and advice for coping with these consequences to prevent long-term problems will be discussed. Information will be provided both verbally and in a booklet. The primary outcome domain is activities and participation, which will be evaluated using the Child and Adolescent Scale of Participation. Participants are evaluated 2 weeks, 3 months and 6 months after the mild traumatic brain injury. DISCUSSION: The results of this study will provide insight into which children with mild traumatic brain injury are at risk for long-term participation problems and may benefit from a psychoeducational intervention. TRIAL REGISTRATION: Netherlands Trial Register identifier NTR5153 . Registered on 17 Apr 2015.

Effect of Virtual Reality Training on Balance and Gait Ability in Patients With Stroke: Systematic Review and Meta-Analysis.

BACKGROUND: Virtual reality (VR) training is considered to be a promising novel therapy for balance and gait recovery in patients with stroke. PURPOSE: The aim of this study was to conduct a systematic literature review with meta-analysis to investigate whether balance or gait training using VR is more effective than conventional balance or gait training in patients with stroke. DATA SOURCES: A literature search was carried out in the databases PubMed, Embase, MEDLINE, and Cochrane Library up to December 1, 2015. STUDY SELECTION: Randomized controlled trials that compared the effect of balance or gait training with and without VR on balance and gait ability in patients with stroke were included. DATA EXTRACTION AND SYNTHESIS: Twenty-one studies with a median PEDro score of 6.0 were included. The included studies demonstrated a significant greater effect of VR training on balance and gait recovery after stroke compared with conventional therapy as indicated with the most frequently used measures: gait speed, Berg Balance Scale, and Timed "Up & Go" Test. Virtual reality was more effective to train gait and balance than conventional training when VR interventions were added to conventional therapy and when time dose was matched. LIMITATIONS: The presence of publication bias and diversity in included studies were limitations of the study. CONCLUSIONS: The results suggest that VR training is more effective than balance or gait training without VR for improving balance or gait ability in patients with stroke. Future studies are recommended to investigate the effect of VR on participation level with an adequate follow-up period. Overall, a positive and promising effect of VR training on balance and gait ability is expected.

Systematic review of cardiopulmonary exercise testing post stroke: Are we adhering to practice recommendations?

OBJECTIVE: To systematically review the use of cardiopulmonary exercise testing in people who have survived a stroke. The following questions are addressed: (i) What are the testing procedures used? (ii) What are the patient, safety and outcomes characteristics in the cardiopulmonary exercise testing procedures? (iii) Which criteria are used to determine maximum oxygen uptake (VO2peak/max) in the cardiopulmonary exercise testing procedures? METHODS: Systematic review of studies of cardiopulmonary exercise testing in stroke survivors. PubMed, EMBASE, and CINAHL were searched from inception until January 2014. MeSH headings and keywords used were: oxygen capacity, oxygen consumption, oxygen uptake, peak VO2, max VO2, aerobic fitness, physical fitness, aerobic capacity, physical endurance and stroke. Search and selection were performed independently by 2 reviewers. Sixty studies were scrutinized, including 2,104 stroke survivors. RESULTS: Protocols included treadmill (n = 21), bicycle (n = 33), stepper (n = 3) and arm (n = 1) ergometry. Five studies reported 11 adverse events (1%). Secondary outcomes were reported in few studies, which hampered interpretation of the patient's effort, and hence the value of the VO2peak. CONCLUSION: Most studies did not adhere, or insufficiently adhered, to the existing cardiopulmonary exercise testing guidelines for exercise testing. Thus, the results of cardiopulmonary exercise testing protocols in stroke patients cannot be compared.

Effects of physical therapist-guided quadriceps-strengthening exercises for the treatment of patellofemoral pain syndrome: a systematic review.

STUDY DESIGN: Systematic literature review. OBJECTIVE: To summarize the evidence for physical therapist-guided quadriceps-strengthening exercises as a treatment for patellofemoral pain syndrome. BACKGROUND: Although quadriceps strengthening is often included in the plan of care for patellofemoral pain syndrome, a systematic review published in 2003 found only limited evidence that exercise was more effective than no exercise for this common condition. METHODS: The PubMed, Embase/MEDLINE, and Cochrane Central Register of Controlled Trials databases, from inception to January 9, 2014, were searched for randomized controlled trials comparing the use of quadriceps-strengthening exercises to interventions consisting of advice/information or a placebo. Outcomes of interest were pain measures and function, as measured with self-report questionnaires. The methodological quality of the randomized controlled trials was assessed with the Physiotherapy Evidence Database scale. Results were summarized using a best-evidence synthesis and graphically illustrated using forest plots without meta-analysis. RESULTS: Seven studies were included in the literature review. These studies reported strong evidence that isolated quadriceps strengthening is more effective in reducing pain and improving function than advice and information alone. In addition, compared to advice and information or placebo, there was strong evidence that quadriceps-strengthening exercises combined with other interventions may be more effective in reducing pain immediately postintervention and after 12 months, but not in improving function. CONCLUSION: The literature provides strong evidence for the use of quadriceps-strengthening exercises, with or without other interventions, for the treatment of patellofemoral pain syndrome.

Soccer injuries and recovery in Dutch male amateur soccer players: results of a prospective cohort study.

OBJECTIVE: To describe characteristics of outdoor soccer injury and recovery among Dutch soccer players. DESIGN: Prospective cohort study. SETTING: The 2009-2010 competitive season (33 weeks). PARTICIPANTS: Four hundred fifty-six Dutch male soccer players of 23 amateur teams. MAIN OUTCOME MEASURES: Coaches recorded individual exposure to all soccer activities. Paramedics or sports trainers collected information on the occurrence (e.g., location, type, circumstances) and consequences (eg, absenteeism, medical treatment) of injuries. RESULTS: In total, 424 time-loss injuries were sustained by 60% (n = 274) of the players, with 23% (n = 105) having more than 1 injury. This corresponds to an overall density of 9.6 (8.7-10.5) injuries per 1000 player hours; 3.9 (3.3-4.7) in training sessions and 20.4 (18.1-23.1) in soccer matches. Almost 30% (n = 123) of the injuries lasted for more than 1 month, 14% (n = 58) were reinjuries (causing longer absence than new injuries), and 54% (n = 230) of the injuries were given medical treatment. The most common diagnoses were muscle/tendon (38%) or joint/ligament injuries (23%) of the lower extremities. After regaining the ability to fully take part in soccer training or matches, 27.4% of the players (n = 116) still reported complaints. CONCLUSIONS: Two recommendations based on the above-mentioned results are (1) prevention should primarily focus on these most common diagnoses and (2) players resuming soccer activities after an injury should be given special attention to resolve the remaining complaints and to prevent reinjuries.

Fitness, depression, and poststroke fatigue: worn out or weary?

Each year, around 15 million people worldwide have a stroke. Of these, at least 5 million die, a third remain disabled, and the remainder make a good recovery.(1) Yet more than half of all these 10 million survivors will have fatigue, one of the most debilitating, but least studied, poststroke symptoms. Poststroke fatigue (PSF) is a multifaceted phenomenon.(2) It has been correlated with lowered mood, as well as being influenced by other factors, like age, sex, and cognition. Many researchers have demonstrated that the presence of fatigue negatively influences quality of life, return to work, and perhaps mortality.(3,4) However, most studies have been conducted cross-sectionally, in the subacute or chronic phase after stroke.(4-6.)

Tolerance and effectiveness of a new dynamic hand-wrist orthosis in chronic stroke patients.

PURPOSE: To evaluate tolerance of a new dynamic hand-wrist orthosis and effectiveness on the prevention of progressive wrist contracture and spasticity after stroke. METHOD: Chronic stroke patients (N = 6) with upper limb spasticity, who had not been able to endure a static orthosis, were provided with a custom-made dynamic orthosis. Tolerance of the orthosis was evaluated by the daily wearing time, and self-reported pain and spasticity. Effectiveness was measured by contracture of wrist and finger flexor muscles, upper limb spasticity and use of spasticity treatment. Outcome measures were collected at time of fitting of the dynamic orthosis (baseline) and after three and six months. RESULTS: Five patients could endure the dynamic orthosis without discomfort for 6 hours daily during the 6-month period. Self-reported spasticity and pain decreased significantly (p < 0.05) compared to wearing the static orthosis. In comparison to baseline, the maximum passive wrist extension increased significantly from -29° to -12° (p < 0.05). Although, no significant change in spasticity was measured, the use of Botulinum Toxin injections decreased for two patients. CONCLUSIONS: The majority of the included chronic stroke patients tolerated the new dynamic orthosis for at least 6 hours daily and the use significantly reduced wrist contractures in a 6-month period.

How effective are exercise-based injury prevention programmes for soccer players? : A systematic review.

BACKGROUND: The incidence of soccer (football) injuries is among the highest in sports. Despite this high rate, insufficient evidence is available on the efficacy of preventive training programmes on injury incidence. OBJECTIVE: To systematically study the evidence on preventive exercise-based training programmes to reduce the incidence of injuries in soccer. DATA SOURCES: The databases EMBASE/MEDLINE, PubMed, CINAHL, Cochrane Central Register of controlled trials, PEDro and SPORTDiscus™ were searched for relevant articles, from inception until 20 December 2011. The methodological quality of the included studies was assessed using the PEDro scale. STUDY SELECTION: The inclusion criteria for this review were (1) randomized controlled trials or controlled clinical trials; (2) primary outcome of the study is the number of soccer injuries and/or injury incidence; (3) intervention focusing on a preventive training programme, including a set of exercises aimed at improving strength, coordination, flexibility or agility; and (4) study sample of soccer players (no restrictions as to level of play, age or sex). The exclusion criteria were: (1) the article was not available as full text; (2) the article was not published in English, German or Dutch; and (3) the trial and/or training programme relates only to specific injuries and/or specific joints. To compare the effects of the different interventions, we calculated the incidence risk ratio (IRR) for each study. RESULTS: Six studies involving a total of 6,099 participants met the inclusion criteria. The results of the included studies were contradictory. Two of the six studies (one of high and one of moderate quality) reported a statistical significant reduction in terms of their primary outcome, i.e. injuries overall. Four of the six studies described an overall preventive effect (IRR<1), although the effect of one study was not statistically significant. The three studies that described a significant preventive effect were of high, moderate and low quality. CONCLUSIONS: Conflicting evidence has been found for the effectiveness of exercise-based programmes to prevent soccer injuries. Some reasons for the contradictory findings could be different study samples (in terms of sex and soccer type) in the included studies, differences between the intervention programmes implemented (in terms of content, training frequency and duration) and compliance with the programme. High-quality studies investigating the best type and intensity of exercises in a generic training programme are needed to reduce the incidence of injuries in soccer effectively.

Effect of inspiratory muscle training before cardiac surgery in routine care.

BACKGROUND: Inspiratory muscle training (IMT) before cardiac surgery has proved to be a promising intervention to reduce postoperative pneumonia in a randomized controlled trial setting. Effects of IMT in routine care have not been reported. OBJECTIVE: The purpose of this study was to investigate the effect of IMT before cardiac surgery on postoperative pneumonia in routine care at a Dutch university medical center using propensity scoring. DESIGN: This was an observational cohort study. METHODS: All candidates for cardiac surgery were preoperatively stratified by a physical therapist for low risk or high risk for postoperative pulmonary complications. Patients at high risk either engaged in an unsupervised IMT program (20 minutes a day) at home for at least 2 weeks before surgery (group 1) or received usual care (no IMT) (group 2). Results in terms of outcome measures were adjusted with propensity scores to reduce bias caused by nonrandom treatment assignment. RESULTS: The results showed that of the 94 patients at high risk in group 1, 1 patient (1.1%) developed a postoperative pneumonia. In group 2, 8 out of the 252 patients at high risk (3.2%) developed this pulmonary complication (adjusted odds ratio=0.34, 95% confidence interval=0.04-3.38). No significant differences were found regarding median (25th-75th percentile) ventilation time (7 [5-9] hours versus 7 [5-10] hours), length of stay in the intensive care unit (23 [21-24] hours versus 23 [21-25] hours), or total postoperative length of stay (7 [6-11] days versus 7 [5-9] days). LIMITATIONS: The most important limitations of this study were confounding, incomplete data collection, and a low incidence of the primary outcome. CONCLUSIONS: Propensity scoring is believed to be a valuable tool of great potential interest to researchers in the field of observational studies. Whether IMT in routine care resulted in less postoperative pneumonia cannot be concluded.

Effectiveness of an injury prevention programme for adult male amateur soccer players: a cluster-randomised controlled trial.

BACKGROUND: The incidence rate of soccer injuries is among the highest in sports, particularly for adult male soccer players. PURPOSE: To investigate the effect of the 'The11' injury prevention programme on injury incidence and injury severity in adult male amateur soccer players. STUDY DESIGN: Cluster-randomised controlled trial. METHODS: Teams from two high-level amateur soccer competitions were randomly assigned to an intervention (n=11 teams, 223 players) or control group (n=12 teams, 233 players). The intervention group was instructed to perform The11 in each practice session during one soccer season. The11 focuses on core stability, eccentric training of thigh muscles, proprioceptive training, dynamic stabilisation and plyometrics with straight leg alignment. All participants of the control group continued their practice sessions as usual. RESULTS: In total, 427 injuries were recorded, affecting 274 of 456 players (60.1%). Compliance with the intervention programme was good (team compliance=73%, player compliance=71%). Contrary to the hypothesis, injury incidences were almost equal between the two study groups: 9.6 per 1000 sports hours (8.4-11.0) for the intervention group and 9.7 (8.5-11.1) for the control group. No significant differences were found in injury severity, but a significant difference was observed in the location of the injuries: players in the intervention group sustained significantly less knee injuries. CONCLUSIONS: This study did not find significant differences in the overall injury incidence or injury severity between the intervention and control group of adult male soccer players. More research is recommended, focusing on injury aetiology and risk factors in adult male amateur soccer players.

How to increase activity level in the acute phase after stroke.

AIMS AND OBJECTIVES: To study how patients with acute stroke spend their day and to determine whether activity levels of patients with acute stroke in a Dutch university hospital increase after the implementation of interventions to stimulate activity. BACKGROUND: Previous studies suggest that patients with acute stroke are prone to inactivity. Early mobilisation and increasing levels of activities are part of several guidelines for patients with stroke. However, implementing interventions to increase activity levels is difficult owing to time and money constrains. DESIGN: This study used a descriptive pre/postdesign. METHODS: Outcomes is assessed on three levels: location, other people involved and activity, and it is determined by direct non-participant observation. An intervention was implemented to stimulate activity levels of the patients. This intervention consisted of (1) increasing the group therapy session and (2) providing a therapy guide that includes exercises patients can do by themselves or together with nurses, therapists or their family to stimulate the patients to be more active. RESULTS: In total, 66 patients have been observed: 35 during the first and 31 during the second observation periods. Compared with the first observation period, patients in the second observation period spent less time in their room and spent less time lying in bed (49 vs. 29%). They did spend more time sitting in bed (13% vs. 20%) and sitting supported (14% vs. 24%). CONCLUSION: Simple interventions can lead to less inactivity in patients with acute stroke. Nurses should be highly involved in implementing and stimulating these interventions. Also, family can play an important role in reducing inactivity in patients after stroke. RELEVANCE TO CLINICAL PRACTICE: Nurses can play an important role in increasing activity levels of patients by using simple interventions.