"We got there in the end . somehow, we got there": a qualitative study of healthcare professionals providing care in the community to people with chronic aphasia, and how technology could assist.

PURPOSE: Little is known about the experience of healthcare professionals (HCPs) in the community providing healthcare to people with aphasia. In this study we aimed to explore the experiences of community HCPs in healthcare conversations with people with aphasia, and whether a high-tech, purpose-built aphasia app could assist. METHODS: A generic qualitative study was conducted. HCPs from seven different clinical backgrounds were interviewed and data was thematically analysed. RESULTS: The experiences of healthcare providers providing healthcare to people with aphasia were identified in six major themes. These were: (1) Healthcare communication topics; (2) HCP knowledge; (3) Communication exchanges during the interactions (4) Communication impacts on care; (5) Interactions and relationships grew easier over time; and (6) How technology could help interactions. CONCLUSIONS: HCPs with more aphasia knowledge reported having more positive experiences. Unsuccessful interactions were believed to lead to negative emotional responses in people with aphasia and HCPs, and that miscommunications could lead to compromised care. HCPs reported that interactions and relationships with people with aphasia grew easier over time. HCPs need system level support to acquire the knowledge and skills needed to engage people with aphasia in effective healthcare conversations. Technology has potential to improve interactions.

The overall experience of Health care professionals (HCPs) providing healthcare to people with aphasia was reported to be challenging, taking extra emotional and intellectual effort and time.When communication was unsuccessful this often led to emotional distress for both the HCP and person with aphasia and compromised care for the person with aphasia.HCPs with more knowledge and skill, who had conversation partner training, were more likely to have successful communication interactions.More system-level supports such as conversation partner training, and technology support were perceived to be beneficial.

The Buffalo Concussion Treadmill and Bike Tests in People With Mild-to-Moderate Traumatic Brain Injury: An Exploratory Clinical Audit.

OBJECTIVE: To assess the performance on the Buffalo Concussion Treadmill and Bike Tests in nonathletic people following a mild-to-moderate traumatic brain injury. SETTING: An outpatient rehabilitation clinic. PARTICIPANTS: Forty-nine patients with mild-to-moderate traumatic brain injury who underwent the Buffalo Concussion Treadmill or Bike Test as usual clinical care. DESIGN: A retrospective clinical audit. MAIN MEASURES: Demographics and brain injury-specific clinical data, Depression Anxiety Stress Scale; Rivermead Post-Concussion Symptom Questionnaire, and performance outcomes on the Buffalo Concussion Treadmill or Bike Test. RESULTS: Forty-nine patients (mean age: 33.7 ± 13.0 years), on average 56.2 ± 36.4 days post-injury, completed the Buffalo Concussion Treadmill or Bike Test. Fourteen patients stopped the test due to symptom exacerbation with a mean test duration of 8.1 ± 4.5 minutes, reaching an age-predicted maximum heart rate of 72.9% ± 12.4% and reporting a rating of perceived exertion of 13.4 ± 2.2. Those who terminated the test for other reasons had a significantly longer test duration (14.0 ± 4.7 minutes, P = .01), with a higher age-predicted maximum heart rate (83.3% ± 12.8%, P = .01) and rating of perceived exertion (17.0 ± 2.5, P = .01). Within the group who stopped for other reasons, 10 were due to symptoms deemed unrelated to the injury at the time of the test and 2 were stopped by the therapist for safety reasons. A significant but weak correlation between heart rate and rating of perceived exertion existed only for those who terminated the test for other reasons ( r = 0.38, P = .02). Overall, a shorter test duration was associated with higher scores of both self-reported depression ( r = -0.41, P < .01) and late postconcussion symptoms ( r = -0.40, P < .01). CONCLUSION: The Buffalo Concussion Treadmill or Bike Test can be used in the nonathletic mild-to-moderate traumatic brain injury population to differentiate between those who experience symptom exacerbation during exercise and those who do not based on symptom exacerbation, test duration, and poor perception of exertion. Further research is required to determine whether other reasons for test termination are related to the injury.

Physical exercise for people with mild traumatic brain injury: A systematic review of randomized controlled trials.

BACKGROUND: Recent research recommends physical exercise rather than rest following a mild traumatic brain injury (mTBI). OBJECTIVE: To determine the effect of physical exercise on persistent symptoms in people with mTBI. METHODS: A search of randomized controlled trials was conducted in CINAHL, Cochrane Library, EMBASE, MEDLINE, SportDiscus and Web of Science, from 2010 to January 2021. Studies were included if they described the effects of a physical exercise intervention in people with mTBI on persistent symptoms. Study quality, intervention reporting, and confidence in review findings were assessed with the CASP, TIDieR and GRADE respectively. RESULTS: 11 eligible studies were identified for inclusion. Study interventions broadly comprised of two categories of physical exercise, i.e., aerobic (n = 8) and vestibular (n = 3). A meta-analysis (n = 3) revealed the aerobic exercise group improvement was significantly larger compared to the usual care group -0.39 (95% CI: -0.73 to -0.05, p = 0.03). Only three studies using vestibular exercise reported on persistent symptoms and yielded mixed results. CONCLUSIONS: This study demonstrated that the use of aerobic exercise is supported by mixed quality evidence and moderate certainty of evidence, yet there is limited evidence for the use of vestibular exercise for improving persistent symptoms in people with mTBI.

Understanding the Barriers and Enablers to Using Outdoor Spaces in Nursing Homes: A Systematic Review.

BACKGROUND AND OBJECTIVES: Despite acknowledged benefits of residents in nursing homes spending time outdoors, little is known about factors related to their use of outdoor space. This systematic review summarizes reported barriers and enablers to nursing home residents' use of outdoor spaces. RESEARCH DESIGN AND METHODS: Multiple databases were searched to May 2018. Qualitative or mixed methods studies describing barriers/enablers to use of outdoor areas by residents of nursing homes (aged 65 years and older), as reported by residents, staff, or family members were included. Study quality rating, thematic analysis, and stratified analyses were performed and confidence in findings assessed using GRADE-CERQual. RESULTS: Twenty-four studies were included. Nineteen collected data from residents, 15 from staff/caregivers, 7 from families. Major themes and key findings concerned: design of the outdoor area (importance of garden greenery and built features), safety concerns and staffing issues, weather and seasons (appropriate shade and shelter), design of the main building (easy to open doors and nearby access points) and social activities. CONCLUSIONS AND IMPLICATIONS: Providing gardens with seasonal plants and interactive features, weather protected seating, manageable doors at accessible thresholds, planned social activities, and appropriate clothing are fundamental to facilitate nursing home residents' access to the outdoors. Cultural change at an organizational level, addressing perceptions of safety as a barrier is important. Incorporation of the recommendations in this review by architects, facility managers, and policy makers in the design and management of nursing homes, may increase use of outdoor areas and improve the quality of life of residents. REGISTRATION: The protocol is registered in Prospero (CRD42018100249).

Effect of walking on sand on gait kinematics in individuals with multiple sclerosis.

BACKGROUND: Walking in the real-world involves negotiating challenging or uneven surfaces, including sand. This can be challenging for people with Multiple Sclerosis (PWMS) due to motor deficits affecting the lower extremities. The study objective was to characterise kinematic gait adaptations made by PWMS when walking on sand and describe any immediate post-adaptation effects. METHODS: 17 PWMS (mean age 51.4 ± 5.5, Disease Steps 2.4 ± 1.0), and 14 age-and gender matched healthy adults (HA) took part in a case-control study. 3D gait analysis was conducted using an eight-camera Vicon motion capture system. Each participant completed walking trials over level ground (baseline), sand (gait adaptation response), and again level ground (post-adaptation). Spatiotemporal data and kinematic data for the hip knee and ankle were recorded. RESULTS: At baseline PWMS showed significantly less total lower limb flexion (p<0.05) compared to HA. PWMS adapted to walking on sand by significantly increasing hip and knee flexion and ankle dorsiflexion (p<0.05) during swing, resulting in an overall 23° greater total lower limb flexion (p<0.05), reaching values within normal range. During the return to level ground walking values of temporal-spatial and kinematic parameters returned towards baseline values. CONCLUSIONS: PWMS adapted to walking on sand by increasing lower limb flexion during swing, and returned to their gait pattern to near baseline levels, in a manner similar to but with values not equalling HA. Further work is required to determine whether this mode of walking has potential to act as a gait retraining strategy to increase flexion of the lower limb.

Anabolic steroids for rehabilitation after hip fracture in older people

ABSTRACT BACKGROUND: 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. METHODS: Search methods: We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialized 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: Randomized 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. MAIN RESULTS: We screened 1290 records and found only three trials involving 154 female participants, all of whom were aged above 65 years and had had hip fracture surgery. All studies had methodological shortcomings that placed them at high or unclear risk of bias. Because of this high risk of bias, imprecise results and likelihood of publication bias, we judged the quality of the evidence for all primary outcomes to be very low. These trials tested two comparisons. One trial had three groups and contributed data to both comparisons. None of the trials reported on patient acceptability of the intervention. Two very different trials compared anabolic steroid versus control (no anabolic steroid or placebo). One trial compared anabolic steroid injections (given weekly until discharge from hospital or four weeks, whichever came first) versus placebo injections in 29 "frail elderly females". This found very low quality evidence of little difference between the two groups in the numbers discharged to a higher level of care or dead (one person in the control group died) (8/15 versus 10/14; risk ratio (RR) 0.75, 95% confidence interval (CI) 0.42 to 1.33; P = 0.32), time to independent mobilization or individual adverse events. The second trial compared anabolic steroid injections (every three weeks for six months) and daily protein supplementation versus daily protein supplementation alone in 40 "lean elderly women" who were followed up for one year after surgery. This trial provided very low quality evidence that anabolic steroid may result in less dependency, assessed in terms of being either dependent in at least two functions or dead (one person in the control group died) at six and 12 months, but the result was also compatible with no difference or an increase in dependency (dependent in at least two levels of function or dead at 12 months: 1/17 versus 5/19; RR 0.22, 95% CI 0.03 to 1.73; P = 0.15). The trial found no evidence of between-group differences in individual adverse events. Two trials compared anabolic steroids combined with another nutritional intervention ('steroid plus') versus control (no 'steroid plus'). One trial compared anabolic steroid injections every three weeks for 12 months in combination with daily supplement of vitamin D and calcium versus calcium only in 63 women who were living independently at home. The other trial compared anabolic steroid injections every three weeks for six months and daily protein supplementation versus control in 40 "lean elderly women". Both trials found some evidence of better function in the steroid plus group. One trial reported greater independence, higher Harris hip scores and gait speeds in the steroid plus group at 12 months. The second trial found fewer participants in the anabolic steroid group were either dependent in at least two functions, including bathing, or dead at six and 12 months (one person in the control group died) (1/17 versus 7/18; RR 0.15, 95% CI 0.02 to 1.10; P = 0.06). Pooled mortality data (2/51 versus 3/51) from the two trials showed no evidence of a difference between the two groups at one year. Similarly, there was no evidence of between-group differences in individual adverse events. Three participants in the steroid group of one trial reported side effects of hoarseness and increased facial hair. The other trial reported better quality of life in the steroid plus group. AUTHORS' CONCLUSIONS: The available evidence is insufficient to draw conclusions on the effects, primarily in terms of functional outcome and adverse events, of anabolic steroids, either separately or in combination with nutritional supplements, after surgical treatment of hip fracture in older people. Given that the available data points to the potential for more promising outcomes with a combined anabolic steroid and nutritional supplement intervention, we suggest that future research should focus on evaluating this combination.

Anabolic steroids for rehabilitation after hip fracture in older people.

BACKGROUND: 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. MAIN RESULTS: We screened 1290 records and found only three trials involving 154 female participants, all of whom were aged above 65 years and had had hip fracture surgery. All studies had methodological shortcomings that placed them at high or unclear risk of bias. Because of this high risk of bias, imprecise results and likelihood of publication bias, we judged the quality of the evidence for all primary outcomes to be very low.These trials tested two comparisons. One trial had three groups and contributed data to both comparisons. None of the trials reported on patient acceptability of the intervention.Two very different trials compared anabolic steroid versus control (no anabolic steroid or placebo). One trial compared anabolic steroid injections (given weekly until discharge from hospital or four weeks, whichever came first) versus placebo injections in 29 "frail elderly females". This found very low quality evidence of little difference between the two groups in the numbers discharged to a higher level of care or dead (one person in the control group died) (8/15 versus 10/14; risk ratio (RR) 0.75, 95% confidence interval (CI) 0.42 to 1.33; P = 0.32), time to independent mobilisation or individual adverse events. The second trial compared anabolic steroid injections (every three weeks for six months) and daily protein supplementation versus daily protein supplementation alone in 40 "lean elderly women" who were followed up for one year after surgery. This trial provided very low quality evidence that anabolic steroid may result in less dependency, assessed in terms of being either dependent in at least two functions or dead (one person in the control group died) at six and 12 months, but the result was also compatible with no difference or an increase in dependency (dependent in at least two levels of function or dead at 12 months: 1/17 versus 5/19; RR 0.22, 95% CI 0.03 to 1.73; P = 0.15). The trial found no evidence of between-group differences in individual adverse events.Two trials compared anabolic steroids combined with another nutritional intervention ('steroid plus') versus control (no 'steroid plus'). One trial compared anabolic steroid injections every three weeks for 12 months in combination with daily supplement of vitamin D and calcium versus calcium only in 63 women who were living independently at home. The other trial compared anabolic steroid injections every three weeks for six months and daily protein supplementation versus control in 40 "lean elderly women". Both trials found some evidence of better function in the steroid plus group. One trial reported greater independence, higher Harris hip scores and gait speeds in the steroid plus group at 12 months. The second trial found fewer participants in the anabolic steroid group were either dependent in at least two functions, including bathing, or dead at six and 12 months (one person in the control group died) (1/17 versus 7/18; RR 0.15, 95% CI 0.02 to 1.10; P = 0.06). Pooled mortality data (2/51 versus 3/51) from the two trials showed no evidence of a difference between the two groups at one year. Similarly, there was no evidence of between-group differences in individual adverse events. Three participants in the steroid group of one trial reported side effects of hoarseness and increased facial hair. The other trial reported better quality of life in the steroid plus group. AUTHORS' CONCLUSIONS: The available evidence is insufficient to draw conclusions on the effects, primarily in terms of functional outcome and adverse events, of anabolic steroids, either separately or in combination with nutritional supplements, after surgical treatment of hip fracture in older people. Given that the available data points to the potential for more promising outcomes with a combined anabolic steroid and nutritional supplement intervention, we suggest that future research should focus on evaluating this combination.

Incidence of nontraumatic spinal cord injury: a Spanish cohort study (1972-2008).

OBJECTIVES: To assess the incidence of nontraumatic spinal cord injury (SCI) in a determined catchment area in Spain, and to evaluate clinical presentations and trends over time. DESIGN: Population-based case series study between January 1972 and December 2008 [corrected]. SETTING: A hospital with a specialized SCI unit in a delimited health area in Spain. PARTICIPANTS: Hospital inpatients and outpatients with nontraumatic SCI. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Age- and sex-specific incidence rates. RESULTS: An adjusted incidence rate of 11.4 per million population was found for this region (12.3 for males, 10.4 for females). A total of 541 cases (53% male) were reported over the 37-year study period. Incidence rates increased with age, with a peak in the 60- to 69-year age group. Tumors were the major cause of SCI. Most of the lesions were at the thoracic level, and C and D were the most frequently observed American Spinal Injury Association grades. CONCLUSIONS: Nontraumatic SCI shows a relatively even sex distribution and tends to affect older adults. Injuries are mainly attributable to age-related conditions and result mostly in incomplete lesions, which present with paraplegia. This study revealed that although incidence rates for nontraumatic SCI are similar to those previously reported for traumatic SCI in the same area and during the same period, demographic and clinical characteristics are different. These findings have important implications regarding the delivery of rehabilitation and support services to this group of patients, and suggest the need for health policies that involve improved care and prevention resources.

Survival after spinal cord injury: a systematic review.

Spinal cord injury (SCI) leading to neurological deficits produces long-term effects that persist over a lifetime. Survival analysis of patients with SCI, at individual and population level, is important for public health management and the assessment of treatment achievements. The current study evaluated survival following traumatic and non-traumatic SCI worldwide. A systematic review was conducted, and all included papers were assessed for quality using a purposely designed assessment form. Survival data were presented in Kaplan-Meier curves and compared using the log-rank test. Sixteen studies were included of which 11 concerned traumatic SCI, four non-traumatic SCI, and one both. Crude standard mortality rates (SMRs) revealed that overall mortality in SCI is up to three times higher than in the general population. Survival rates were statistically significantly lower in non-traumatic SCI than in traumatic SCI (log-rank p = 0.000). Age at injury, neurological level, extent of lesion, and year of injury have been described as predictors of survival. Causes of death stem from secondary complications, with failure of the respiratory system being the leading cause. This is the first systematic literature review on survival analysis following SCI worldwide. An increase in survival over time was found. However, the SMRs of individuals with SCI still exceed those of an age-matched non-disabled population, mainly due to secondary complications. Lower survival rates were observed in non-traumatic SCI compared with traumatic SCI.