Is an instrumented spasticity assessment an improvement over clinical spasticity scales in assessing and predicting the response to integrated botulinum toxin type a treatment in children with cerebral palsy? Comprehensive quantification of the spastic catch in children with cerebral palsy. Interventions aimed at increasing research use in nursing: a systematic review Differences in kinematic parameters and plantarflexor reflex responses between manual (Ashworth) and isokinetic mobilisations in spasticity assessment Validation of portable muscle tone measurement device for quantifying velocity-dependent properties in elbow spasticity. Psychometric testing of fatigue instruments for use with cancer patients. Reduction of spastic hypertonia during repeated passive knee movements in stroke patients. Spasticity versus strength in cerebral palsy: relationships among involuntary resistance, voluntary torque, and motor function. Combining strength training and botulinum neurotoxin intervention in children with cerebral palsy: the impact on muscle morphology and strength Cannabinoids for treatment of spasticity and other symptoms related to multiple sclerosis (CAMS study): multicentre randomised placebo-controlled trial Muscle Strengthening in Children and Adolescents With Spastic Cerebral Palsy: Considerations for Future Resistance Training Protocols Physical rehabilitation interventions for adult patients with critical illness across the continuum of recovery: an overview of systematic reviews protocol Functional electrical stimulation of dorsiflexor muscle: effects on dorsiflexor strength, plantarflexor spasticity, and motor recovery in stroke patients. Caries-preventive effect of glass ionomer and resin-based fissure sealants on permanent teeth: An update of systematic review evidence Development of the risk appraisal measure: a brief screen to identify risk areas and guide interventions for dementia caregivers. Protocol for a systematic review of time to antibiotics (TTA) in patients with fever and neutropenia during chemotherapy for cancer (FN) and interventions aiming to reduce TTA Radial extracorporeal shock wave therapy (rESWT) in the treatment of spasticity in cerebral palsy: a randomized, placebo-controlled clinical trial. Does Nintendo Wii Balance Board improve standing balance? A randomized controlled trial in children with cerebral palsy. Are we underestimating the clinical efficacy of botulinum toxin (type A)? Quantifying changes in spasticity, strength and upper limb function after injections of Botox® to the elbow flexors in a unilateral stroke population Modified Constraint-Induced Movement Therapy combined with Bimanual Training (mCIMT-BiT) in children with unilateral spastic cerebral palsy: how are improvements in arm-hand use established? Systematic review of cognitive behavioural therapy for the management of headaches and migraines in adults Rehabilitation for people with multiple sclerosis: an overview of Cochrane Reviews. Kinematic Aiming Task: Measuring Functional Changes in Hand and Arm Movements After Botulinum Toxin-A Injections in Children with Spastic Hemiplegia
OBJECTIVE To compare responsiveness and predictive ability of clinical and instrumented spasticity assessment s after botulinum toxin type A ( BTX ) treatment combined with casting in the medial hamstrings ( MEHs ) in children with spastic cerebral palsy ( CP ) . DESIGN Prospect i ve cohort study . SETTING Hospital . PARTICIPANTS Consecutive sample of children ( N=31 ; 40 MEH muscles ) with CP requiring BTX injections . INTERVENTION Clinical and instrumented spasticity assessment s before and on average ± SD 53±14 days after BTX . MAIN OUTCOME MEASURES Clinical spasticity scales included the Modified Ashworth Scale and the Modified Tardieu Scale . The instrumented spasticity assessment integrated biomechanical ( position and torque ) and electrophysiological ( surface electromyography ) signals during manually performed low- and high-velocity passive stretches of the MEHs . Signals were compared between both stretch velocities and were examined pre- and post-BTX . Responsiveness of clinical and instrumented assessment s was compared by percentage exact agreement . Prediction ability was assessed with a logistic regression and the area under the receiver operating characteristic ( ROC ) curves of the baseline parameters of responders versus nonresponders . RESULTS Both clinical and instrumented parameters improved post-BTX ( P≤.005 ) ; however , they showed a low percentage exact agreement . The baseline Modified Tardieu Scale was the only clinical scale predictive for response ( area under the ROC curve=0.7 ) . For the instrumented assessment , baseline values of root mean square ( RMS ) electromyography and torque were better predictors for a positive response ( area under the ROC curve=.82 ) . Baseline RMS electromyography remained an important predictor in the logistic regression . CONCLUSIONS The instrumented spasticity assessment showed higher responsiveness than the clinical scales . The amount of RMS electromyography is considered a promising parameter to predict treatment response In clinical setting s , the spastic catch is judged subjectively . This study assessed the psychometric properties of objective parameters that define and quantify the severity of the spastic catch in children with cerebral palsy ( CP ) . A convenience sample of children with spastic CP ( N=46 ; age range : 4 - 16 years ) underwent objective spasticity assessment s. High velocity , passive stretches were applied to the gastrocnemius ( GAS ) and medial hamstrings ( MEH ) .  Muscle activity was measured with surface electromyography ( sEMG ) , joint angle characteristics using inertial sensors and reactive torque using a force sensor . To test reliability , a group of 12 children were retested after an average of 13 ± 9 days . The angle of spastic catch ( AOC ) was estimated by three biomechanical definitions : joint angle at ( 1 ) maximum angular deceleration ; ( 2 ) maximum change in torque ; and ( 3 ) minimum power . Each definition was checked for reliability and validity . Construct and clinical validity were evaluated by correlating each AOC definition to the averaged root mean square envelope of EMG ( RMS-EMG ) and the Modified Tardieu Scale ( MTS ) . Severity categories were created based on selected parameters to establish face validity . All definitions showed moderate to high reliability . Significant correlations were found between AOC3 and the MTS of both muscles and the RMS-EMG of the MEH , though coefficients were only weak . AOC3 further distinguished between mild , moderate and severe catches . Objective parameters can define and quantify the severity of the spastic catch in children with CP . However , a comprehensive underst and ing requires the integration of both biomechanical and RMS-EMG data Background There has been considerable interest recently in developing and evaluating interventions to increase research use by clinicians . However , most work has focused on medical practice s ; and nursing is not well represented in existing systematic review s. The purpose of this article is to report findings from a systematic review of interventions aim ed at increasing research use in nursing . Objective To assess the evidence on interventions aim ed at increasing research use in nursing . Methods A systematic review of research use in nursing was conducted using data bases ( Medline , CINAHL , Healthstar , ERIC , Cochrane Central Register of Controlled Trials , and Psychinfo ) , grey literature , ancestry search ing ( Cochrane Data base of Systematic Review s ) , key informants , and manual search ing of journals . R and omized controlled trials and controlled before- and after- studies were included if they included nurses , if the intervention was explicitly aim ed at increasing research use or evidence -based practice , and if there was an explicit outcome to research use . Method ological quality was assessed using pre-existing tools . Data on interventions and outcomes were extracted and categorized using a pre-established taxonomy . Results Over 8,000 titles were screened . Three r and omized controlled trials and one controlled before- and after- study met the inclusion criteria . The method ological quality of included studies was generally low . Three investigators evaluated single interventions . The most common intervention was education . Investigators measured research use using a combination of surveys ( three studies ) and compliance with guidelines ( one study ) . Research er-led educational meetings were ineffective in two studies . Educational meetings led by a local opinion leader ( one study ) and the formation of multidisciplinary committees ( one study ) were both effective at increasing research use . Conclusion Little is known about how to increase research use in nursing , and the evidence to support or refute specific interventions is inconclusive . To advance the field , we recommend that investigators : ( 1 ) use theoretically informed interventions to increase research use , ( 2 ) measure research use longitudinally using theoretically informed and psychometrically sound measures of research use , as well as , measuring patient outcomes relevant to the intervention , and ( 3 ) use more robust and method ologically sound study design s to evaluate interventions . If investigators aim to establish a link between using research and improved patient outcomes they must first identify those interventions that are effective at increasing research use OBJECTIVE The purpose of this study was first to compare the kinematic parameters of imposed ankle mobilizations measured during Ashworth or isokinetic tests and , second , to better underst and why the stretch reflex was more or less easily elicited by one method or the other . METHODS Passive dorsiflexions were applied on eight adult patients with plantarflexor spasticity in two conditions : ( i ) manually , using the Ashworth test where passive dorsiflexions were performed freely by seven rehabilitation clinicians , and ( ii ) instrumentally , using an isokinetic device ( Cybex Norm ) and a dorsiflexion velocity at 300 degrees /s .  Mean values of initial ankle position , maximal angular velocity ( theta;'(max ) ) , maximal angular acceleration ( theta;''(max ) ) and plantarflexor reflex responses obtained with each method were compared . RESULTS During the Ashworth test , all the patients presented reflex activities in the triceps surae while , during the isokinetic mobilization , only three out of the eight patients tested shown reflex responses . theta;'(max ) values were significantly higher ( P<0.05 ) in the manual test ( 308+/-80 degrees /s vs 216+/-5.5 degrees /s for the isokinetic test ) . The most marked difference concerned the theta;''(max ) values ( 5046+/-2181 degrees /s(2 ) for the Ashworth test vs 819+/-18 degrees /s(2 ) for the isokinetic test , P<0.001 ) . This parameter was significantly correlated with the mean rms-EMG values of the gastrocnemius lateralis ( GL ) and the soleus ( SOL ) . CONCLUSIONS This study indicates that passive dorsiflexions imposed during Ashworth and isokinetic tests largely differ in velocity and acceleration , and the higher dynamic parameters evaluated during the Ashworth test could mainly explain that the stretch reflex was more easily elicited during this manual testing . SIGNIFICANCE If isokinetic devices offer numerous advantages in the assessment of passive resistance to spastic muscle stretch , they can not be used to simulate the manual test The objective of this study is to develop a portable device for quantifying the velocity-dependent properties of spastic elbow muscles .  Based on a motor-driven system , validation tests of the portable system such as accuracy and response of sensors were first examined . Furthermore , simulated modules ( inertia , damper and spring ) as well as elbow joints ( 15 control and 15 hemiplegic subjects ) were manually stretched under four different frequencies ( 1/3 , 1/2 , 1 and 3/2 Hz ) through 60 degrees range of motion . Joint resistance and displacement during sinusoidal stretch were collected for further analysis . Two quantitative parameters ( i.e. , viscous components under each frequency and averaged viscosity across four frequencies ) were derived to estimate the velocity-dependent properties of elbow joint . Tests of simulated modules confirm the manual stretch protocol and data analysis are valid in estimating the velocity-dependent component during a sinusoidal stretch . Compared to normal control , viscous component in each stretch frequency and averaged viscosity were significantly higher in subjects with spasticity ( P < 0.001 ) . The viscous component and averaged viscosity were found highly correlated with the modified Ashworth scale . These findings suggest that measurements of viscous component and averaged viscosity during manual sinusoidal stretching using the portable device could be clinical ly useful in evaluating spasticity BACKGROUND Cancer treatment-related fatigue ( CRF ) is a common side effect of cancer treatment . A problem identified in most review s of CRF is lack of sound approaches to measurement that are congruent with the conceptualization of CRF as a self-perceived state . The diversity of instruments available to measure fatigue and the lack of comprehensive testing of several promising instruments with cancer patients undergoing treatment provided the rationale for this study . The purpose of this article is to report the results of psychometric testing of several fatigue instruments in patients undergoing cancer treatment . OBJECTIVES The aims of this study were to determine the reliability , validity , and responsiveness of each instrument and to determine the ability of each instrument to capture CRF . METHODS Existing fatigue instruments with published psychometric information that indicated suitability for further testing were selected and included the Profile of Mood States Short Form fatigue subscale ( F_POMS-sf ) ,  Multidimensional Assessment of Fatigue ( MAF ) ,  Lee Fatigue Scale ( LFS ) , and the  Multidimensional Fatigue Inventory ( MFI ) . Data were collected at a university-based clinical cancer center and a freest and ing comprehensive cancer center . Subjects completed all study instruments , which were presented in r and om order , at a time when CRF was expected to be high and again when it was expected to be low . A subset of subjects completed the instruments within 48 hours of one of the data collection points when CRF was expected to be relatively unchanged to provide stability data . RESULTS Reliability estimates using Cronbach 's alpha indicated that all instruments examined had good internal consistency . Test-retest correlations showed good stability for total scores on all the instruments , but some subscales of the LFS and MFI had marginal stability . Factor analysis of all instruments indicated that only the LFS and the F_POMS-sf fully supported their construct validity . All of the instruments showed responsiveness to changes in CRF related to treatment . CONCLUSIONS The results of the study provide research ers and clinicians with detailed comparisons of the performance of established fatigue measures in cancer patients undergoing treatment to use when selecting measures of CRF OBJECTIVES To quantify changes in spastic hypertonia during repeated passive isokinetic knee movements in stroke patients and to assess the role of muscle activity . DESIGN A between-groups design with repeated measures . SETTING Rehabilitation center for stroke patients . PARTICIPANTS Ten stroke patients with hypertonia and 10 healthy subjects matched for age and gender . INTERVENTION With an isokinetic apparatus , movements were imposed on the knee in series of 10 repetitions at speeds of 60 degrees /s , 180 degrees /s , and 300 degrees /s . MAIN OUTCOME MEASURES Spastic hypertonia was assessed on the basis of torque measurement and electromyographic activity of the quadriceps , hamstrings , and gastrocnemius muscles . RESULTS Compared with the controls , stroke patients presented a significantly stronger torque reduction during the mid- and endphases of movements at all speeds tested ( P<.05 ) . The strongest torque decline occurred during knee flexion and during the first movements . The effect increased toward the end phase of movements and with increasing speeds . The effect of movement repetitions on torque measurements was unchanged after electromyographic activity was included in the statistical analysis , except during extension movements at 180 degrees /s and 300 degrees /s . CONCLUSION Passive movements of the knee induced a decrease of spastic hypertonia in stroke patients through a combination of reflexive and mechanical factors . The role of these mechanisms is velocity dependent and differs for flexion and extension movements Despite the lack of consensus of the role of spasticity in the observed motor disability in cerebral palsy ( CP ) , alleviation of spasticity remains a primary focus in the clinical management of these patients . The purpose s of this study were to : ( 1 ) quantify voluntary torque and passive resistance across speeds in the hamstrings and quadriceps muscle groups with respect to the presence of stretch responses and /or passive muscle stiffness in patients with CP compared to age-related children without disability , and ( 2 ) relate these parameters to each other and to functional performance , as measured by the Gross Motor Function Measure ( GMFM ) , in CP . Included were 23 subjects with CP , sub-grouped by the presence or absence of stretch responses as determined by electromyography , and 9 subjects without CP .  Results indicated that peak torque was considerably greater in the comparison group than for each of the CP groups and resistance was greater in the CP group with spasticity compared to the nonspastic CP group in both muscles at all speeds . Stiffness differed between the spastic CP group and the comparison group only for the quadriceps at the fastest speed . Higher passive resistance torque and stiffness were correlated with decreased voluntary torque , particularly for the antagonists , and with lower GMFM scores . In conclusion , strength and motor function are related to the magnitude of resistance torque and stiffness in CP , although the small amount of variance explained reinforces the multidimensional nature of this disorder , and the challenges inherent in managing it Purpose : Investigate the combination effects of strength training and Botulinum Toxin Type-A ( BoNT-A ) on muscle strength and morphology in children with Cerebral Palsy ( CP ) . Methods : Fifteen children receiving BoNT-A , classified as Spastic Diplegic CP , GMFCS I-II , and aged 5–12 years were recruited for this study . R and omly allocated to 10 weeks of strength training either before or after BoNT-A , children were assessed over 6 months . Eight of the 15 children also completed a control period . The Modified Ashworth Scale measured spasticity . The Goal Attainment Scale ( GAS ) assessed achievement of functional goals . Magnetic Resonance Imaging assessed muscle volume ( MV ) . Instrumented dynamometry assessed strength . Results : Spasticity was significantly reduced following BoNT-A injection ( p = 0.033 ) . Children made significant isokinetic strength gains ( mean p = 0.022 , ES = 0.57 ) in the intervention period compared to the control period ( mean p = 0.15 , ES = 0.56 ) . Irrespective of timing , significant strength improvements were seen immediately ( 10 weeks ) and over 6 months for all children . This was also the case for improvements in the GAS ( immediately : mean p = 0.007 , ES = 4.17 , 6 months : mean p = 0.029 , ES = 0.99 ) , and improvements in MV in all assessed muscles . Conclusion : The simultaneous use of BoNT-A and strength training was successful in spasticity reduction , improving strength and achieving functional goals , over and above treatment with BoNT-A alone . Muscles targeted for BoNT-A injection should be included in strength training . Implication s for Rehabilitation Cerebral Palsy Botulinum toxin type-A ( BoNT-A ) and strength training are available interventions that , on their own have found success in managing spasticity and muscle weakness ( both significant motor impairments ) , respectively in children with Cerebral Palsy ( CP ) . This study has demonstrated that the concurrent treatment of BoNT-A and strength training can achieve positive outcomes in terms of strength , spasticity and for the achievement of set functional goals . The results of this study show that the improved muscle strength can be associated with hypertrophy , which could indicate the potential role of strength training in altering the rate of muscle growth , in an aim to improve the failure of muscle growth associated with CP . Home based strength training , based on a child ’s individual goals is shown to be successful in improving strength and goal attainment for children with CP BACKGROUND Multiple sclerosis is associated with muscle stiffness , spasms , pain , and tremor . Much anecdotal evidence suggests that cannabinoids could help these symptoms . Our aim was to test the notion that cannabinoids have a beneficial effect on spasticity and other symptoms related to multiple sclerosis . METHODS We did a r and omised , placebo-controlled trial , to which we enrolled 667 patients with stable multiple sclerosis and muscle spasticity . 630 participants were treated at 33 UK centres with oral cannabis extract ( n=211 ) , Delta9-tetrahydrocannabinol ( Delta9-THC ; n=206 ) , or placebo ( n=213 ) . Trial duration was 15 weeks . Our primary outcome measure was change in overall spasticity scores , using the Ashworth scale . Analysis was by intention to treat . FINDINGS 611 of 630 patients were followed up for the primary endpoint . We noted no treatment effect of cannabinoids on the primary outcome ( p=0.40 ) . The estimated difference in mean reduction in total Ashworth score for participants taking cannabis extract compared with placebo was 0.32 ( 95 % CI -1.04 to 1.67 ) , and for those taking Delta9-THC versus placebo it was 0.94 ( -0.44 to 2.31 ) . There was evidence of a treatment effect on patient-reported spasticity and pain ( p=0.003 ) , with improvement in spasticity reported in 61 % ( n=121 , 95 % CI 54.6 - 68.2 ) , 60 % ( n=108 , 52.5 - 66.8 ) , and 46 % ( n=91 , 39.0 - 52.9 ) of participants on cannabis extract , Delta9-THC , and placebo , respectively . INTERPRETATION Treatment with cannabinoids did not have a beneficial effect on spasticity when assessed with the Ashworth scale . However , though there was a degree of unmasking among the patients in the active treatment groups , objective improvement in mobility and patients ' opinion of an improvement in pain suggest cannabinoids might be clinical ly useful Resistance training of the lower limbs is now commonly used in clinical practice in children and adolescents with spastic cerebral palsy ( CP ) . However , the effectiveness of this type of training is still disputed . The most recently published systematic review with meta- analysis included interventions such as electrical stimulation and resistance training and found insufficient evidence to support or refute the efficacy of these exercises in children with CP . Thus , the aim of this article is to evaluate the extent to which training protocol s from the most recent r and omized controlled trials are in keeping with the evidence for effective resistance  training in children who are developing typically , as reflected in the training guidelines of the National Strength and Conditioning Association . Recommendations for resistance training protocol s , based on this evidence and appropriate to children with CP , are provided to help guide both future research and clinical practice for resistance training in children with CP Background Patients admitted to the intensive care unit with critical illness often experience significant physical impairments , which typically persist for many years following resolution of the original illness . Physical rehabilitation interventions that enhance restoration of physical function have been evaluated across the continuum of recovery following critical illness including within the intensive care unit , following discharge to the ward and beyond hospital discharge . Multiple systematic review s have been published appraising the exp and ing evidence investigating these physical rehabilitation interventions , although there appears to be variability in review methodology and quality . We aim to conduct an overview of existing systematic review s of physical rehabilitation interventions for adult intensive care patients across the continuum of recovery . Methods / design This protocol has been developed according to the Preferred Reporting Items for Systematic Review s and Meta-Analyses Protocol ( PRISMA -P ) guidelines . We will search the Cochrane Systematic Review Data base , Data base of Abstract s of Review s of Effectiveness , Cochrane Central Register of Controlled Trials , MEDLINE , Excerpta Medica Data base and Cumulative Index to Nursing and Allied Health Literature data bases . We will include systematic review s of r and omised controlled trials of adult patients , admitted to the intensive care unit and who have received physical rehabilitation interventions at any time point during their recovery . Data extraction will include systematic review aims and rationale , study types , population s , interventions , comparators , outcomes and quality appraisal method . Primary outcomes of interest will focus on findings reflecting recovery of physical function . Quality of reporting and method ological quality will be appraised using the PRISMA checklist and the Assessment of Multiple Systematic Review s tool . Discussion We anticipate the findings from this novel overview of systematic review s will contribute to the synthesis and interpretation of existing evidence regarding physical rehabilitation interventions and physical recovery in post-critical illness patients across the continuum of recovery . Systematic review registration PROSPERO CRD42015001068 OBJECTIVE To evaluate the therapeutic effects of Functional Electrical Stimulation ( FES ) of the tibialis anterior muscle on plantarflexor spasticity , dorsiflexor strength , voluntary ankle dorsiflexion , and lower extremity motor recovery with stroke survivors . DESIGN We conducted a prospect i ve interventional study . SETTING Rehabilitation ward , physiotherapy unit and gait analysis laboratory . PARTICIPANTS Fifty-one patients with foot drop result ing from stroke . INTERVENTION The functional electrical stimulation ( FES ) group ( n=27 ) received 20 - 30 minutes of electrical stimulation to the peroneal nerve and anterior tibial muscle of the paretic limb along with conventional rehabilitation program ( CRP ) . The control group ( n=24 ) treated with CRP only . The subjects were treated 1 hr per day , 5 days a week , for 12 weeks . MAIN OUTCOME MEASURES Plantarflexor spasticity measured by modified ashworth scale ( MAS ) , dorsiflexion strength measured by manual muscle test ( MMT ) , active/passive ankle joint dorsiflexion range of motion , and lower-extremity motor recovery by Fugl-Meyer assessment ( FMA ) scale . RESULTS After 12 weeks of treatment , there was a significant reduction in a plantarflexor spasticity by 38.3 % in the FES group and 21.2 % in control group ( P < 0.05 ) , between the beginning and end of the trial . Dorsiflexor muscle strength was increased significantly by 56.6 % and 27.7 % in the FES group and control group , respectively . Similarly , voluntary ankle dorsiflexion and lower-extremity motor function improved significantly in both the groups . No significant differences were found in the baseline measurements among groups . When compared with control group , a significant improvement ( p < 0.05 ) was measured in all assessed parameters in the FES group at post-treatment assessment , thus FES therapy has better effect on recovery process in post-stroke rehabilitation . CONCLUSIONS Therapy combining FES and conventional rehabilitation program was superior to a conventional rehabilitation program alone , in terms of reducing spasticity , improving dorsiflexor strength and lower extremity motor recovery in stroke patients Background This article constitutes a partial up date of the original systematic review evidence by Yengopal et al. from 15 January 2008 ( published in the Journal of Oral Science in 2009 ) with primary focus on research quality in regard to bias risk in trials . Its aim is to up date the existing systematic review evidence from the English literature as to whether caries occurrence on pits and fissures of teeth sealed with either GIC or resin is the same . Methods In addition to the 12 trials included during the original systematic review , 5 new trials were identified during the data base search ( up to 26 August 2010 ) and 2 further trials were included from a h and search and reference check . Of these , 3 trials were excluded and 16 were accepted for data extraction and quality assessment . The quality of accepted trials was assessed , using up date d quality criteria , and the risk of bias was investigated in more depth than previously reported . In addition , the focus of quantitative synthesis was shifted to single data sets that were extracted from the accepted trials . Results Twenty-six dichotomous and 4 continuous data sets were extracted . Meta- analysis and cumulative meta- analysis were used in combining clinical ly homogenous data sets . The overall outcome of the computed data sets suggest no difference between the caries-preventive effects of GIC- and resin-based fissure sealants . Conclusions This overall outcome is in agreement with the conclusions of the original systematic review . Although the findings of the trials identified in this up date may be considered to be less affected by attrition- and publication bias , their risk of selection - and detection-/performance bias is high . Thus , verification of the currently available results requires further high quality r and omised control trials OBJECTIVES To develop and vali date a brief screening measure for use in research , healthcare , and community setting s to systematic ally assess well-being and identify needed areas of support for caregivers of patients with dementia . DESIGN This study used data from Re sources for Enhancing Alzheimer 's Caregiver Health ( REACH II ) , a multisite r and omized clinical trial of a behavioral intervention design ed to improve the quality of life of caregivers in multiple domains . SETTING REACH II . PARTICIPANTS Two hundred twelve Hispanic , 211 black , and 219 white family caregivers providing in-home care to patients with dementia . MEASUREMENT Based on conceptual and psychometric analyses , a 16-item measure was developed that assesses six domains linked to caregiver risk and amenable to intervention : depression , burden , self-care and health behaviors , social support , safety , and patient problem behaviors . The reliability and validity of the instrument was evaluated with 642 dementia caregiver dyads from the REACH II program . RESULTS The measure was found to have acceptable internal consistency for a multidimensional scale and similar measurement properties for each of the racial and ethnic groups . Concurrent validity was also demonstrated for the measure . CONCLUSION The REACH Risk Appraisal Measure developed in this study shows promise as an assessment tool that can be used in research , clinical , and community setting s to guide , prioritize , and target needed areas of support for caregivers of patients with dementia Background Fever and  neutropenia ( FN ) is a common complication of chemotherapy for cancer . Prompt empiric broad-spectrum antibiotic therapy in FN is typically considered st and ard of care , but the definition of prompt is not clear . We seek to systematic ally review the available data on the association between time to antibiotics ( TTA ) administration and clinical outcomes in patients with FN being treated with chemotherapy .  There have been several efforts to reduce TTA in patients with FN , by implementing specific interventions , presuming there will be a beneficial effect on patient-important outcomes . This systematic review will also collect data on such interventions and their effect to reduce TTA and potentially change clinical outcomes . Methods / design The search will cover MEDLINE , MEDLINE In-Process & Other Non-Indexed Citations , EMBASE , CINAHL , CDSR , CENTRAL , and LILACS . A full- search strategy is provided . Lists of studies identified by references cited and forward citation search ing of included articles will also be review ed . Studies will be screened , and data extracted by one research er and independently checked by a second . Confounding biases and quality of studies will be assessed with the risk of bias in non-r and omised studies -of interventions ( ROBINS-I ) tool . Data will be presented in narrative and tabular forms ; in addition , if appropriate data is available , r and om effects meta- analysis will be used to examine TTA.A detailed analysis plan , including an assessment of heterogeneity and publication bias , is provided . Discussion This study aims to evaluate the association between TTA and patient-important clinical outcomes . Additionally , it will identify , critically appraise , and synthesis e information on performed interventions and its effect to reduce TTA as a way of gaining insight into the potential use of these approaches . This will provide better knowledge for an adjusted treatment approach of FN . Systematic review registration PROSPERO [ CRD42018092948 AIM The aim of this study was to evaluate the efficacy and safety of radial extracorporeal shock wave therapy ( rESWT ) in the treatment of spasticity in patients with cerebral palsy . METHODS Fifteen patients with spastic cerebral palsy , 12 men and 3 women , aged 10 - 46 years ( mean age 31 ) . The 15 patients presented 40 spastic muscles that were divided in three groups using a computerized r and om-number generator . The first group , received rESWT in spastic muscle . The second group received rESWT in spastic muscle + rESWT in antagonist muscle . The third group received placebo .  Range of motion and Ashworth Scale were performed . This study is a r and omized , placebo-controlled clinical trial . The patients were treated in 3 sessions at intervals of one week . RESULTS There are significant differences between groups treated with rESWT and group placebo . A significant decrease in the Ashworth Scale , an increase in the range of motion , were observed in all patients that were treated with rESWT . Positive results were maintained for at least 2 months after treatment . INTERPRETATION The treatment with rESWT is more effective than placebo in decreasing spasticity of patients with CP BACKGROUND Evidence on the effect of systemic exercise programs to improve the st and ing balance with the Nintendo Wii system is very limited and its post-treatment effectiveness is unknown in cerebral palsy ( CP ) patients . AIM Primary aim was to compare the effect of Nintendo Wii balance board ( Wii-therapy ) and st and ard physiotherapy ( SPT ) , on the performance of st and ing balance in children and adolescents with CP . Secondary aim was to determine the post-treatment effectiveness of Wii-therapy and SPT . DESIGN Two-arm , matched-pairs , parallel-groups , r and omized , controlled clinical trial . SETTING Outpatient Rehabilitation Centre in the city of Talca . POPULATION Patients with CP type spastic hemiplegia ( SHE ) and spastic diplegia ( SDI ) , aged 7 to 14 years , and level I or II of GMFCS or GMFCS-ER . Were excluded patients with FSIQ<80 , epilepsy , previous surgeries and application of Botulinum Toxin-A in the lower limb , uncorrected vision and hearing disorders . METHODS Thirty-two CP patients ( 10.7±3.2 years old ) were r and omly assigned to either Wii-therapy ( SDI=7 ; SHE=9 ) or SPT intervention ( SDI=7 ; SHE=9 ) . In each group , patients received three sessions per week over a period of 6 weeks . St and ing balance was assessed at baseline and every 2 weeks . Additionally , two follow-up assessment s ( 4 additional weeks ) were performed to determine post-treatment effectiveness . St and ing balance was quantified on force platform obtaining the outcomes area of center-of-pressure ( CoP ) sway ( CoPSway ) , st and ard deviation in the medial-lateral ( SDML ) and the anterior-posterior ( SDAP ) directions , and velocity in both directions ( VML and VAP ) . RESULTS Compared to SPT , Wii-therapy significantly reduced the CoPSway ( P=0.02 ) and SDAP in the eyes-open condition ( P=0.01 ) . However , the effects wane after 2 - 4 weeks . Post-hoc analysis revealed that only SHE children benefited from Wii-therapy . CONCLUSIONS Wii-therapy was better than SPT in improving st and ing balance in patients with CP , but improves the balance only in SHE patients .  Also , Wii-therapy effectiveness waned 2 - 4 weeks after the end the intervention . CLINICAL REHABILITATION IMPACT A systematic exercise program like Wii-therapy using the Nintendo Wii Balance Board device can be considered to improves the st and ing balance in patients with CP , specifically in the SHE type . This program is easy to transfer to physiotherapists and rehabilitation centers Objective : To quantify the clinical efficacy of botulinum toxin type A in treating elbow flexor spasticity in a unilateral stroke population . Location : A spasticity clinic at a regional neurological rehabilitation centre . Study design : A convenience sample longitudinal study . Fourteen subjects with elbow flexor spasticity secondary to a stroke were recruited . Two repeated measures , one before and another four weeks after treatment , were taken to quantify clinical efficacy . Outcome measures : Elbow flexor spasticity was simultaneously rated with the modified Ashworth scale ( MAS ) and quantified by measuring the surface EMG from the flexors using a custom-built device . Strength at the elbow ( isometric ) , grip strength and upper limb function ( Action Research Arm test ) were also assessed . Treatment : Injections of botulinum toxin type A ( Botox ® ) to the m.biceps brachii ( mean dose 70 U ) , m.brachioradialis ( mean dose 56.5 U ) and m.flexor digitorum longus ( mean dose 83.3 U ) . Results : Following treatment , spasticity ( as measured by flexor EMG activity ) reduced but the MAS was unable to detect this improvement . In some subjects , isometric flexor strength at the elbow as well as grip strength increased . This was contrary to the expected weakening following treatment with botulinum toxin type A and suggests an optimization of motor control . Conclusion : Treatment with Botox ® reduces spasticity but does not necessarily cause a reduction in the force generating capabilities at the joint . The improvement in strength may have contributed to the improvements in upper limb function . The MAS is an inappropriate measure of spasticity A recent r and omized controlled trial indicated that modified Constraint-Induced Movement Therapy followed by Bimanual Training ( mCIMT-BiT ) is an effective intervention to improve spontaneous use of the affected upper limb in children with unilateral spastic cerebral palsy ( CP ) . The present study aim ed to investigate how the above-mentioned improvements as a result of 8 weeks mCIMT-BiT were established . 52 children with unilateral spastic CP with Manual Ability Classification System ( MACS ) scores I , II or III and aged 2.5 - 8 years were r and omly allocated to either mCIMT-BiT ( n = 28 ) or Usual Care ( UC ) ( n = 24 ) . Developmental disregard ( ' learned non-use ' ) and upper limb capacity and performance scores were derived from the Video Observations Aarts and Aarts , module Determine Developmental Disregard . Active and passive range of motion at the affected wrist and elbow were assessed using goniometry during isolated movements . Upper limb capacity and performance demonstrated significantly greater improvements after mCIMT-BiT compared to UC , which lasted up to 8 weeks follow-up , whereas developmental disregard and passive and active range of motion did not show differential effects . The results support the notion that improvement of capacity and performance of the upper limb through mCIMT-BiT in children with unilateral spastic CP is based on a better utilization of existing motor functions of the affected arm and h and . However , enhancement of the overall amount of use ( or the reduction of learned non-use ) may still be suboptimal leaving room for improvement of this treatment Aim : This systematic review aim ed to establish if cognitive behavioural therapy ( CBT ) can reduce the physical symptoms of chronic headache and migraines in adults . Methods : Evidence from search es of eight data bases was systematic ally sought , appraised and synthesis ed . Screening of title and abstract s was conducted independently by two review ers . Full papers were screened , data extracted and quality assessed by one review er and checked by a second . Data were synthesis ed narratively by intervention due to the heterogeneity of the studies . The inclusion criteria specified r and omised controlled trials with CBT as an intervention in adults suffering from chronic headaches/migraines not associated with an underlying pathology/medication overuse .  CBT was judged on the basis of authors describing the intervention as CBT . The diagnosis of the condition had to be clinician verified . Studies had to include a comparator and employ headache/migraine-specific outcomes such as patient-reported headache days . Results : Out of 1126 screened titles and abstract s and 20 assessed full papers , 10 studies met the inclusion criteria of the review . Some studies combined CBT with another intervention , as well as employing varying numbers of comparators . CBT was statistically significantly more effective in improving some headaches-related outcomes in CBT comparisons with waiting lists ( three studies ) , in combination with relaxation compared with relaxation only ( three studies ) or antidepressant medication ( one study ) , with no statistically significant differences in three studies . Conclusions : The findings of this review were mixed , with some studies providing evidence in support of the suggestion that people experiencing headaches or migraines can benefit from CBT , and that CBT can reduce the physical symptoms of headache and migraines . However , methodology inadequacies in the evidence base make it difficult to draw any meaningful conclusions or to make any recommendations BACKGROUND Multiple sclerosis ( MS ) is a major cause of chronic , neurological disability , with a significant long-term disability burden , often requiring comprehensive rehabilitation . OBJECTIVES To systematic ally evaluate evidence from published Cochrane Review s of clinical trials to summarise the evidence regarding the effectiveness and safety of rehabilitation interventions for people with MS ( pwMS ) , to improve patient outcomes , and to highlight current gaps in knowledge . METHODS We search ed the Cochrane Data base of Systematic Review s up to December 2017 , to identify Cochrane Review s that assessed the effectiveness of organised rehabilitation interventions for pwMS . Two review ers independently assessed the quality of included review s , using the Revised Assessment of Multiple Systematic Review s ( R-AMSTAR ) tool , and the quality of the evidence for reported outcomes , using the GRADE framework . MAIN RESULTS Overall , we included 15 review s published in the Cochrane Library , comprising 164 r and omised controlled trials ( RCTs ) and four controlled clinical trials , with a total of 10,396 participants . The included review s evaluated a wide range of rehabilitation interventions , including : physical activity and exercise therapy , hyperbaric oxygen therapy ( HBOT ) , whole-body vibration , occupational therapy , cognitive and psychological interventions , nutritional and dietary supplements , vocational rehabilitation , information provision , telerehabilitation , and interventions for the management of spasticity . We assessed all review s to be of high to moderate method ological quality , based on R-AMSTAR criteria .Moderate- quality evidence suggested that physical therapeutic modalities ( exercise and physical activities ) improved functional outcomes ( mobility , muscular strength ) , reduced impairment ( fatigue ) , and improved participation ( quality of life ) . Moderate- quality evidence suggested that inpatient or outpatient multidisciplinary rehabilitation programmes led to longer-term gains at the levels of activity and participation , and interventions that provided information improved patient knowledge . Low-qualitty evidence suggested that neuropsychological interventions , symptom-management programmes ( spasticity ) , whole body vibration , and telerehabilitation improved some patient outcomes . Evidence for other rehabilitation modalities was inconclusive , due to lack of robust studies . AUTHORS ' CONCLUSIONS The evidence suggests that regular specialist evaluation and follow-up to assess the needs of patients with all types of MS for appropriate rehabilitation interventions may be of benefit , although the certainty of evidence varies across the different types of interventions evaluated by the review s. Structured , multidisciplinary rehabilitation programmes and physical therapy ( exercise or physical activities ) can improve functional outcomes ( mobility , muscle strength , aerobic capacity ) , and quality of life . Overall , the evidence for many rehabilitation interventions should be interpreted cautiously , as the majority of included review s did not include data from current studies . More studies , with appropriate design , which report the type and intensity of modalities and their cost-effectiveness are needed to address the current gaps in knowledge Rameckers EAA , Speth LAWM , Duysens J , Vles JSH , Smits-Engelsman BCM : Kinematic aim ing task : measuring functional changes in h and and arm movements after botulinum toxin-a injections in children with spastic hemiplegia . Am J Phys Med Rehabil 2007;86:538–547 . Objective : To describe different aspects of a kinematic aim ing task ( KAT ) as a quantitative way to assess changes in arm movements within 2 wks after botulinum toxin-A ( BTX-A ) injections in children with spastic hemiplegia . Design : Intervention study r and omized clinical trial ; follow-up within 4 wks after baseline measurement . Results : The KAT gave a high intraclass correlation on movement time , spread of end points ( END ) , and index of performance effective ( IP-E ) . After BTX-A , a significant increase of END and IP-E was shown if precision dem and in the KAT was high , whereas the inverse occurred when speed was more important . These functional changes coincided with a significant decrease of the maximum voluntary contraction of the flexor muscles of the forearm . Muscle tone measured with the Ashworth scale did show a nonsignificant decrease of muscle tone , as did the stretch restricted angle and the active and passive ranges of motion of the elbow and wrist . Conclusions : Muscle force decreased immediately after BTX-A , showing the direct effect of BTX-A. The KAT is an adequate , reproducible way to quantify functional changes after BTX-A in the upper limb . BTX-A has an inverse effect in the precision task when accuracy is important , and it has a positive effect when speed prevails
Parameters that integrated electrophysiological signals with joint movement characteristics were best able to quantify spasticity .
There were conflicting results regarding biomechanical-based parameters that quantify the resistance to passive stretch .
AIM The first aim of this study was to systematic ally review and critically assess manually controlled instrumented spasticity assessment methods that combine multidimensional signals .
The second aim was to extract a set of quantified parameters that are psychometrically sound to assess spasticity in a clinical setting .