Category Archives: Journal Reviews

Apr 30 2014
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Journal Reviews

Rehab Journal Review – April 2014

 

BMJ, 10 April 2014

Do you fear premature death? Many do, especially while reading those apocalyptic predictions during peaks of flu pandemics. Taking advantage of your fear, if somebody sold you Rs.500 worth of prophylactic magic pills assuring that’s the only way to keep flu away, without disclosing to you a private secret that the drug is in fact not as effective, isn’t that bad? The seller in question is the big pharma Roche, who chose not to fully disclose the bad results section of the clinical trial data while convincing governments across the world to buy stocks of the magic pill Oseltamivir (Tamiflu). To say that Roche and its shareholders made a fortune from Tamiflu sales is an understatement. The stockpiling of Tamiflu over years across continents was to the tune of about 10 billion USD. For the perspective, the cost of sending Chandrayaan to moon was 0.06 billion USD. Almost the entire stockpile of the wrongly sold Tamiflu is now lying unused. This Cochrane review on potential benefits and harms of Oseltamivir (Tamiflu) published in BMJ is one of the hottest in clinical academic circles the past month, with multiple discussions in many major medical journals. The reviewers had to expend unprecedented magnitudes of efforts to access complete data from Roche. Though Tamiflu is in no way related to rehabilitation, this study is mentioned here for being one of the landmark events in the right direction in recent times for healthcare; for providing the optimism that the WHO, and the FDA, and the NHS and big pharma can all be questioned with big data, when they choose not to be honest and accountable. “These findings provide reason to question the stockpiling of oseltamivir, its inclusion on the WHO list of essential drugs, and its use in clinical practice as an anti-influenza drug”. (If you are a medical or allied health professional and have never heard of the term ‘Cochrane’, you should consider reading this)

 

Spinal Cord, March 2014

 175 Cochrane reviews could be dud too. Here is the example. This systematic review on respiratory muscle training in tetraplegia has only surrogate outcomes of pulmonary function tests, and not hard clinical endpoints that matter to the individual. That, they say, is published in another review. Zzz.

255 Reading this ‘letter to editor’, I realized I’d never given a thought to post-partum breast-feeding issues in women with cervical spine injury. There are concerns about hypogalactia due to impaired sympathetic innervation, but seems there are ways around it.

 

Spinal Cord, April 2014

295 The proactive Swiss Paraplegic Center has come out with this good observational study on bladder stones among 2825 persons with SCI. No surprises. SPC and indwelling transurethral catheters were associated with the highest incidence of stones, shortest time interval and highest rate of recurrence. “Indwelling catheters (transurethral/SPC) are associated with the highest risk to develop bladder stones and therefore should be avoided if possible. If unavoidable, SPC are superior to transurethral catheters”. Intermittent catheterization, as expected, fared better in most outcomes, second only to voiding without use of a catheter.

313 This small Turkish study on 26 women with SCI, many months post injury, found that most women had not received any counseling about sexuality and pregnancy related issues. I’m not sure if things are any better over here.

 

Practice tidbits:

  • Should you advise epidural steroids for patients with lumbar disc related back pain? Yes, says this review article, suggesting “strong evidence for short-term efficacy from multiple high-quality trials”.
  • Do you often end up ordering investigations, prescribing medications and doing surgeries because of the delusion ‘if-you-are-a-doctor-you-need-to-do-something’ even if you know what you do is ineffective? You should read this news article on why more need not be always better.
  • Do we have enough evidence to believe that strengthening program and electrical stimulation for children with cerebral palsy are actually useful in improving gait and functions? A recent systematic review concluded “Strengthening and electrical stimulation could increase muscle strength and gait”. A York CRD critical abstract of the review, though, opines “In this review small, varied trials, which may have been subject to bias, were pooled in an unorthodox and questionable way. The authors’ conclusion should not be considered to be reliable.”

 

 

Liked from twitter: People who think a computer can replace a doctor believe that what doctors do is make decisions. That’s about 10% of what we do

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Mar 31 2014
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Journal Reviews

Rehab Journal Review: March 2014

Archives of PMR, January 2014

10 Education helps, at least for a year. That’s the finding in this American study on effectiveness of an education protocol for wheelchair use in persons with Spinal Cord Injury. The study protocol was based on evidence based guidelines published in 2005. I was curious. Turns out, unsurprisingly, that the quality of evidence for most of the 35 enlisted recommendations was poor. That is not different from most other EB guidelines for anything related to rehabilitation. THE need, therefore: less junk research. For anyone interested in doing good research, a repeat reading of Ionnidis’ wonderful article “Increasing value and reducing waste in research design, conduct and analysis” would do no harm.

87 Assessment of Participation (life in real world) is one outcome measure that could mean more than any other surrogate in-hospital assessment for rehabilitation. In this study from Utrecht, Netherlands, the authors compared their own tool ‘USER-Particpation’ against two others- ‘IMPACT-S’,  ‘WHODAS-II’. The authors claim their tool was “generally satisfactory”, and that “the IMPACT-S showed the best psychometric properties”. ‘Validating a tool’ is among the many things I need to read and do more to understand better.

94 Often, an honest opinion based on clinical judgment, suggesting discharge-to-home, or outpatient follow-up for continued therapy is not received well. Neither by the referring doctors, nor the patients and family. In this background, the key findings of this meta-analysis of RCTs on Economic Evaluation of Adult Rehabilitation are heart-warming. “This review found high-level evidence that rehabilitation in the home or community is less costly than inpatient rehabilitation (for stroke)… It also found that the secondary outcomes of function, quality of life, discharge destination, and mortality were not compromised when patients received the less costly intervention…The results of cost savings without compromise to patient outcomes for rehabilitation in the home appear to be similar to rehabilitation in the community and outpatient rehabilitation services.” We need region and disability specific data for our country to see if these findings still hold good. And, to spread the message.

 

Archives of PMR, February 2014

269 It’s risky to draw inferences from observational studies on interventions. Against the findings of the above mentioned meta-economic-analysis, conclusions such as this must be interpreted cautiously-“The volume of inpatient rehabilitation therapy and mortality were significantly inversely related in the patients with ischemic stroke”. The association is probably true, needs to be looked into, but there is this small issue of confounders. The authors have recommended changes in practice, based on these findings. I would hesitate to do so.

 

Spinal Cord, January 2014

49 To cystoscope or not, ask the authors about persons with SCI on chronic indwelling catheter drainage. The answer is in favor of regular screening to pick up pre-malignant lesions, which are not quite uncommon as previously suspected, it seems. How many of those really progress to malignant lesions? We need to tread cautiously, to avoid unnecessary panic. There are lessons to be learnt from the PSA/prostate screening fiasco. Our own data would make more sense. We have a reasonably good cohort following up regularly over the last couple of decades. We haven’t had a single known mortality related to bladder malignancy. Are we missing something, or it’s just that we are different?

 

65 “The WISCI II (to assess walking in SCI) has high IRR and intrarater reliability and good reproducibility in the acute and subacute phase when administered by trained raters”. Yes, that’s why we intend to start using it routinely, hopefully this month onwards.

 

Spinal Cord, February 2014

163 Simple things bring about big changes with the right type of impact. Czech authors report that Intermittent Catheterization in tetraplegia patients might not be hard to achieve, in those with levels C5 and below. They report use of positioning splints and ‘ergohand device’ to achieve this. It’s a small group of patients, but that’s not the point. The overall health benefits of such could be significant.

 

I’d recently retweeted something on doctor burn-out: “If you want to discourage workers, subject them to policies and procedures that don’t make sense.” And read a related corollary ““If we want doctors to do better work, we need to give them better work to do.”

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Feb 28 2014
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Journal Reviews

Rehab Journal Review: February 2014

Archives of PMR, November 2013

2112 ‘I’m asked to specify before I start my research what quantum of change in outcome would be considered as significant; if I’d known why I would do the study’. If you’ve ever wondered so after a visit to the statistician, you’re not alone, and you’re not correct. The ‘minimal important clinical difference’ for every outcome measure has to be spelt out in advance based on a comprehensive review of literature. If no precedence, then it has to be based on clinical judgment. Pronouncing these values in advance serves two purposes. 1. You don’t get carried away by the rubbish of just the p-values and statistical significance at the end of the study. 2. You are more likely to report in negative, and rightly so, if clinically significant change is not observed. This study on Whole Body Vibration for balance improvement in type-2 Diabetes clearly specifies these minimal important clinical differences. But, in spite of between-group differences in 9 out of 10 balance measures being not significant (based on the reported confidence interval ranges in Table 2), the authors have tried to somehow report this as a positive study though it is not. And, the outcome measures used have been just the surrogate measures of balance master and TUG test, and not clinical relevant outcomes such as number of falls, activity limitations/participation restriction.

2146 Potential thesis topic alert. Ultrasound elastography in soft tissues seems interesting. Here the authors claim we could actually see and quantify the tissue changes in myofascial trigger point injections using elastography. Needs replication.

2174 “In 1-year follow-up, subjects with Osseointegration Prostheses significantly increased walking ability and prosthesis-related quality of life” claims this study comparing Osseointegration Prostheses with socket prostheses. A natural evolution, perhaps, for prosthetic fitting technology, and a precursor to bionic limbs.

2203 Following up 7228 persons with TBI who survived at least one year post-trauma, the National Institute on Disability and Rehabilitation Research, USA, confirms what seems logical– “Survival was poorer than that of the general population (standardized mortality ratio=2.1; 95% confidence interval, 1.9–2.3). Age, sex, and functional disability were significant significant risk factors for mortality.”

Archives of PMR, December 2013

2357 Power of a cohort database once again. Among13746 veterans with femur fractures, 396 withspinal cord Injury were identified. Those receiving surgical Vs non surgical management were analysed and compared with non SCI veterans.  The key observation was that surgical treatment minimizes the risks of complications due to immobilization, possibly minimizing mortality as with non-SCI, and hence should be considered in appropriate SCI patients as well.

Spinal cord, December 2013

873 A systematic review on bowel management and the success rate of the various treatment modalities in spina bifida patients crystallises a couple of useful findings. Unlike neurogenic bladder management options where one method (Clean Intermittent Catheterization)  is superior to others, there is no such primus inter pares in  bowel management. “Evidence favors an individually tailored stepwise approach with surgery as a final step in case of failure of conservative measures. Continued specialized support throughout life remains important to maintain continence. Cross-over and comparative trials are needed in order to optimize treatment.” Case rested.

919 I remember New Zealand for Sachin’s first ever marauding OD I innings of 82 in 49 balls at Auckland in 1994, most of which I watched while trying to work Chemistry equations at my teacher Mr.Doss’ place.  This small study from the Kiwiland throws some light on what could possibly make rehabilitation click for persons with SCI in the long run. “In New Zealand, most people followed over 2 and a half years after sustaining a SCI retained their income and standard of living. Rates of return to work were high overall (49%). The reason for both these findings appears to be the no-fault compensation scheme for injury available to the majority of participants.” ” If such economic outcomes are also accompanied by re-integration into society and regaining of quality of life, then such a no-fault compensation scheme should be seen as a model for rehabilitation after SCI—traumatic and non-traumatic.”

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Medical research showing signs of some honest soul searching. Two medical students (you heard it right, medical students!) from Yale recently had first author publications in JAMA, doing big data analysis of (unnecessary) cardiac evaluations and (inapprpriate) drug approvals.  A Canadian study following 89835 women for 25 years (!!!) emphatically concludes ” Annual mammography in women aged 40-59 does not reduce mortality from breast cancer beyond that of physical examination or usual care “, questioning the utility of billions spent on (futile) screening worldwide. Non-maleficence.

Jan 31 2014
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Journal Reviews

Rehab Journal Review: January 2014

Spinal Cord October 2014

 

771 For those who are just beginning their journey in reading and understanding journal articles, one of the many concepts difficult to grasp straight away is ‘Conflict of Interests’. Experts please skip to the last sentence. My favorite illustration of the concept: Tom & Jerry. Tom’s natural instinct (interest 1) is to go after Jerry. Assume he’s given the responsibility of babysitting Jerry (interest 2), then this interest-2 is in direct conflict with his interest-1. Unless proven otherwise, interest-1 always supersedes interest-2. Now, let’s change the characters. Tom is now Mr.X, a researcher employed by an all-powerful drug company. His interest-1 is to serve his employer well. Jerry is the ‘Aam Aadmi’ (they haven’t copywrited the term yet, have they?). Mr X conducts a study on a drug sold by his employer, to see if the drug really benefits the Aam Aadmi (interest-2). What would he do if he finds that the drug is useless? Of course, he would try and focus on the grain of positives within the puddle of factual negatives. Thought you should know, in case you didn’t, after reading through this article’s Conflicts of Interest and Acknowledgement sections. Incidentally, Ben Goldacre has just given an insight into the choice of slangs one should be prepared to be called by if habitually pointing out such trivia.

 

784 Predictors of mortality in veterans with traumatic spinal cord injury is not a study whose findings could be readily extrapolated to the general population. Yet, a few findings are worth noting. Infection still is the leading cause of death following SCI. Pneumonia, UTI, pressure ulcers are the three leading causes. Of late, non-communicable diseases are catching up. “Importantly, when effective prevention of SCI-related complications and better control of modifiable vascular risk factors such as hypertension, hyperlipidemia, diabetes mellitus, obesity and smoking cessation were undertaken by us, between 2008 and 2011, the survival of tSCI patients improved from an average of 63% between 2000 and 2007 to 72%”. The lesson: SCI or no, quit smoking, stay active, and you’re likely to live longer.

 

Spinal Cord November 2013

 

823 There is a new cook in the already crowded Spinal Cord Regeneration kitchen. Broth is nowhere in sight. Glibenclamide reduces acute lesion expansion in a rat model of spinal cord injury, says the emphatic title of this study. Those who have been in business long enough know what to expect from this in immediate future in terms of actual patient care.

 

A remotely Forrest-Gump-esque series of events. I remember mentioning somewhere a few years ago about my new-found interests in golf, cycling and F1, courtesy the greats who were ruling at that time. While Tiger and Lance fell in different ways, figuratively, Michael literally did about a month ago.  The box of chocolates.

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Dec 31 2013
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Journal Reviews

Rehab Journal Review: December 2013

 

Archives of PMR, September 2013

 

1699 Treat the patient and not the X-Ray, was what we were told during our orthopedics clinical training. Not quite that in this systematic review on Shock Wave Therapy for Calcific tendinitis of shoulder. Results seem to favor SWT in improving, you-know-what, radiological signs; disappointing that there are no forest-plots of changes in pain/functional outcomes.  “It would be of interest to determine whether and, if so, to what degree there exists a correlation between decreased pain and functional recovery, on the one hand, and the resorption of calcific deposits”. To me, pain and functional recovery should be the primary outcomes that matter.

1753 Rick Hanson Institute in Canada is not just about an illustrious founder. Going by their twitter feed, there is some good work being done for the public cause. This community follow-up questionnaire for their SCI registry, though, like many such check-box tools, with more than 150 items, is too extensive to try out in an active clinical practice.

 

Archives of PMR, October 2013

Topical focus: Research on Disorders of Consciousness (DOC)

“It was not uncommon to find patients in a vegetative state undergoing several hours of daily therapy for many months after injury regardless of the neurologic progress achieved.” Sounds familiar?? Read on.

You might want to quickly flip through the issue for a couple of interesting articles, starting with the opening special communication that rightly touches upon many related ethical and clinical dilemmas. The American authors note that most persons with DOC do not received structured rehabilitation in the US (what does Obamacare say about this?). They propose a system, where “…all patients with DOC receive an early period of expert assessment and management that focuses on accurate diagnosis, tracking of functional change with sensitive objective measures, medical management to stabilize and resolve complications, and caregiver education and prognostic planning. Those who make substantial functional progress within such a system would be transitioned to more active rehabilitation and those who fail to make progress would be triaged to nursing facilities or family homes, but with well-developed rehabilitation plans in place, periodic monitoring of change planned for, and a consultation link available to address new and unanticipated changes”. Glad we are already doing something similar, not to “all patients with DOC”, but to whoever manages to wade through the convoluted admission process that’s unavoidable due to many factors, primarily the disparity between high case loads and bed availability.

1855 Functional outcomes in traumatic disorders of consciousness: 5 year outcomes, is a retrospective chart review study from the TBI model systems, USA. They looked at functional outcomes at discharge, 1 year, 2 years and 5 years among persons with absent command-following at admission to rehabilitation (Minimally conscious state/Locked-in syndrome not accounted for!). With data losses at multiple levels, records of just 108 individuals make the cut. 1988 to 2009, from 16 sites across the US, that’s paltry numbers. Such reports from hospital-based databases just cannot compete with the likes of the robust, all-inclusive Scandinavian population databases. Still, there are a few stats that might be of clinical value. Persons who start showing command-following abilities by the time of discharge continue to show improvements in physical independence, not in cognitive independence, till 5 years. In contrast, those who start showing responses after discharge max out on all improvements by 2 years; “In other words, the early recovery group tended to have a larger gap between physical and cognitive independence, whereas the late recovery group tended to be more similarly impaired across domains”.

1891 It’s festive season all around, and let’s wind-up with some fantasy stuff. Can mental imagery fMRI predict recovery in patients with disorders of consciousness? Yes, say the German authors, who found in this observational study that all 5 patients in vegetative state who showed significant activity in the region of interest on fMRI progressed to at least minimally conscious state at the end of the observation period. And none of the 5 non-responders improved from vegetative state. That works out to a fantastic 100% sensitivity and 100% specificity! The authors propose a new term for the responders- “functional minimally conscious state” till the time they progress to clinically apparent minimally conscious state. The findings beg to be replicated. A potential thesis topic if funding can be arranged.

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Response to this blog has been expectedly underwhelming. Yet, I intend to continue as long as all the reading that goes into the writing amuses me. An African proverb from my twitter feed read “If you want to go fast, go alone. If you want to go far, go together”. Let’s go far. New Year greetings to all!

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Dec 05 2013
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Journal Reviews

Rehab Journal Review: November 2013

After a few roller coaster weeks of curricular, co-curricular and extra-curricular activities, here is the delayed follow-up act.

Spinal cord, Volume 51, Issue 8, August 2013

596 A few years ago, a couple of junior consultants in our department submitted a study proposal to the institutional review board- an RCT to study whether anticoagulants offered clinically appreciable benefits as against no treatment in persons with acute/post-acute spinal cord injury. Our proposal was shot down by the IRB, saying it was unethical to have a placebo/no-treatment group. Seems it probably might not have been unethical. Heparin for venous thromboembolism prophylaxis in acute SCI, a review article from China (Open access in Spinal Cord is a rarity) reports a few such studies with no-treatment groups. After you wade through the typos in page 601, the authors conclude that “in acute SCI, low dose unfractionated heparin (LDUH) have no thromboprophylaxis effect compared to placebo or no treatment (0/4 studies). LMWH reduce bleeding risk, but cannot prophylaxis thromboembolism compared with LDUH (8/9 studies). [Tinzaparine is the exception here (Green D 1994), but I don’t remember ever discussing that name for clinical use. Anyone??] Because no good quality studies existed in this setting, well-designed RCTs are urgently needed.”

The related clinical dilemma expressed by this BMJ article in July 2013 adds to the intrigue in situations warranting therapeutic anticoagulation. “Combination of large increase in incidence, reduced case fatality (in-hospital deaths among people with a diagnosis of pulmonary embolism), and a minimal decrease in mortality (deaths from pulmonary embolism in the population) suggests that many of the extra emboli being detected are not clinically important. Harms from overdiagnosis—Substantial increase in complications from anticoagulation. Anxiety and inconvenience for patients following diagnosis and treatment”. So, are there clots that we don’t need to treat? “Without prospectively observing untreated patients, it is impossible to be certain which emboli are not clinically important”.

Now, I’m keen to revive the rejected study proposal.

642 Assisted Reproductive Techniques in SCI is a retrospective cohort analysis of 32 patients, reported from Israel. The authors claim testicular aspiration success rates of almost 90%. Primary testicular failure and elevated FSH levels are reported to be associated with poor pregnancy outcomes. “Clinical pregnancy rate was 32/106 (30.2%) per cycle, and 19/32 (59.3%) per couple.” Not bad, just that most of our patients cannot afford one cycle of IVF.

645 Compliance with clean intermittent catheterization in spinal cord injury patients from Turkey. This is a retrospective review of medical notes of 164 patients in 10 years. At discharge, 63% on CIC, 10% indwelling catheter, 15% reflex voiding. Compliance with CIC at followup (54months±28) was 58%. Of those who stopped, 74% started reflex voiding. Commonest cause for stopping CIC was urinary tract infections. All these numbers do not mean much since no data is provided on clinical end points related to long term urological health.

Spinal Cord Volume 51, Number 9, September 2013

694 Gluteal blood flow and oxygenation during electrical stimulation-induced muscle activation pressure relieving movements in wheelchair users with a spinal cord injury. The learning point is not in the results but in the notion that electrical stimulation can potentially reduce pressures over the ischial tuberosity. Could this be a viable alternative to those not capable of doing pressure-relief measures?

715 Studies on telehealth in general are yet to come out with anything substantial to justify resources spent. A pilot study of a telehealth intervention for persons with spinal cord dysfunction doesn’t break the trend. Though the authors report that women who listened to telephonic health education instructions had 100% ulcer healing, it must be noted that only stage 1 and 2 ulcers were included. Other interventions were neither controlled for, nor data collected. Hence, no clinically meaningful interpretations can be made.

Archives of PMR, Volume 94, No. 8, August 2013

Functional benefits (emerging evidence do not support them) versus Complications (common in clinical practice) of partial foot amputations is the subject of this article from the editor’s desk. They looked at outcomes of ankle power generation and energy expenditure during gait, as well as Quality Of Life. They conclude “Despite high rates of complications experienced by persons with partial foot amputation, …is still preferred to transtibial amputation… we should adopt practices that minimize the likelihood of ulceration and secondary amputation…”. There might be some truth in this, going by what we see in our diabetic foot clinic (We don’t have actual numbers).

1473 Meta-Analysis of Botulinum Toxin A Detrusor Injections in the Treatment of Neurogenic Detrusor Overactivity After Spinal Cord Injury. The topic of the study seemed very relevant to our practice, and I was keen to look at the results. One look at the forest plots and the diamonds seemed impressively in favor of BTX-A. Into the text then. The study selection flowchart says that of the 269 potentially relevant studies, 14 studies met inclusion criteria. Good so far. “Only one study was a randomized controlled trial”. Dud. 12 of those studies had no control group. The conclusion still inexplicably states “BTX-A injections into the detrusor muscle were associated with significant beneficial treatment effects”. The abstract too makes no mention of the fact that 12 of 14 studies reported only pre-post data and were not RCTs. The one RCT included in the meta-analysis would have sufficed to make interpretations, but the authors chose (and Archives colluded) to unnecessarily beef up the thin evidence. Read the conflict of interest section and you might understand why. Gullible readers could be tricked to believe this is level I stuff.

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Top among the few things I came to know about the past couple of months that made me pause and reflect on lines of the road taken and not taken:

1. a book written by a friend from schooldays

2. a tamil movie being produced by my namesake batch-mate from MBBS days.

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Oct 15 2013
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Journal Reviews

Rehab Journal Review: October 2013

Blame it on procrastination. This initiative has had a stuttering course from idea to action. Though inspired by a family physician who took no vacation in 15 years of weekly journal reviewing, I can’t assure even a second month. These musings are an expression of a self-learning process in interpreting scientific research, and the reader is encouraged to take these with a generous pinch of salt. Articles that find a mention here are those that are likely to be relevant to practice of rehabilitation medicine as I understand at my current workplace. Non-mention does not mean to undermine clinical significance otherwise, but would imply just my ignorance. Any tinge of irreverence in these passages might not be entirely unintended. What is written about here would be constrained by the availability of full texts, electronic or hardcopy (The paywalls, grrr). Hence, I’m starting with just the dated Archives of PM&R, Volume 94, No 6, June 2013. Do send in no-holds-barred feedbacks to make the learning more purposeful and mutual.

Conflicts of interest: Nothing to do with the industry. I’m likely to be biased in favor of evidence based healthcare, and against clinical studies that do not have clinically relevant hard endpoints as outcome measures.

A recently concluded MD thesis in our department studied the efficacy of an indigenously designed peroneal nerve stimulator (PNS) in gait of persons with stroke. This study from the Case Western Reserve University was done to see if there is any motor relearning with such PNS compared to usual care (AFO when necessary). The stimulator they used was a commercial product with a pressure-sensing foot-switch to detect heel rise at pre-swing (we had used a hand-operated manual switch). Better technology didn’t prove to be too beneficial though; the authors have been honest with the results in concluding “there was no motor relearning in either … groups”. More importantly, at 6 months, usual care fared as well as the stimulator in terms of functional mobility and quality of life. PNS will have to wait.

Taiwanese authors aren’t far behind in honest conclusions in their study on mirror therapy in chronic stroke. They conclude “application of mirror therapy…may not translate into daily functions in the population with chronic stroke”.

It takes just two hours to instill confidence in use of manual wheelchair among older adults who are completely inexperienced previously, as this paper reports. Let’s remember to find those 2 hours for each of our KAFO dependent functional-walkers too; will come handy sometime, somewhere.

This could have been easily dismissed as just an observational study, but the authors conclude “Long-stay home care patients who receive rehabilitation at home have improved outcomes and lower utilization of costly health services. Our findings suggest that investment in PT and OT services for relatively short periods may provide savings to the health care system over the longer term.” Encouraging words for anyone keen on population rehabilitation (a derivative of the term population medicine advocated by Muir Gray).

Robotics might be the next big thing in rehabilitation, but in this before-after clinical intervention study, there is nothing for anyone as of now, probably except for the uber-rich interested to try out some toys. I am a fan of Tony Stark’s excursions in his gizmo suit, in case you doubted that I’m an anti-technologist.

Didn’t know about wearable laser Doppler flowmetry probes; that’s the only thing to know from this study. Could someone suggest how to put these probes to better use, design a good study and come out with a clinically useful prediction model for pressure ulcer incidence.

Glad to find friend and former colleague Apurba Barman’s name in the list of reviewers acknowledged in this edition of Archives of PMR (the links would not lead to full-texts if your institution does not pay for online editions of the linked journals, please see the print edition instead. The paywalls *!@#$*)

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