Professor Derick Wade

Introduction. 
People with Parkinson’s disease (PwPD) present motor alterations which can impact daily life tasks that require speed and/or accuracy of movement.

Objective. 
A sub analysis of NCT01439022, aiming to estimate the extent to which two different exercise training protocols (global and handwriting upper limb exercise training) impact reaction time, travel speed, and accuracy in PwPD.

Methods. 
Seventy PwPD, right-side dominant were randomised 1:1 into two six-month training protocol groups; 35 PwPD performed global exercise training and 35 performed specific training (handwriting upper limb exercise movements). Assessments of speed-accuracy and trade-off were carried out at baseline, after 3 and 6 months of training, and at a 12-month follow-up. The current study used data from a previous publication of a randomised controlled trial that included a 6-month self-managed community exercise programme for PwPD. For the present study we included only the participants who completed the Fitts’ task during the baseline assessment.

Results. 
In the upper limb assessments, no main effects were found for the number of touches, but the exercise group showed a marginal increase over time on the left side. Error averages on the left side decreased significantly for the exercise group from baseline to 6 and 12 months. The exercise group also presented a lower Error CoV and the Reaction Time CoV increased on the right side. Significant findings for Fitts r on the left side indicated lower values for the exercise group, with improvements continuing at 12 months.

Conclusion. 
We report the potential of global exercise interventions to facilitate improvements in reaction time and travel speed, as well as other motor control metrics, with lasting effects at 12 months, particularly on the non-dominant side.

Background

Exercise is recommended as the first-line management for knee osteoarthritis (KOA); however, it is difficult to determine which specific exercises are more effective. This study aimed to explore the potential mechanism and effectiveness of a leg-swinging exercise practiced in China, called ‘KOA pendulum therapy’ (KOAPT). Intraarticular hydrostatic and dynamic pressure (IHDP) are suggested to partially explain the signs and symptoms of KOA. As such this paper set out to explore this mechanism in vivo in minipigs and in human volunteers alongside a feasibility clinical trial. The objective of this study is 1) to analyze the effect of KOAPT on local mechanical and circulation environment of the knee in experimental animals and healthy volunteers; and 2) to test if it is feasible to run a large sample, randomized/single blind clinical trial.

Methods

IHDP of the knee was measured in ten minipigs and ten volunteers (five healthy and five KOA patients). The effect of leg swinging on synovial blood flow and synovial fluid content depletion in minipigs were also measured. Fifty KOA patients were randomly divided into two groups for a feasibility clinical trial. One group performed KOAPT (targeting 1000 swings/leg/day), and the other performed walking exercise (targeting 4000 steps/day) for 12 weeks with 12 weeks of follow-up.

Results

The results showed dynamic intra-articular pressure changes in the knee joint, increases in local blood flow, and depletion of synovial fluid contents during pendulum leg swinging in minipigs. The intra-articular pressure in healthy human knee joints was −11.32 ± 0.21 (cmH2O), whereas in KOA patients, it was −3.52 ± 0.34 (cmH2O). Measures were completed by 100% of participants in all groups with 95–98% adherence to training in both groups in the feasibility clinical trial. There were significant decreases in the Oxford knee score in both KOAPT and walking groups after intervention (p 

Conclusion

We conclude that KOAPT exhibited potential as an intervention to improve symptoms of KOA possibly through a mechanism of normalising mechanical pressure in the knee; however, optimisation of the method, longer-term intervention and a large sample randomized-single blind clinical trial with a minimal 524 cases are needed to demonstrate whether there is any superior benefit over other exercises.

The translational potential of this article

The research aimed to investigate the effect of an ancient leg-swinging exercise on knee osteoarthritis. A minipig animal model was used to establish the potential mechanism underlying the exercise of knee osteoarthritis pendulum therapy, followed by a randomised, single-blind feasibility clinical trial in comparison with a commonly-practised walking exercise regimen. Based on the results of the feasibility trial, a large sample clinical trial is proposed for future research, in order to develop an effective exercise therapy for KOA.

Objective:
To test the extent to which initial walking speed influences dual-task performance after walking intervention, hypothesising that slow walking speed affects automatic gait control, limiting executive resource availability.

Design:
A secondary analysis of a trial of dual-task (DT) and single-task (ST) walking interventions comparing those with good (walking speed ⩾0.8 m s−1, n = 21) and limited (walking speed

Setting:
Community.

Subjects:
Adults six-months post stroke with walking impairment.

Interventions:
Twenty sessions of 30 minutes treadmill walking over 10 weeks with (DT) or without (ST) cognitive distraction. Good and limited groups were formed regardless of intervention received.

Main measures:
A two-minute walk with (DT) and without (ST) a cognitive distraction assessed walking. fNIRS measured prefrontal cortex activation during treadmill walking with (DT) and without (ST) Stroop and planning tasks and an fMRI sub-study used ankle-dorsiflexion to simulate walking.

Results:
ST walking improved in both groups (∆baseline: Good = 8.9 ± 13.4 m, limited = 5.3±8.9 m, Group × time = P

Conclusion:
In individual who walk slowly it may be difficult to improve dual-task walking ability.

The problem:
Rehabilitation services in the UK are inadequate, with insufficient capacity or flexibility to meet the needs of patients after Covid-19.

History:
Rehabilitation developed in a piecemeal way, focused on specific problems: spinal cord injury, burns, polio, stroke, back pain, equipment and adaptations etc. Rehabilitation is also provided using other names (e.g. intermediate care). Patients with complex needs do not fit easily within this system.

System failure:
After Covid-19, patients have problems that cross existing condition-specific and/or treatment-specific services. Covid-19 has exposed the lack of any coherent organisational principle underlying development or commissioning of rehabilitation services. Consequently, in order to have their needs met, patients either have to engage with two or more separate services or they receive good management for some problems and sub-optimal management for other problems.

The goals:
The multitude of small specific services need to coalesce into an integrated service able to meet all the needs of any patient referred. Second, rehabilitation needs to be fully integrated into all healthcare services.

A solution:
The purpose of healthcare is to ‘improve our health and well-being . . . to stay as well as we can to the end of our lives’. (NHS constitution) All healthcare services need to consider patients holistically, giving equal attention to disease, disability, and distress. Rehabilitation, acute care, mental health and palliative care services need to work in parallel to achieve this purpose. Healthcare providers, supported by commissioners and rehabilitation experts, could achieve structural and organisational change, meeting the needs of patients.

Objective. To establish the feasibility of a randomised, placebo-controlled trial to investigate the effect of a specific immunotherapy bacterial lysate OM-89  (Uro-Vaxom®) in reducing the frequency of urinary tract infections in people with neurogenic bladder dysfunction.

Design. A parallel-group, double-blind, randomised, placebo-controlled trial.

Setting. Patients at home, recruited through out-patient contact, social media and patient support groups.

Subjects. People with a spinal cord injury, multiple sclerosis, transverse myelitis or cauda equina syndrome who had suffered three or more clinically diagnosed urinary tract infections treated with antibiotics over the preceding 12 months.

Interventions. All participants took one capsule of oral OM-89 immunotherapy (6mg) or matching Placebo (randomisation ratio 1:1), once daily in the morning for three months.

Main measures. The primary outcome was occurrence of a symptomatic urinary tract infection treated with an antibiotic, assessed at three and six months. Feasibility measures included recruitment, retention and practical difficulties.

Results. Of 115 patients screened, 49 were recruited, one withdrew before randomisation, and 23 were allocated to the control group receiving matching placebo.  Six participants, all in the control group, discontinued the intervention; all participants provided full data at both follow-up times. Over six months, 18/25 active group patients had 55 infections, and 18/23 control group patients had 47 infections. Most research and clinical procedures were practical, and acceptable to participants.

Conclusion. It is feasible to undertake a larger trial. We recommend broader inclusion criteria to increase eligibility and generalisability.

Objective: To investigate the effect of small needle-knife therapy in people with painful knee osteoarthritis.
Design Pilot randomised, controlled trial.
Setting. Rehabilitation hospital.
Subjects. In-patients with osteo-arthritis of the knee.
Interventions: Either 1-3 small needle-knife treatments over 7 days or oral Celecoxib. All patients stayed in hospital three weeks, receiving the same mobility-focused rehabilitation.
Measures. Oxford Knee Score (OKS), gait speed and kinematics were recorded at baseline, at 3 weeks (discharge) and at three-months (OKS only). Withdrawal from the study, and adverse events associated with the small needle knife therapy were recorded.
Results: 83 patients were randomized: 44 into the control group, of whom 10 were lost by 3 weeks and 12 at 3 months; 39 into the experimental group of whom 8 were lost at 3 weeks and 3 months. The mean (SE) OKS scores at baseline were Control 35.86 ( 1.05), Exp 38.38 ( 0.99); at three weeks 26.64 (0.97) and 21.94
(1.23); and at three months 25.83 (0.91) and 20.48 (1.14) The mean (SE) gait speed at baseline was 1.07 (0.03) m/sec (Control) and 0.98 (0,03), and at three weeks was 1.14 (0.03) and 1.12 (0.03) (p Conclusions: Small needle-knife therapy added to standard therapy for patients with knee osteoarthritis, was acceptable, safe, and reduced pain and improved global function on the Oxford Knee Score. Further research is warranted.

Background. There is no agreement about or understanding of what rehabilitation is; those who pay for it, those who provide it, and those who receive it all have different interpretations. Further, within each group, there will a variety of opinions. Definitions based on authority or on theory also vary and do not give a clear description of what someone buying, providing or receiving rehabilitation can actually expect. 
Method. This editorial extracts information from systematic reviews that find rehabilitation to be effective, to discover the key features and to develop an empirical definition.
Findings. The evidence shows that rehabilitation may benefit any person with a longer-lasting disability, arising from any cause, may do so at any stage of the illness, at any age, and may be delivered in any setting. Effective rehabilitation depends on an expert multi-disciplinary team, working within the biopsychosocial model of illness, and working collaboratively towards agreed goals. The effective general interventions include exercise, practice of tasks, education of and self-management by the patient, and psychosocial support. In addition, a huge range of other interventions may be needed, making rehabilitation an extremely complex process; specific actions must be tailored to the needs, goals and wishes of the individual patient, but the consequences of any action are unpredictable, and may not even be those anticipated.
Conclusion. Effective rehabilitation is a person-centred process, with treatment tailored to the individual patient’s needs and, importantly, personalised monitoring of changes associated with intervention, with further changes in goals and actions if needed.

The impact of flavonoids on fatigue has not been investigated in Relapsing and Remitting Multiple Sclerosis (RRMS). Objective. To determine the feasibility and estimate the potential effect of flavonoid-rich cocoa on fatigue and fatigability in RRMS.  Methods. A randomised double-blind placebo-controlled feasibility study in people recently diagnosed with RRMS and fatigue, throughout the Thames Valley (ISRCTN: 69897291). During a six week intervention participants consumed a high or low flavonoid cocoa beverage daily. Fatigue and fatigability were measured at three visits (weeks 0, 3 and 6). Feasibility and fidelity were assessed through recruitment and retention, adherence and a process evaluation. Results. 40 pwMS (10 men, 30 women, age 44 ± 10 yrs) were randomised and allocated to high (n=19) or low (n=21) flavonoid groups and included in analysis. Missing data was 75%. There was a small effect on fatigue (Neuro-QoL: effect size {ES} 0.04; confidence interval {CI} -0.40-0.48) and a moderate effect on fatigability (six-minute walk test: ES 0.45; CI -0.18 - 1.07). There were seven adverse events (four control, three intervention), only one of which was possibly related and it was resolved.   Conclusion. A flavonoid beverage demonstrates the potential to improve fatigue and fatigability in RRMS. 

Objective. To determine the short-term effects of supplying hospital inpatients with earplugs and eye masks, preparatory to a full-scale trial. Design. A single centre open-label, two-arm, parallel group, randomised controlled trial. Setting. Thirteen medical and surgical wards in a large teaching hospital in the United Kingdom. Participants. Everyone admitted to hospital aged 18 years or older, who stayed overnight, and had the mental capacity and sufficient understanding of English to give consent, the ability to complete the study questionnaire, and the ability to use earplugs and eye masks unaided was considered. Interventions. The intervention group were provided with earplugs and eye masks for use the following night, and the control group received standard care. Main measures. Sleep quality assessed using the SleepSure questionnaire after the first night of using the intervention; use of earplugs and eye masks; number of falls throughout their inpatient stay; use of zopiclone during inpatient stay; length of stay; recruitment rate. Results.1,600 patients admitted, 626 (39%) eligible, 206 (13% total, 33% eligible) recruited (intervention group, 109). The intervention group’s mean sleep quality score was 6·33 (95% CI: 5·89 to 6·77), compared with 5·09 (95% CI 4·66 to 5·52) in the control group (p

Objective. To evaluate the tolerability of, adherence to and efficacy of a community walking training  programme with simultaneous cognitive demand (dual‐task) compared to a control walking training programme without cognitive distraction. Methods. Adult stroke survivors, at least 6 months after stroke with a visibly obvious gait abnormality or reduced two‐minute walk distance were included into a 2‐arm parallel randomized controlled trial of complex intervention with blinded assessments. Participants received a 10 week, bi‐weekly, 30 minutes treadmill program at an aerobic training intensity (55‐85% heart rate maximum), either with, or without simultaneous cognitive demands. Outcome measured at 0, 11 and 22 weeks. Primary: two‐minute‐walk tests with and without cognitive distraction, dual task effect on walking and cognition; secondary: SF‐36, EuroQol‐5D‐5L, Physical Activity Scale for Elderly (PASE), and step activity. Results. Fifty stroke patients were included, 43 received allocated training and 45 completed all assessments. The experimental group (n = 26) increased mean (SD) two‐minute walking distance from 90.7 (8.2) to 103.5 (8.2) metres, compared with 86.7 (8.5) to 92.8 (8.6) in the control group, and their PASE score from 74.3 (9.1) to 89.9 (9.4), compared with 94.7 (9.4) to 77.3 (9.9) in the control group. Statistically, only the change in the PASE differed between the groups (p = 0.029), with the dual‐task group improving more. There were no differences in other measures. Conclusions. Walking with specific additional cognitive distraction (dual‐task training) might increase activity more over 12 weeks, but the data are not conclusive.

Background. The majority of stroke patients are inactive outside formal therapy sessions. Tailored activity feedback via a Smartwatch has the potential to increase inpatient activity. Objective. to identify the challenges and support needed by ward staff and researchers and to examine the feasibility of conducting a randomised controlled trial (RCT) using Smartwatch activity monitors in research naive rehabilitation wards. Objectives (Phase 1 and 2) were to report any challenges and support needed and determine the recruitment and retention rate, completion of outcome measures, Smartwatch adherence rate (Phase 2 only) readiness to randomise, adherence to protocol (intervention fidelity) and potential for effect. Methods. First admission, stroke patients (onset

Objective: To report on the control group of a trial primarily designed to investigate exercise for improving mobility in people with Parkinson’s Disease (pwP). The control group undertook a handwriting intervention to control for attention and time spent practising a specific activity.

Design: Secondary analysis of a two arm parallel phase II randomised controlled trial with blind assessment.

Setting: Community

Participants: PwP able to walk ≥100meters and with no contraindication to exercise recruited from the Thames valley, UK and randomised (1:1) to exercise or handwriting, via a concealed computer-generated list.

Intervention: Handwriting was undertaken at home and exercise in community facilities, both were delivered through workbooks with monthly support visits and involved practice for one hour, twice weekly, over six months.

Main measures:  Handwriting was assessed, at baseline, 3, 6 and 12months, using a pangram giving writing speed, amplitude (area) and progressive reduction in amplitude (ratio). The MSD-UPDRS item 2.7 (UPDRS-2.7) measured self-reported handwriting deficits.

Results:  105 pwP were recruited (analysed: n=51 handwriting, n=54 exercise).  Forty pwP adhered to the handwriting program most completing ≥1 session/week. Moderate effects were found for amplitude (total area: d=0.32 95%CI -0.11:0.7, p=0.13) in favour of handwriting over 12months, effects for writing speed and ratio parameters were small ≤0.11. Self-reported handwriting difficulties also favoured handwriting (UPDRS-2.7: OR= 0.55 95%CI 0.34:0.91, p=0.02).  No adverse effects were reported 

Conclusion: PwP generally adhere to self-directed home handwriting which may provide benefit with minimal risk. Encouraging effects were found in writing amplitude and, moreover, perceived ability. (ClinicalTrials.Gov:NCT01439022).

Aim Evaluate safety and adherence to a minimally supported community exercise intervention and estimate effect sizes (ES).
 

Methods Two arm parallel phase II randomised controlled trial with blind assessment. PwP able to walk ≥100meters and with no contraindication to exercise were recruited from the Thames valley, UK and randomised (1:1) to intervention (exercise) or control (handwriting) groups, via a concealed computer-generated list. Groups received a six month, twice weekly program. Exercise was undertaken in community facilities (30minutes aerobic and 30minutes resistance) and handwriting at home, both were delivered through workbooks with monthly support visits. Primary outcome was a 2minute walk, with motor symptoms (MDS-UPDRS III), fitness, health and wellbeing measured.
 

 Results  Between December 2011 and August 2013,  n=53  (n=54 analysed) were allocated to exercise and n=52 (n=51 analysed) to handwriting. n=37 adhered to the exercise, most attending ≥1 session/week. Aerobic exercise was performed in 99% of attended sessions and resistance in 95%. Attrition and adverse events (AE) were similar between groups, no Serious AEs (n=2 exercise, n=3 handwriting) were related, exercise group related AEs (n=2) did not discontinue intervention. Largest effects were for motor symptoms (2minute walk ES= 0.20 (95%CI=-0.44:0.45) and MDS-UPDRS III ES=-0.30 (95%CI=0.07:0.54)) in favour of exercise over the 12month follow-up period. Some small effects were observed in fitness and wellbeing measures (ES >0.1).
 

Conclusion pwP exercised safely and the possible long-term benefits observed support a substantive evaluation of this community program.(ClinicalTrials.Gov:NCT01439022).

Determining fitness to drive is a major concern affecting aging and disabled populations, particularly concerning reduced cognitive functioning, functional limitations and reduced vision [1, 2]. The Royal Society for Prevention of Accidents encourages aging drivers to maintain their licence (for independence, mobility and quality of life), emphasising that prematurely removing someone’s driving licence negatively affects their quality of life - the consequences of which outweigh the chance of being involved in a collision, for both the driver and the remainder of society [3].

The gold standard test in the United Kingdom (UK) to determine the ability to drive is an on-road driving assessment, and clinicians have the opportunity to refer patients to an independent Mobility Centre (accredited by Driving Mobility) where an assessment will be performed based upon on-road driving experience as judged by a professional driving instructor and occupational therapist[4]. The assessment is resource expensive and only a limited number of individuals are referred. To date no screening test is clinically implemented in the UK which accurately determines fitness to drive[4].

This study sets out to evaluate the potential of the Montreal Cognitive Assessment (MOCA) as a screening tool, for people with concerns regarding cognitive capacity; to determine pass/fail cuts offs for on-road driving assessment.

Background: Survivors of a cardiac arrest frequently have cognitive and emotional problems and their quality of life is at risk. We developed a brief nursing intervention to detect cognitive and emotional problems, provide information and support, promote self-management, and refer them to specialised care if necessary. This study examined its effectiveness.
Methods: Multicentre randomised controlled trial with measurements at two weeks, three months and twelve
months after cardiac arrest. 185 adult cardiac arrest survivors and 155 caregivers participated. Primary outcome measures were societal participation and quality of life of the survivors at one year. Secondary outcomes were the patient's cognitive functioning, emotional state, extended daily activities and return to work, and the caregiver's well-being. Data were analysed using ‘intention to treat’ linear mixed model analyses.
Results: After one year, patients in the intervention group had a significantly better quality of life on SF-36 domains Role Emotional (estimated mean differences (EMD) = 16.38, p = 0.006), Mental Health (EMD = 6.87, p = 0.003) and General Health (EMD = 8.07, p = 0.010), but there was no significant difference with regard to societal participation. On the secondary outcome measures, survivors scored significantly better on overall emotional state (HADS total, EMD = −3.25, p = 0.002) and anxiety (HADS anxiety, EMD = −1.79, p =
0.001) at one year. Furthermore, at three months more people were back at work (50% versus 21%, p =
0.006). No significant differences were found for caregiver outcomes.
Conclusion: The outcomes of cardiac arrest survivors can be improved by an intervention focused on detecting and managing the cognitive and emotional consequences of a cardiac arrest.
Trial registration: Current controlled trials, ISRCTN74835019

PURPOSE:

The purpose of this appraisal is to offer guidance to clinicians on applying motor imagery in neurorehabilitation and provide guidance to support this process.

METHOD:

We used evidence from a variety of fields as well as clinical experience with motor imagery to develop guidance for employing motor imagery during neurorehabilitation.

RESULTS:

Motor imagery is a relatively new intervention for neurorehabilitation supported by evidence from areas such as cognitive neuroscience and sports psychology. Motor imagery has become a very popular intervention modality for clinicians but there is insufficient information available on how to administer it in clinical practice and make deliberate decisions during its application.

CONCLUSIONS:

We provide evidence-based guidance for employing motor imagery in neurorehabilitation and use the principles of motor learning as the framework for clinical application.

Objective: To investigate the agreement between a patient's therapist and an independent assessor in scoring goal attainment by a patient. Methods: Data were obtained on hospital patients with neurological disorders participating in a randomized trial. The patients' therapists set 2-4 goals using a goal attainment scaling method. Six weeks later attainment was scored by: (i) the treating therapists; and (ii) an independent assessor unfamiliar with the patient, using a semi-structured interview method with direct assessment as appropriate. Results: A total of 112 goals in 29 neurological patients were used. The intraclass correlation coefficient (ICC((A,k)) = 0.478) and limits of agreement (-1.52 +/- 24.54) showed poor agreement between the two scoring procedures. There was no systematic bias. Conclusion: The agreement between the patients' therapists scoring the goals and the independent assessor was low, signifying a large difference between the two scoring procedures. Efforts should be made to improve the reproducibility of goal attainment scaling before it is to be used as an outcome measure in blinded randomized controlled trials.

Objective: To investigate the feasibility of a motor imagery program integrated into physiotherapy and occupational therapy. Design: A parallel-group, phase II, assessor-blind randomized controlled trial comparing motor imagery embedded in usual therapy with usual therapy only. Setting: A neurologic rehabilitation center (Oxford, United Kingdom). Participants: Inpatients and outpatients diagnosed with stroke, brain injury, or multiple sclerosis, participating in a rehabilitation program with sufficient language skills to undertake the intervention were recruited (N=30) and assessed at baseline, after 6 weeks (postintervention), and after 12 weeks (follow-up). Interventions: A motor imagery strategy was developed that could be integrated into usual therapy, tailored to individual goals, and used for any activity. The control group received standard care. Main Outcome Measures: Goal attainment scaling was used as the primary outcome measure. Other measures included the Barthel activities of daily living index and the Rivermead Mobility Index. Results: Compliance with advised treatment was poor in 85% of the therapists and in 72% of the patients. Goal attainment scaling scores significantly improved at postintervention and follow-up (F(2.27)=45.159; P<.001), but no significant difference was observed between the groups over time (F(1.28)=.039; P=.845). Conclusions: Therapist and patient compliance with performing the intervention was low, restricting the conclusions regarding the effectiveness of the integrated motor imagery program. Future studies will need to explore barriers and facilitators to uptake of this intervention in clinical practice. Trial recruitment and retention were good. The study demonstrated that imagery could be successfully integrated into usual therapy and tailored for a wide range of functional activities.

Objective: To determine the efficacy of Sativex (USAN: nabiximols) in the alleviation of spasticity in people with multiple sclerosis. Methods: The results from three randomized, placebo-controlled, double-blind parallel group studies were combined for analysis. Patients: 666 patients with multiple sclerosis and spasticity. Measures: A 0-100 mm Visual Analogue Scale (VAS, transformed to a 0-10 scale) or a 0-10 Numerical Rating Scale (0-10 NRS) was used to measure spasticity. Patients achieving a >= 30% improvement from baseline in their spasticity score were defined as 'responders'. Global impression of change (GIC) at the end of treatment was also recorded. Results: The patient populations were similar. The adjusted mean change of the numerical rating scale from baseline in the treated group was -1.30 compared with -0.97 for placebo. Using a linear model, the treatment difference was -0.32 (95% CI -0.61, -0.04, p = 0.026). A statistically significant greater proportion of treated patients were responders (odds ratio (OR) = 1.62, 95% CI 1.15, 2.28; p = 0.0073) and treated patients also reported greater improvement: odds ratio 1.67 (95% CI 1.05, 2.65; p = 0.030). High numbers of subjects experienced at least one adverse event, but most were mild to moderate in severity and all drug-related serious adverse events resolved. Conclusion: The meta-analysis demonstrates that nabiximols is well tolerated and reduces spasticity.

Objective: To describe the current evidence on the frequency and nature of cognitive impairments in survivors of out-of- hospital cardiac arrest. Design: Systematic review. Data sources: Pubmed, Embase, PsychInfo and Cinahl (1980-2006). No language restriction was imposed. Review methods: The following inclusion criteria were used: participants had to be survivors of out-of-hospital cardiac arrest, 18 years or older, and there had to be least one cognitive outcome measure with a follow-up of 3 months or more. Case reports and qualitative studies were excluded. The articles were screened on title, abstract and full text by two reviewers. All selected articles were reviewed and assessed by two reviewers independently using a quality criteria list. Results: Out of the 286 articles initially identified, 28 were selected for final evaluation. There was a high heterogeneity between the studies with regard to study design, number of participants, outcome measures and duration of follow-up. in general, the quality of the articles appeared low, with a few positive exceptions. The reported frequency of cognitive impairments in survivors of out-of-hospital cardiac arrest ranged from 6% to 100%. Memory problems were the most common cognitive impairment, followed by impairments in attention and executive functioning. Three high-quality prospective studies found that cognitive problems occurred in about half of the survivors of out-of-hospital cardiac arrest. Conclusion: There are few good studies on the frequency of cognitive impairments after out-of-hospital cardiac arrest. However, cognitive problems, in particular memory problems, seem common in survivors of out-of-hospital cardiac arrest.

Previous studies have shown that walking is not a purely automatic motor task but places demands on sensory and cognitive systems. We set out to investigate whether complex walking tasks, as when walking down a steeper gradient while performing a concurrent cognitive task, would demand gait adaptation beyond those required for walking under low-challenge conditions. Thirteen healthy young individuals walked at their self-selected speed on a treadmill at different inclinations (0, 5 and 10%). Gait spatio-temporal measures, pelvis angular excursion, and sacral centre of mass (CoM) motion were acquired while walking or while walking and performing a mental tracking task. Repeated-measures ANOVAs revealed that decreasing treadmill inclination from 0 to 10% resulted in significant decreased walking speed (P < 0.001), decreased stride length (P < 0.001), increased pelvis tilt (P = 0.006) and obliquity variability (P = 0.05), decreased pelvis rotation (P = 0.02), and increased anterio-posterior (A-P) CoM displacement (P = 0.015). Compared to walking alone, walking under dual-task condition resulted in increased step width (P < 0.001), and increased medio-lateral (M-L) CoM displacement (P = 0.039) regardless of inclination grade, while sagittal plane dynamics did not change. Findings suggest that gait adapts differently to cognitive and mechanical constraints; the cognitive system is more actively involved in controlling frontal than sagittal plane gait dynamics, while the reverse is true for the mechanical system. Finally, these findings suggest that gait adaptations maintain the ability to perform concurrent tasks while treadmill walking in healthy young adults.

Objective: To measure the inter-rater reliability of the interview-administered version of the Frenchay Activities Index (FAI).

Design: Comparison of FAI score on the same person when administered by two raters (mean time between interviews 15.2 days).

Subjects: Fifty-nine Oxfordshire residents who either had had a stroke (n = 35) or were the main carer (n = 24).

Results: The 95% limits of agreement for the FAI totals were –9.9 to +8.4. The kappa statistic for nine of the 15 items showed a good level of agreement between the two research interviews (0.64–0.80). The other six items showed fair or moderate strength of agreement (0.26–0.52). Three items showed significant differences between the two raters p < 0.05 (Wilcoxon's sign paired rank sum test). The mean difference between the total scores was –0.76 (95% confidence interval from –1.98 to 0.46). Spearman's rho correlation coefficient for FAI totals of rater B against A was r(59) = 0.93 (p < 0.001).

Conclusion: The FAI is a reliable tool for measuring outcome following stroke. Suggestions are made to strengthen the reliability, and consequently the validity of the measure.