[ARTICLE] Adherence to Guidelines in Adult Patients with Traumatic Brain Injury: A Living Systematic Review – Full Text

Abstract

Guidelines aim to improve the quality of medical care and reduce treatment variation. The extent to which guidelines are adhered to in the field of traumatic brain injury (TBI) is unknown. The objectives of this systematic review were to (1) quantify adherence to guidelines in adult patients with TBI, (2) examine factors influencing adherence, and (3) study associations of adherence to clinical guidelines and outcome. We searched EMBASE, MEDLINE, Cochrane Central, PubMed, Web of Science, PsycINFO, SCOPUS, CINAHL, and grey literature in October 2014. We included studies of evidence-based (inter)national guidelines that examined the acute treatment of adult patients with TBI. Methodological quality was assessed using the Research Triangle Institute item bank and Quality in Prognostic Studies Risk of Bias Assessment Instrument. Twenty-two retrospective and prospective observational cohort studies, reported in 25 publications, were included, describing adherence to 13 guideline recommendations. Guideline adherence varied considerably between studies (range 18–100%) and was higher in guideline recommendations based on strong evidence compared with those based on lower evidence, and lower in recommendations of relatively more invasive procedures such as craniotomy. A number of patient-related factors, including age, Glasgow Coma Scale, and intracranial pathology, were associated with greater guideline adherence. Guideline adherence to Brain Trauma Foundation guidelines seemed to be associated with lower mortality. Guideline adherence in TBI is suboptimal, and wide variation exists between studies. Guideline adherence may be improved through the development of strong evidence for guidelines. Further research specifying hospital and management characteristics that explain variation in guideline adherence is warranted.

Introduction

Traumatic brain injury (TBI) is a major public health concern affecting approximately 150–300 per 100,000 persons annually in Europe.¹ The World Health Organization has predicted that TBI will be one of the leading causes of death and disability worldwide by the year 2020.²

The care for patients with TBI is often complex and multidisciplinary. Guidelines, protocols, and care pathways have been developed to improve quality of care, to reduce variation in practice, and to ensure that evidence-based care is optimally implemented.³

A 2013 systematic review⁴ found that the use of protocols in the management of severe TBI in the intensive care unit (ICU) led to improved patient outcomes. The findings, however, were based on observational studies that did not report on adherence rates. Without an understanding of adherence rates, the improved outcomes stated in the review cannot be directly attributed to the use of protocols.

Guideline adherence can be defined as the proportion of patients treated according to a guideline recommendation, which often represents evidence-based or best practice care. Previous studies have found that guideline adherence in medicine is generally low^5–7 and varies widely across centers,^7,8 medical condition,⁹ types of guideline,^10,11 and time period.^8,10 As a result, many patients do not receive evidence-based care, while others receive unnecessary care that may even be harmful.⁵To date, no systematic review of the literature about guideline adherence in TBI has been conducted.

The aim of this systematic review was to provide a comprehensive overview of professionals’ adherence to guidelines in adult patients with TBI. The objectives were threefold:

• 1. To quantify adherence to guidelines in adult patients with TBI.

• 2. To explore factors influencing adherence to TBI guidelines in those studies reporting on adherence.

• 3. To examine the association between adherence to guidelines and outcome in patients with TBI in those studies reporting on adherence.

Continue —> Adherence to Guidelines in Adult Patients with Traumatic Brain Injury: A Living Systematic Review | Journal of Neurotrauma

[Abstract] Effectiveness of interventions to improve therapy adherence in people with upper limb conditions: A systematic review

Abstract

Study Design

Systematic review.

Introduction

Patient adherence to orthosis wear and/or prescribed exercises improves functional outcome after acute injury and can prevent deformities, contractures, and reinjury of tissues. This is the first systematic review to review the evidence of the effectiveness of interventions to improve treatment adherence in children and adults with acute or chronic upper limb injuries or conditions.

Purpose of the Study

The purpose of this study is to establish the effectiveness of interventions to improve hand therapy adherence in people with upper limb conditions and to report on outcome measures used when reporting adherence.

Methods

A literature search of MEDLINE (OVID), Embase (OVID), CENTRAL (OVID), CINAHL (EBSCO), and EmCare (OVID) (from inception to March 2017) was undertaken. Studies were selected if they met the following inclusion criteria: clinical trials; in adults or children with any injury or condition affecting the upper limb including acute trauma and injury; chronic and acquired musculoskeletal conditions; and neurological conditions. Two independent assessors rated the study quality and risk of bias using the Cochrane Collaboration tool for assessing the risk of bias.

Results

Eight studies met the inclusion criteria. Study quality ranged from 3 to 6 out of 7 points on the Cochrane risk of bias tool. There were 4 categories of intervention for improving adherence: orthosis/cast material/design; orthosis wear schedule; patient education mode for home exercise programs; and behavioral approaches. Due to heterogeneity of condition acuity, interventions, and outcomes reported, it was not possible to pool the results from all studies. Therefore, a narrative best evidence synthesis was undertaken. There is weak evidence from a very small number of trials that orthosis/cast material has no influence on treatment adherence in acute or chronic conditions and mode of patient education (audio-visual vs written) has no effect in acute conditions. There is low-to-moderate quality of evidence in support of behavioral interventions for achieving treatment adherence in chronic rheumatoid arthritis.

Conclusion

Behavioral approaches that encourage self-efficacy are likely to be useful in achieving treatment adherence in populations with chronic upper limb conditions. There is insufficient evidence for other interventions aimed at improving adherence in acute upper limb injuries and conditions.

via Effectiveness of interventions to improve therapy adherence in people with upper limb conditions: A systematic review – Journal of Hand Therapy

[ARTICLE] 6-REXOS: Upper Limb Exoskeleton Robot with Improved pHRI – Full Text PDF

Abstract

Close interaction can be observed between an exoskeleton robot and its wearer. Therefore, appropriate physical human-robot interaction (pHRI) should be considered when designing an exoskeleton robot to provide safe and comfortable motion assistance. Different features have been used in recent studies to enhance the pHRI in upperlimb exoskeleton robots. However, less attention has been given to integrating kinematic redundancy into upper-limb exoskeleton robots to improve the pHRI.

In this context, this paper proposes a six-degrees-of-freedom (DoF) upperlimb exoskeleton robot (6-REXOS) for the motion assistance of physically weak individuals. The 6-REXOS uses a kinematically different structure to that of the human lower arm, where the exoskeleton robot is worn. The 6-REXOS has four active DoFs to generate the motion of the human lower arm. Furthermore, two flexible bellow couplings are attached to the wrist and elbow joints to generate two passive DoFs. These couplings not only allow translational motion in wrist and elbow joints but also a redundancy in the robot. Furthermore, the compliance of the flexible coupling contributes to avoiding misalignments between human and robot joint axes. The redundancy in the 6- REXOS is verified based on manipulability index, mini‐ mum singular value, condition number and manipulability ellipsoids. The 6-REXOS and a four-DoF exoskeleton robot are compared to verify the manipulation advantage due to the redundancy. The four-DoF exoskeleton robot is designed by excluding the two passive DoFs of the 6- REXOS. In addition, a kinematic model is proposed for the human lower arm to validate the performance of the 6- REXOS. Kinematic analysis and simulations are carried out to validate the 6-REXOS and human-lower-arm model.

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