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Improving sleep after stroke: A randomised controlled trial of digital cognitive behavioural therapy for insomnia
SummaryStroke is frequently accompanied by long‐term sleep disruption. We therefore aimed to assess the efficacy of digital cognitive behavioural therapy for insomnia to improve sleep after stroke. A parallel group randomised controlled trial was conducted remotely in participant's homes/online. Randomisation was online with minimisation of between‐group differences in age and baseline Sleep Condition Indicator‐8 score. In total, 86 community‐dwelling stroke survivors consented, of whom 84 completed baseline assessments (39 female, mean 5.5 years post‐stroke, mean 59 years old), and were randomised to digital cognitive behavioural therapy or control (sleep hygiene information). Follow‐up was at post‐intervention (mean 75 days after baseline) and 8 weeks later. The primary outcome was self‐reported insomnia symptoms, as per the Sleep Condition Indicator‐8 (range 0–32, lower numbers indicate more severe insomnia, reliable change 7 points) at post‐intervention. There were significant improvements in Sleep Condition Indicator‐8 for digital cognitive behavioural therapy compared with control (intention‐to‐treat, digital cognitive behavioural therapy n = 48, control n = 36, 5 imputed datasets, effect of group p ≤ 0.02, = 0.07–0.12 [medium size effect], pooled mean difference = −3.35). Additionally, secondary outcomes showed shorter self‐reported sleep‐onset latencies and better mood for the digital cognitive behavioural therapy group, but no significant differences for self‐efficacy, quality of life or actigraphy‐derived sleep parameters. Cost‐effectiveness analysis found that digital cognitive behavioural therapy dominates over control (non‐significant cost savings and higher quality‐adjusted life years). No related serious adverse events were reported to the researchers. Overall, digital cognitive behavioural therapy for insomnia effectively improves sleep after stroke. Future research is needed to assess earlier stages post‐stroke, with a longer follow‐up period to determine whether it should be included as part of routine post‐stroke care. Clinicaltrials.gov NCT04272892.
Nurse-delivered sleep restriction therapy in primary care for adults with insomnia disorder: a mixed-methods process evaluation
BackgroundSleep restriction therapy (SRT) is a behavioural therapy for insomnia.AimTo conduct a process evaluation of a randomised controlled trial comparing SRT delivered by primary care nurses plus a sleep hygiene booklet with the sleep hygiene booklet only for adults with insomnia disorder.Design and settingA mixed-methods process evaluation in a general practice setting.MethodSemi-structured interviews were conducted in a purposive sample of patients receiving SRT, the practice nurses who delivered the therapy, and also GPs or practice managers at the participating practices. Qualitative data were explored using framework analysis, and integrated with nurse comments and quantitative data, including baseline Insomnia Severity Index score and serial sleep efficiency outcomes to investigate the relationships between these.ResultsIn total, 16 patients, 13 nurses, six practice managers, and one GP were interviewed. Patients had no previous experience of behavioural therapy, needed flexible appointment times, and preferred face-to-face consultations; nurses felt prepared to deliver SRT, accommodating patient concerns, tailoring therapy, and negotiating sleep timings despite treatment complexity and delays between training and intervention delivery. How the intervention produced change was explored, including patient and nurse interactions and patient responses to SRT. Difficulties maintaining SRT, negative attitudes towards treatment, and low self-efficacy were highlighted. Contextual factors, including freeing GP time, time constraints, and conflicting priorities for nurses, with suggestions for alternative delivery options, were raised. Participants who found SRT a positive process showed improvements in sleep efficiency, whereas those who struggled did not.ConclusionSRT was successfully delivered by practice nurses and was generally well received by patients, despite some difficulties delivering and applying the intervention in practice.
Sleep regularity index as a novel indicator of sleep disturbance in stroke survivors: a secondary data analysis
Abstract Sleep disturbance is common but often overlooked after stroke. Regular sleep is increasingly recognised as important for overall health, yet little is known about how sleep regularity changes after stroke. This study examined differences in the Sleep Regularity Index (SRI) between stroke survivors and healthy controls using actigraphy data from an existing dataset (~ 1 week per participant). Data were analysed for 162 stroke survivors (mean age 61 ± 14 years, 5 ± 5 years post-stroke, 89 males) and 60 controls (mean age 57 ± 17 years, 32 males). Stroke survivors had significantly lower SRI scores than controls (p = 0.001), indicating less regular sleep. In the stroke group, higher SRI correlated with longer total sleep time (p = 0.003) and better self-reported sleep quality (p = 0.001) but not with other sleep metrics. Lower SRI was associated with worse depressive symptoms (p = 0.006) and lower quality of life (p = 0.001) but not with disability (p = 0.886) or time since stroke (p = 0.646). These findings suggest that sleep regularity is disrupted post-stroke and may influence well-being. Future research should explore interventions to improve sleep regularity and related health outcomes in stroke survivors.
Decoding dynamic brain networks in Parkinson's disease with temporal attention.
Detecting brief, clinically meaningful changes in brain activity is crucial for understanding neurological disorders. Conventional imaging analyses often overlook these subtle events due to computational demands. IMPACT (Integrative Multimodal Pipeline for Advanced Connectivity and Time-series) addresses this challenge by converting 3D/4D fMRI scans into time-series signals using a standardized brain atlas. This approach integrates regional signals, network patterns, and dynamic connectivity, and employs machine learning to detect subtle fluctuations. In Parkinson's disease diagnosis across two independent cohorts (n=43 and n=40), it achieves high accuracy (area under the curve = 0.97-0.98), outperforming conventional methods. Analyses reveal transient connectivity disruptions that align with dopaminergic mechanisms, while interpretability highlights the critical time windows and regions driving classification. This reproducible, standardized pipeline is readily adaptable to other conditions where short-lived brain changes serve as key diagnostic markers.
Does Your Bedside Neurological Examination for Suspected Peripheral Neuropathies Measure Up?
SYNOPSIS: Neurological testing is essential for screening and diagnosing suspected peripheral neuropathies. Detecting changes in somatosensory and motor nerve function can also have direct implications for management decisions. Nevertheless, there is considerable variation in what is included in a bedside neurological examination and how it is performed. Neurological examinations are often used as screening tools to detect neurological deficits but not used to their full potential for monitoring progress or deterioration. Here, we advocate for better use of the neurological examination within a clinical reasoning framework. Constrained by the lack of research in this field, our Viewpoint is based on neuroscientific principles. We highlight 6 challenges for clinicians when conducting neurological examinations and propose ways to overcome these challenges in clinical practice. We challenge widely held ideas about how the results of neurological examinations for peripheral neuropathies are interpreted and how the examinations are performed in practice. J Orthop Sports Phys Ther 2023;53(3):107-112. Epub: 28 October 2022. doi:10.2519/jospt.2022.11281.
How effective are physiotherapy interventions in treating people with sciatica? A systematic review and meta-analysis
Abstract Purpose Physiotherapy interventions are prescribed as first-line treatment for people with sciatica; however, their effectiveness remains controversial. The purpose of this systematic review was to establish the short-, medium- and long-term effectiveness of physiotherapy interventions compared to control interventions for people with clinically diagnosed sciatica. Methods This systematic review was registered on PROSPERO CRD42018103900. Cochrane Central Register of Controlled Trials (CENTRAL), CINAHL (EBSCO), Embase, PEDro, PubMed, Scopus and grey literature were searched from inception to January 2021 without language restrictions. Inclusion criteria were randomised controlled trials evaluating physiotherapy interventions compared to a control intervention in people with clinical or imaging diagnosis of sciatica. Primary outcome measures were pain and disability. Study selection and data extraction were performed by two independent reviewers with consensus reached by discussion or third-party arbitration if required. Risk of bias was assessed independently by two reviewers using the Cochrane Risk of Bias tool with third-party consensus if required. Meta-analyses and sensitivity analyses were performed with random effects models using Revman v5.4. Subgroup analyses were undertaken to examine the effectiveness of physiotherapy interventions compared to minimal (e.g. advice only) or substantial control interventions (e.g. surgery). Results Three thousand nine hundred and fifty eight records were identified, of which 18 trials were included, with a total number of 2699 participants. All trials had a high or unclear risk of bias. Meta-analysis of trials for the outcome of pain showed no difference in the short (SMD − 0.34 [95%CI − 1.05, 0.37] p = 0.34, I2 = 98%), medium (SMD 0.15 [95%CI − 0.09, 0.38], p = 0.22, I2 = 80%) or long term (SMD 0.09 [95%CI − 0.18, 0.36], p = 0.51, I2 = 82%). For disability there was no difference in the short (SMD − 0.00 [95%CI − 0.36, 0.35], p = 0.98, I2 = 92%, medium (SMD 0.25 [95%CI − 0.04, 0.55] p = 0.09, I2 = 87%), or long term (SMD 0.26 [95%CI − 0.16, 0.68] p = 0.22, I2 = 92%) between physiotherapy and control interventions. Subgroup analysis of studies comparing physiotherapy with minimal intervention favoured physiotherapy for pain at the long-term time points. Large confidence intervals and high heterogeneity indicate substantial uncertainly surrounding these estimates. Many trials evaluating physiotherapy intervention compared to substantial intervention did not use contemporary physiotherapy interventions. Conclusion Based on currently available, mostly high risk of bias and highly heterogeneous data, there is inadequate evidence to make clinical recommendations on the effectiveness of physiotherapy interventions for people with clinically diagnosed sciatica. Future studies should aim to reduce clinical heterogeneity and to use contemporary physiotherapy interventions.
Collaborative care model versus usual care for people with musculoskeletal conditions and co-existing anxiety and depression: protocol for a feasibility mixed-methods randomised controlled trial.
BACKGROUND: In the UK 17.8 million people have musculoskeletal pathophysiology, which becomes universal with age. Levels of discomfort and incapability correlate with symptoms of anxiety and depression. People with sufficient symptoms who seek care can benefit from collaborative diagnosis and treatment of mental and physical health organised by a case manager. This paper presents the protocol for a feasibility trial of collaborative care in an orthopaedic setting. AIMS: To determine the feasibility and acceptability of providing collaborative care for patients with musculoskeletal conditions and co-existing symptoms of anxiety and depression identified on a screening tool in a physical and occupational therapy out-patient setting. METHOD: A two-arm parallel-group randomised controlled trial will recruit 40 adult out-patients with at least moderate anxiety and depression, who have been referred for physiotherapy and occupational therapy. Participants will be allocated on a 1:1 ratio to collaborative care or to usual care. Co-primary outcomes will be key feasibility indicators collected at baseline and at 6 months. A qualitative study will be conducted post-intervention to explore the acceptability and potential improvements to the collaborative care model. RESULTS: This study will investigate the use of the collaborative care model for patients with musculoskeletal and co-existing moderate or severe levels of anxiety or depression. CONCLUSIONS: The results will provide important evidence to determine a future trial.
The prevalence of musculoskeletal pain and therapy needs in adults with Osteogenesis Imperfecta (OI) a cross-sectional analysis.
BACKGROUND: Osteogenesis Imperfecta affects approximately 1 in every 10,000 people. Musculoskeletal disorders and pain are common in adults with Osteogenesis Imperfecta, but specific knowledge of the problems people have is lacking. Access to therapy services for adults with Osteogenesis Imperfecta is variable. We designed this analysis to better understand the musculoskeletal disorders and consequent therapy needs for adults with Osteogenesis Imperfecta. METHODS: This study was a cross-sectional analysis of outpatients with Osteogenesis Imperfecta. Adults attending a newly established multidisciplinary clinic at a tertiary centre in 2019 were included. A highly specialist physiotherapist worked within the clinic to offer therapy input if required and to refer patients to appropriate therapy as needed. People over the age of 18 were included if they had a diagnosis of Osteogenesis Imperfecta. Data were collected over a five month period using routinely collected clinical information and patient reported outcomes. RESULTS: Over five months 50 patients attended the clinic. Musculoskeletal pain was a significant feature reported by 84% of patients. Over 50% of patients reported persistent pain for longer than one year duration and the most common site of pain was in the spine (46%). No difference in pain between types of OI and age. Forty five per cent (n = 19) of patients reported moderate to severe problems with mobility on the EQ-5D with over half reporting problems with self-care and ability to carry out usual activities. Over 50% of patients in clinic also reported anxiety (EQ-5D). During the consultation 70% of patients received therapy input which was either advice in clinic or an onward referral to the appropriate service. The referral rate to specialist out-patient rehabilitation services at a tertiary centre was 30%. CONCLUSIONS: This analysis highlights the high prevalence of MSK pain in adults with OI and the effect on physical function and emotional wellbeing. This study demonstrates the diverse needs of the adult Osteogenesis Imperfecta population and the need for suitable multidisciplinary therapy services.
Early surgery for sciatica.
Does new evidence challenge a stepped care approach for all patients?