Evidence-based perspective on CP rehabilitation : Reviews on physiotherapy, physiotherapy-related motor-based interventions and orthotic devices

This thesis utilises an evidence-based approach to critically evaluate and summarize effectiveness research on physiotherapy, physiotherapy-related motor-based interventions and orthotic devices in children and adolescents with cerebral palsy (CP). It aims to assess the methodological challenges of the systematic reviews and trials, to evaluate the effectiveness of interventions in current use, and to make suggestions for future trials Methods: Systematic reviews were searched from computerized bibliographic databases up to August 2007 for physiotherapy and physiotherapy-related interventions, and up to May 2003 for orthotic devices. Two reviewers independently identified, selected, and assessed the quality of the reviews using the Overview Quality Assessment Questionnaire complemented with decision rules. From a sample of 14 randomized controlled trials (RCT) published between January 1990 and June 2003 we analysed the methods of sampling, recruitment, and comparability of groups; defined the components of a complex intervention; identified outcome measures based on the International Classification of Functioning, Disability and Health (ICF); analysed the clinical interpretation of score changes; and analysed trial reporting using a modified 33-item CONSORT (Consolidated Standards of Reporting Trials) checklist. The effectiveness of physiotherapy and physiotherapy-related interventions in children with diagnosed CP was evaluated in a systematic review of randomised controlled trials that were searched from computerized databases from January 1990 up to February 2007. Two reviewers independently assessed the methodological quality, extracted the data, classified the outcomes using the ICF, and considered the level of evidence according to van Tulder et al. (2003). Results: We identified 21 reviews on physiotherapy and physiotherapy-related interventions and five on orthotic devices. These reviews summarized 23 or 5 randomised controlled trials and 104 or 27 observational studies, respectively. Only six reviews were of high quality. These found some evidence supporting strength training, constraint-induced movement therapy or hippotherapy, and insufficient evidence on comprehensive interventions. Based on the original studies included in the reviews on orthotic devices we found some short-term effects of lower limb casting on passive range of movement, and of ankle-foot orthoses on equinus walk. Long term effects of lower limb orthoses have not been studied. Evidence of upper limb casting or orthoses is conflicting. In the sample of 14 RCTs, most trials used simple randomisation, complemented with matching or stratification, but only three specified the concealed allocation. Numerous studies provided sufficient details on the components of a complex intervention, but the overlap of outcome measures across studies was poor and the clinical interpretation of observed score changes was mostly missing. Almost half (48%) of the applicable CONSORT-based items (range 28 32) were reported adequately. Most reporting inadequacies were in outcome measures, sample size determination, details of the sequence generation, allocation concealment and implementation of the randomization, success of assessor blinding, recruitment and follow-up dates, intention-to-treat analysis, precision of the effect size, co-interventions, and adverse events. The systematic review identified 22 trials on eight intervention categories. Four trials were of high quality. Moderate evidence of effectiveness was established for upper extremity treatments on attained goals, active supination and developmental status, and of constraint-induced therapy on the amount and quality of hand use and new emerging behaviours. Moderate evidence of ineffectiveness was found for strength training's effect on walking speed and stride length. Conflicting evidence was found for strength training's effect on gross motor function. For the other intervention categories the evidence was limited due to the low methodological quality and the statistically insignificant results of the studies. Conclusions: The high-quality reviews provide both supportive and insufficient evidence on some physiotherapy interventions. The poor quality of most reviews calls for caution, although most reviews drew no conclusions on effectiveness due to the poor quality of the primary studies. A considerable number of RCTs of good to fair methodological and reporting quality indicate that informative and well-reported RCTs on complex interventions in children and adolescents with CP are feasible. Nevertheless, methodological improvement is needed in certain areas of the trial design and performance, and the trial authors are encouraged to follow the CONSORT criteria. Based on RCTs we established moderate evidence for some effectiveness of upper extremity training. Due to limitations in methodological quality and variations in population, interventions and outcomes, mostly limited evidence on the effectiveness of most physiotherapy interventions is available to guide clinical practice. Well-designed trials are needed, especially for focused physiotherapy interventions.

Mechanism of RNA Translocation by a Viral Packaging Motor

Molecular motors are proteins that convert chemical energy into mechanical work. The viral packaging ATPase P4 is a hexameric molecular motor that translocates RNA into preformed viral capsids. P4 belongs to the ubiquitous class of hexameric helicases. Although its structure is known, the mechanism of RNA translocation remains elusive. Here we present a detailed kinetic study of nucleotide binding, hydrolysis, and product release by P4. We propose a stochastic-sequential cooperative model to describe the coordination of ATP hydrolysis within the hexamer. In this model the apparent cooperativity is a result of hydrolysis stimulation by ATP and RNA binding to neighboring subunits rather than cooperative nucleotide binding. Simultaneous interaction of neighboring subunits with RNA makes the otherwise random hydrolysis sequential and processive. Further, we use hydrogen/deuterium exchange detected by high resolution mass spectrometry to visualize P4 conformational dynamics during the catalytic cycle. Concerted changes of exchange kinetics reveal a cooperative unit that dynamically links ATP binding sites and the central RNA binding channel. The cooperative unit is compatible with the structure-based model in which translocation is effected by conformational changes of a limited protein region. Deuterium labeling also discloses the transition state associated with RNA loading which proceeds via opening of the hexameric ring. Hydrogen/deuterium exchange is further used to delineate the interactions of the P4 hexamer with the viral procapsid. P4 associates with the procapsid via its C-terminal face. The interactions stabilize subunit interfaces within the hexamer. The conformation of the virus-bound hexamer is more stable than the hexamer in solution, which is prone to spontaneous ring openings. We propose that the stabilization within the viral capsid increases the packaging processivity and confers selectivity during RNA loading. Finally, we use single molecule techniques to characterize P4 translocation along RNA. While the P4 hexamer encloses RNA topologically within the central channel, it diffuses randomly along the RNA. In the presence of ATP, unidirectional net movement is discernible in addition to the stochastic motion. The diffusion is hindered by activation energy barriers that depend on the nucleotide binding state. The results suggest that P4 employs an electrostatic clutch instead of cycling through stable, discrete, RNA binding states during translocation. Conformational changes coupled to ATP hydrolysis modify the electrostatic potential inside the central channel, which in turn biases RNA motion in one direction. Implications of the P4 model for other hexameric molecular motors are discussed.

Bone health and vitamin D status in children with motor disability and adults with intellectual disability

Osteoporosis is not only a disease of the elderly, but is increasingly diagnosed in chronically ill children. Children with severe motor disabilities, such as cerebral palsy (CP), have many risk factors for osteoporosis. Adults with intellectual disability (ID) are also prone to low bone mineral density (BMD) and increased fractures. This study was carried out to identify risk factors for low BMD and osteoporosis in children with severe motor disability and in adults with ID. In this study 59 children with severe motor disability, ranging in age from 5 to 16 years were evaluated. Lumbar spine BMD was measured with dual-energy x-ray absorptiometry. BMD values were corrected for bone size by calculating bone mineral apparent density (BMAD), and for bone age. The values were transformed into Z-scores by comparison with normative data. Spinal radiographs were assessed for vertebral morphology. Blood samples were obtained for biochemical parameters. Parents were requested to keep a food diary for three days. The median daily energy and nutrient intakes were calculated. Fractures were common; 17% of the children had sustained peripheral fractures and 25% had compression fractures. BMD was low in children; the median spinal BMAD Z-score was -1.0 (range -5.0 – +2.0) and the BMAD Z-score <-2.0 in 20% of the children. Low BMAD Z-score and hypercalciuria were significant risk factors for fractures. In children with motor disability, calcium intakes were sufficient, while total energy and vitamin D intakes were not. In the vitamin D intervention studies, 44 children and adolescents with severe motor disability and 138 adults with ID were studied. After baseline blood samples, the children were divided into two groups; those in the treatment group received 1000 IU peroral vitamin D3 five days a week for 10 weeks, and subjects in the control group continued with their normal diet. Adults with ID were allocated to receive either 800 IU peroral vitamin D3 daily for six months or a single intramuscular injection of 150 000 IU D3. Blood samples were obtained at baseline and after treatment. Serum concentrations of 25-OH-vitamin D (S-25-OHD) were low in all subgroups before vitamin D intervention: in almost 60% of children and in 77% of adults the S-25-OHD concentration was below 50 nmol/L, indicating vitamin D insufficiency. After vitamin D intervention, 19% of children and 42% adults who received vitamin D perorally and 12% of adults who received vitamin D intramuscularly had optimal S-25-OHD (>80 nmol/L). This study demonstrated that low BMD and peripheral and spinal fractures are common in children with severe motor disabilities. Vitamin D status was suboptimal in the majority of children with motor disability and adults with ID. Vitamin D insufficiency can be corrected with vitamin D supplements; the peroral dose should be at least 800 IU per day.

Ruumis ja rauta : esseitä esineiden sosiaalisuudesta

"Body and Iron: Essays on the Socialness of Objects" focuses on the bodily-material interaction of human subjects and technical objects. It poses a question, how is it possible that objects have an impact on their human users and examines the preconditions of active efficacy of objects. In this theoretical task the work relies on various discussions drawing from realistic ontology, phenomenology of body, neurophysiology of Antonio Damasio and psychoanalysis to establish both objects and bodies as material entities related in a causal interaction with each other. Out of material interaction emerge a symbolic field, psyche and culture that produce representations of interactions with material world they remain dependent on and conditioned by. Interaction with objects informs the human body via its somatosensory systems: interoseptive and proprioseptive (or kinesthetic) systems provide information to central nervous system of the internal state of the body and muscle tensions and motor activity of the limbs. Capability to control the movements of one's body by the internal "feel" of being a body turns out to be a precondition to the ability to control artificial extensions of the body. Motor activity of the body is involved in every perception of environment as the feel of one's own body is constitutive of any perception of external objects. Perception of an object cause changes in the internal milieu of the body and these changes in the organism form a bodily representation of an external object. Via these "muscle images" the subject can develop a feel for an instrument. Bodily feel for an object is pre-conceptual, practical knowledge that resists articulation but allows sensing the world through the object. This is what I would call sensual knowledge. Technical objects intervene between body and environment, transforming the relation of perception and motor activity. Once connected to a vehicle, human subject has to calibrate visual information of his or her position and movement in space to the bodily actions controlling the machine. It is the machine that mediates the relation of human actions to the relation of her body to its environment. Learning to use the machine necessarily means adjusting his or her bodily actions to the responses of the machine in relation to environmental changes it causes. Responsiveness of the machine to human touch "teaches" its subject by providing feedback of the "correctitude" of his or her bodily actions. Correct actions form a body technique of handling the object. This is the way of socialness of objects. While responding to human actions they generate their subjects. Learning to handle a machine means accepting the position of the user in the program of action materialized in the construction of the object. Objects mediate, channel and transform the relation of the body to its environment and via environment to the body itself according to their material and technical construction. Objects are sensory media: they channel signals and information from the environment thus constituting a representation of environment, a virtual or artificial reality. They also feed the body directly with their powers equipping their user with means of regulating somatic and psychic states of her self. For these reasons humans look for the company of objects. Keywords: material objects, material culture, sociology of technology, sociology of body, mobility, driving

Information Technology in Construction – Domain Definition and Research Issues

This article discusses the scope of research on the application of information technology in construction (ITC). A model of the information and material activities which together constitute the construction process is presented, using the IDEF0 activity modelling methodology. Information technology is defined to include all kinds of technology used for the storage, transfer and manipulation of information, thus also including devices such as copying machines, faxes and mobile phones. Using the model the domain of ITC research is defined as the use of information technology to facilitate and re-engineer the information process component of construction. Developments during the last decades in IT use in construction is discussed against a background of a simplified model of generic information processing tasks. The scope of ITC is compared with the scopes of research in related areas such as design methodology, construction management and facilities management. Health care is proposed as an interesting alternative (to the often used car manufacturing industry), as an IT application domain to compare with. Some of the key areas of ITC research in recent years; expert systems, company IT strategies, and product modelling are shortly discussed. The article finishes with a short discussion of the problems of applying standard scientific methodology in ITC research, in particular in product model research.

The Nature of Learning about Customers in a Customer Service Setting - A Study of Frontline Contact Persons

The starting point of this thesis is the notion that in order for organisations to understand what customers value and how customers experience service, they need to learn about customers. The first and perhaps most important link in an organisation-wide learning process directed at customers is the frontline contact person. Service- and sales organisations can only learn about customers if the individual frontline contact persons learn about customers. Even though it is commonly recognised that learning about customers is the basis for an organisation’s success, few contributions within marketing investigate the fundamental nature of the phenomenon as it occurs in everyday customer service. Thus, what learning about customers is and how it takes place in a customer-service setting is an issue that is neglected in marketing research. In order to explore these questions, this thesis presents a socio-cultural approach to understanding learning about customers. Hence, instead of considering learning equal to cognitive processes in the mind of the frontline contact person or learning as equal to organisational information processing, the interactive, communication-based, socio-cultural aspect of learning about customers is brought to the fore. Consequently, the theoretical basis of the study can be found both in socio-cultural and practice-oriented lines of reasoning, as well as in the fields of service- and relationship marketing. As it is argued that learning about customers is an integrated part of everyday practices, it is also clear that it should be studied in a naturalistic and holistic way as it occurs in a customer-service setting. This calls for an ethnographic research approach, which involves direct, first-hand experience of the research setting during an extended period of time. Hence, the empirical study employs participant observations, informal discussions and interviews among car salespersons and service advisors at a car retailing company. Finally, as a synthesis of theoretically and empirically gained understanding, a set of concepts are developed and they are integrated into a socio-cultural model of learning about customers.

Shareholder/Stakeholder Value Management, Company Growth and

There has been considerable discussion in the literature about the relative merits of shareholder value management and stakeholder value management, but relatively little empirical research has been reported concerning the relationship between these types of management and financial performance. The present study puts forward a hypothesis that true shareholder value management also encompasses stakeholder value management. This combination of shareholder/stakeholder value management is hypothesised to be associated with superior financial performance and sales growth. Using a sample of chief financial officers' ratings of the contemporary management accounting techniques economic value added and the balanced scorecard to represent the two management types, the study found evidence in support of the hypothesis.

Strategic Priorities, Company Performance and Attitudes Towards Management Accounting Techniques: an Empirical Study

The study investigates whether there is an association between different combinations of emphasis on generic strategies (product differentiation and cost efficiency) and perceived usefulness of management accounting techniques. Previous research has found that cost leadership is associated with traditional accounting techniques and product differentiation with a variety of modern management accounting approaches. The present study focuses on the possible existence of a strategy that mixes these generic strategies. The empirical results suggest that (a) there is no difference in the attitudes towards the usefulness of traditional management accounting techniques between companies that adhere either to a single strategy or a mixed strategy; (b) there is no difference in the attitudes towards modern and traditional techniques between companies that adhere to a single strategy, whether this is product differentiation or cost efficiency, and c) companies that favour a mixed strategy seem to have a more positive attitude towards modern techniques than companies adhering to a single strategy