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Baguley I.J.,University of Sydney | Nott M.T.,University of Sydney | Turner-Stokes L.,King's College London | Graaff S.D.,Caulfield General Medical Center | And 4 more authors.
Journal of Rehabilitation Medicine | Year: 2011

Background: Limited empirical information exists regarding botulinum toxin-A injector decision-making practices for adult upper limb post-stroke spasticity. The design of most studies prevents such an assessment, as injection sites and dosage are mandated by researcher protocols. This contrasts to usual injector practices, where individualized decisionmaking is the standard of care. Design: Secondary data analysis from an Australian randomized controlled trial of 90 adults with upper limb poststroke spasticity where experienced clinicians followed their standard clinical injecting practice rather than a mandated injection regimen. Methods: Clinicians were hypothesized to tailor their injection practices according to the subject's degree of spasticity and/or the type of functional gain desired. Hypothesis testing was conducted using non-parametric analysis. Results: Muscle selection and botulinum toxin-A dosage were not significantly associated with spasticity severity or with patient-identified goals. Between-site differences in injection practices suggested that injector beliefs, rather than patient characteristics, were the dominant feature driving botulinum toxin-A injection strategy for post-stroke upper limb spasticity. Conclusion: This result looks into the "black box" of rehabilitation, revealing significant variation in injector beliefs. Findings suggest that further scientific work is required to maximize the efficacy of botulinum toxin-A injections in post-stroke upper limb spasticity management. © 2011 Foundation of Rehabilitation Information.


Frossard L.,Queensland University of Technology | Frossard L.,University of Queensland | Gow D.L.,Caulfield General Medical Center | Hagberg K.,Sahlgrenska University Hospital | And 5 more authors.
Gait and Posture | Year: 2010

The purpose of this proof-of-concept study was to determine the relevance of direct measurements to monitor the load applied on the osseointegrated fixation of transfemoral amputees during static load bearing exercises. The objectives were (A) to introduce an apparatus using a three-dimensional load transducer, (B) to present a range of derived information relevant to clinicians, (C) to report on the outcomes of a pilot study and (D) to compare the measurements from the transducer with those from the current method using a weighing scale. One transfemoral amputee fitted with an osseointegrated implant was asked to apply 10 kg, 20 kg, 40 kg and 80 kg on the fixation, using self-monitoring with the weighing scale. The loading was directly measured with a portable kinetic system including a six-channel transducer, external interface circuitry and a laptop. As the load prescribed increased from 10 kg to 80 kg, the forces and moments applied on and around the antero-posterior axis increased by four-fold anteriorly and 14-fold medially, respectively. The forces and moments applied on and around the medio-lateral axis increased by nine-fold laterally and 16-fold from anterior to posterior, respectively. The long axis of the fixation was overloaded and underloaded in 17% and 83% of the trials, respectively, by up to ±10%. This proof-of-concept study presents an apparatus that can be used by clinicians facing the challenge of improving basic knowledge on osseointegration, for the design of equipment for load bearing exercises and for rehabilitation programs. © 2009 Elsevier B.V.


Turner-Stokes L.,King's College London | Baguley I.J.,Westmead Hospital | De Graaff S.,Caulfield General Medical Center | Katrak P.,University of New South Wales | And 3 more authors.
Journal of Rehabilitation Medicine | Year: 2010

Objective: To examine goal attainment scaling for evaluation of treatment for upper limb post-stroke spasticity with botulinum toxin-A. Design: Secondary analysis of a multi-centre double-blind, placebo-controlled randomized clinical trial. Setting: Six outpatient clinics in Australia. Participants: Patients (n=90) completing per protocol 2 cycles of treatment/placebo. Mean age 54.5 (standard deviation 13.2) years. Mean time since stroke 5.9 (standard deviation 10.5) years. Interventions: Intramuscular botulinum toxin-A (Dysport® 500-1000U) or placebo given at 0 and 12 weeks. Measurement points were baseline, 8 and 20.weeks. Main outcome measures: Individualized goal attainment and its relationship with spasticity and other person-centred measures - pain, mood, quality of life and global benefit. Results: A significant treatment effect was observed with respect to goal attainment (Mann-Whitney z=-2.33,p≤0.02). Goal-attainment scaling outcome T-scores were highly correlated with reduction in spasticity (rho = 0.36,/?=0.001) and global benefit (rho = 0.45, p<0.001), but not with other outcome measures. Goal-attainment scaling T-scores were lower than expected (median 32.4, interquartile range 29.6-40.6). Goals related to passive tasks were more often achieved than those reflecting active function. Qualitative analysis of goals nevertheless demonstrated change over a wide area of patient experience. Conclusion: Goal-attainment scaling provided a responsive measure for evaluating focal intervention for upper limb spasticity, identifying outcomes of importance to the individual/carers, not otherwise identifiable using standardized measures. Journal Compilation © 2010 Foundation of Rehabilitation Information.


Giummarra M.J.,Monash University | Fitzgibbon B.M.,Monash University | Georgiou-Karistianis N.,Monash University | Nicholls M.E.R.,Flinders University | And 3 more authors.
Perception | Year: 2010

Pain synaesthetes experience pain in a presensitised region when observing or imagining another person in pain. We conducted an upper-limb embodiment study using a modified rubber-hand illusion in which lower-limb amputees originally participated as control subjects for the upper-limb amputees. While we found all subjects experienced topographic illusory sensations, we also serendipitously found that lower-limb amputee pain synaesthetes experienced pain or a motor response in their phantom leg when the embodied hand was threatened (eg with a retractable knife, mousetrap, or syringe) or submitted to high-frequency stimulation (eg vibration). Embodiment illusions were brought about by touching, manipulating, or threatening a rubber or real hand which was observed through a mirror so that it was superimposed upon the target hand (phantom hand for upper-limb amputees, or real hand in others). Participants included eight pain synaesthetes (six lower-limb amputees, one upper-limb amputee, and one nonamputee), and thirty-one controls (eight lower-limb amputees, twelve upper-limb amputees, and eleven non-amputees). We documented participant's subjective reports, together with quantitative measures including the Questionnaire Measure of Emotional Empathy. We found no association between pain synaesthesia and empathy scores. On the basis of related literature we suggest that pain synaesthetes likely experienced phantom-leg pain because (a) the motor system was already engaged during visual capture; (b) threatening stimuli, to which they are hyper-vigilant, triggered avoidance or escape' motor schemata; and (c) there could be no feedback confirming that initiated motor schemata for the phantom limb were successfully performed. Ultimately, we have further defined this new condition, synaesthesia for pain, as not only having a sensory pain component, but also a key motor component, manifesting itself in avoidance, contraction, and withdrawal 'actions'. © 2010 a Pion publication.


Moran C.,Monash University | Moran C.,Monash Medical Center | Moran C.,Caulfield General Medical Center | Beare R.,Murdoch Childrens Research Institute | And 7 more authors.
Neurology | Year: 2015

Objective: Our objective was to investigate whether type 2 diabetes mellitus (T2DM) influences neurodegeneration in a manner similar to Alzheimer disease (AD), by promoting brain β-amyloid (Aβ) or tau. Methods: We studied the cross-sectional associations of T2DM with cortical thickness, brain Aβ load, and CSF levels of Aβ and tau in a sample of people from the Alzheimer's Disease Neuroimaging Initiative with diagnoses of AD dementia, mild cognitive impairment, and normal cognition. All (n 816) received MRI, and a subsample underwent brain amyloid imaging (n 102) and CSF Aβ and tau measurements (n 415). Analyses were performed across and within cognitive diagnostic strata. Results: There were 124 people with T2DM (mean age 75.5 years) and 692 without T2DM (mean age 74.1 years). After adjusting for age, sex, total intracranial volume, APO ε4 status, and cognitive diagnosis, T2DM was associated with lower bilateral frontal and parietal cortical thickness (mL) (β-0.03, p 0.01). T2DM was not associated with 11 C Pittsburgh compound B standardized uptake value ratio (AU) in any brain region or with CSF Aβ 42 levels (pg/mL). T2DM was associated with greater CSF total tau (pg/mL) (β 16.06, p 0.04) and phosphorylated tau (β 5.84, p 0.02). The association between T2DM and cortical thickness was attenuated by 15% by the inclusion of phosphorylated tau. Conclusions: T2DM may promote neurodegeneration independent of AD dementia diagnosis, and its effect may be driven by tau phosphorylation. The mechanisms through which T2DM may promote tau phosphorylation deserve further study. © 2015 American Academy of Neurology.


Mahar P.D.,Alfred Hospital | Wasiak J.,Monash University | O'Loughlin C.J.,Monash University | Christelis N.,Alfred Hospital | And 4 more authors.
Burns | Year: 2012

Introduction: Pain continues to be an ongoing issue of concern in adult burn patients. Inadequate pain assessment hinders meaningful research, and prevents the optimal management of burn pain. The objective of this study was to examine the content of existing research in burn pain with the frequency and context of pain assessment tool use in randomized clinical trials in order to further inform their use for future researchers and clinicians. Methods: Electronic searches of MEDLINE, CINAHL, EMBASE and The Cochrane Library databases from 1966 onwards were used to identify English articles related to clinical trials utilising pain assessment in adult burns patients. Results: The systematic literature search identified 25 randomized clinical trials utilising pain assessment tools. Unidimensional pain assessment tools were most frequently used pain assessment tools, with multidimensional tools used less often, despite the multifaceted and complex nature of burn pain. Conclusion: The review highlights the lack of consistency of pain assessment tool use in randomized clinical trials with respect to managing burn pain. We recommend a broader but consistent use of multidimensional pain assessment tools for researchers undertaking clinical trials in this field. The review supports the need for an international expert consensus to identify the necessary critical outcomes and domains for clinicians and researchers undertaking further research into burn pain. © 2011 Elsevier Ltd and ISBI. All rights reserved.


Ward S.A.,Monash University | Ward S.A.,Sunshine Hospital | Parikh S.,Monash University | Parikh S.,Caulfield General Medical Center | Workman B.,Monash University
Best Practice and Research: Clinical Anaesthesiology | Year: 2011

Populations globally are ageing, in part due to dramatic increases in life expectancies, forcing a reconsideration of what constitutes being "elderly" and "old." The proportion of older adults living with disability may be decreasing, yet older individuals are living with a significant burden of chronic disease, geriatric impairments in cognition, vision and hearing and reduced physiological reserve (frailty). Caring for a growing number of medically complex individuals has implications for medical workforce size and composition, health programmes and expenditure. Future responses to an ageing population will require further innovation in health-care delivery models, and increasing representation of older adults in clinical trials. © 2011 Elsevier Ltd. All rights reserved.


O'Connor D.W.,Monash University | O'Connor D.W.,Southern Health | Gardner B.,Monash University | Presnell I.,Monash University | And 5 more authors.
Journal of Affective Disorders | Year: 2010

Background: We report on the outcomes in aged patients with severe, treatment-resistant depression or psychosis who were given ongoing outpatient continuation-maintenance ECT of varying duration to prevent remission and relapse following a successful course of acute ECT. Methods: A retrospective chart review of 58 consecutive patients of three Australian aged psychiatry services comparing the number and length of psychiatric admissions before and after the start of continuation-maintenance ECT. Results: Four patients had only one treatment and two received over 50 (mean 14.7). Five were still enrolled in a maintenance program two years later. In the two years after continuation-maintenance ECT started, admissions fell by 53% in number and 79% in duration compared with the previous two years. Within the actual treatment period which varied from one patient to another, admissions fell by 90% in number and 97% in duration compared with the same period beforehand. Conclusion: A treatment effect cannot be proven but the severity and chronicity of patients' conditions make placebo effects and spontaneous remission unlikely. Randomised, controlled trials are almost impossible in this setting and so carefully conducted reviews and case-control studies are still of value. Our findings suggest that continuation-maintenance ECT is effective in carefully selected patients at high risk of relapse. © 2009 Elsevier B.V. All rights reserved.


Rose M.,Cabrini Medical Center | Pan H.,Caulfield General Medical Center | Levinson M.R.,Cabrini Institute | Staples M.,Cabrini Institute
Internal Medicine Journal | Year: 2014

The Reported Edmonton Frail Scale was used to describe the prevalence of frailty in an acute general medical unit. The relationship between frailty, discharge destination, mortality and length of hospital stay was explored. We found that age was associated with frailty, and frailty correlated to an increasing length of hospital stay. © 2014 Royal Australasian College of Physicians.


Parikh S.,Harvard University | Parikh S.,Beth Israel Deaconess Medical Center | Parikh S.,Caulfield General Medical Center | Shrank W.H.,Harvard University | And 2 more authors.
Journal of General Internal Medicine | Year: 2010

BACKGROUND: Coronary artery disease (CAD) is highly prevalent in nursing home residents and is associated with a substantial clinical and economic burden. Statins reduce mortality and hospitalization rates in older patients with CAD. OBJECTIVES: To assess rates and predictors of statin use among high-risk patients with symptomatic coronary artery disease (CAD) admitted to nursing homes after acute cardiac hospitalization. DESIGN: Cohort study. PARTICIPANTS: Medicare beneficiaries enrolled in either a state-run drug assistance program or Medicaid in nursing homes in New Jersey from 1994 through 2005. MEASUREMENTS: Statin utilization within 60 days of nursing home admission was determined for patients recently hospitalized with symptomatic CAD in whom statins are indicated consisting of those with: acute coronary syndrome (ACS) without revascularization, ACS with revascularization and congestive heart failure (CHF) with revascularization. Predictors of statin use were evaluated with multivariate logistic regression models. RESULTS: While statin use over the 11-year period increased from 1.2% to 31.8%, overall utilization was very low. Predictors of greater statin use included prior cardiac hospitalization [odds ratio (OR) 1.32, 95% confidence interval (95% CI) 1.13 to 1.57], prior statin use (OR 6.92, 95% CI 5.86 to 8.82) and receipt of a concurrent cardiac medication (range of odds ratios, 2.36-3.40). Older patients admitted for ACS with or without revascularization were less likely to receive a statin. Patients who had received anti-platelets or angiotensin-modifying agents prior to their hospitalization were less likely to receive statins after discharge. Renal disease, prior stroke, diabetes, hypertension and hyperlipidemia did not influence statin utilization. Predictors of treatment did not change when the cohort was dichotomized according to length of stay. CONCLUSIONS: Patients are infrequently treated with statins when discharged to nursing homes following hospitalization for a symptomatic cardiovascular event. Barriers to statin treatment in this setting require closer examination. © 2010 Society of General Internal Medicine.

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