Embedded motivational interviewing combined with a smartphone application to increase physical activity in people with sub-acute low back pain: a cluster randomised controlled trial.

BACKGROUND: Moderately vigorous physical activity (PA) may be beneficial for people with sub-acute low back pain (LBP), but may initially be painful for patients and challenging for physical therapists to facilitate. OBJECTIVES: This study investigated motivational interviewing (MI) delivered by physical therapists and a smartphone app for increasing PA in people with LBP. METHODS: A mixed methods cluster randomised controlled trial involving 46 adults with LBP in Melbourne, Australia. Participants attended weekly 30-min physical therapy consultations for 6 weeks. Experimental group physical therapists were taught to embed MI into consultations and patients were provided with a self-directed app. The primary outcome was accelerometer-derived moderately vigorous PA. Secondary outcomes were LBP disability (Oswestry Disability Index), functional capacity (Patient Specific Functional Scale), and self-efficacy (Pain Self-Efficacy Questionnaire). Between-group differences were analysed by ANCOVA post-intervention. RESULTS: There was no statistically significant difference between the experimental group and control group for PA. Between-group differences in LBP disability (MD= 19.4 units, 95% CI: 8.5, 30.3), functional capacity (primary MD= -4.1 units, 95% CI: -6.9, -1.3; average MD= -3.1, 95% CI: -4.9, -1.2) and self-efficacy (MD -11.3 units, 95%CI -20.2, -2.5) favoured the control group with small to moderate effect sizes. There were low levels of overall engagement with the app. CONCLUSION: The embedded MI intervention was no more beneficial than physical therapy alone for PA and was associated with poorer LBP disability, function, and self-efficacy. The effectiveness of embedding MI and a smartphone app into usual care for LBP was not supported.

Embedded Motivational Interviewing combined with a smartphone app to increase physical activity in people with sub-acute low back pain: Study protocol of a cluster randomised control trial.

BACKGROUND: Motivational Interviewing is an evidence-based, client-centred counselling technique that has been used effectively to increase physical activity, including for people with low back pain. One barrier to implementing Motivational Interviewing in health care settings more broadly is the extra treatment time with therapists. The aim of this paper is to describe the design of a cluster randomised controlled trial evaluating the effect of an intervention that pairs Motivational Interviewing embedded into usual physiotherapy care with a specifically designed app to increase physical activity in people with sub-acute low back pain. METHODS: The study is a cluster randomised controlled in which patients aged over 18 years who have sub-acute low back pain (3-12 weeks duration) are recruited from four public hospital outpatient clinics. Based on the recruitment site, participants either receive usual physiotherapy care or the Motivational Interviewing intervention over 6 consecutive weekly outpatient sessions with a specifically designed app designed to facilitate participant-led physical activity behaviour change in between sessions. Outcome measures assessed at baseline and 7 weeks are: physical activity as measured by accelerometer (primary outcome), and pain-related activity restriction and pain self-efficacy (secondary outcomes). Postintervention interviews with physiotherapists and participants will be conducted as part of a process evaluation. DISCUSSION: This intervention, which comprises trained physiotherapists conducting conversations about increasing physical activity with their patients in a manner consistent with Motivational Interviewing as part of usual care combined with a specifically designed app, has potential to facilitate behaviour change with minimal extra therapist time.

The validity of using activity monitors to detect step count after lumbar fusion surgery.

Purpose: Measuring step count using activity monitors is an increasingly popular method of quantifying physical activity, however it is unknown whether gait irregularities or the use of gait aids affect the accuracy of these devices. This study evaluates the validity of the ActivPAL3, Fitbit Flex, and Jawbone UP Move activity monitors for measuring step count in hospital inpatients after lumbar fusion.Methods: The ActivPAL3 was tested on the thigh, the Fitbit, and the Jawbone were tested on the wrist and thigh, each monitor was tested 20 times. Validity was examined by calculating the percentage of steps detected by each monitor compared to the criterion measure of observed step count, the Standard Error of Measurement, and the Intraclass Correlation Coefficient.Results: The ActivPAL3 detected 85% (SD 27%) of observed steps. On the wrist, the Fitbit detected 24% (SD 34%) and the Jawbone detected 17% (SD 40%) of observed steps. On the thigh, the Fitbit detected 66% (SD 42%) and the Jawbone detected 22% (SD 35%) of observed steps.Conclusion: The ActivPAL3 activity monitor is a sufficiently valid tool to detect step count immediately after lumbar fusion. Wrist worn monitors are not recommended in this population, particularly with patients using gait aids.Implications for RehabilitationWalking may be quantified using activity monitoring, as both an assessment tool and as an adjunct to treatmentThe ActivPAL3 is sufficiently valid for use after lumbar fusion surgeryThe Fitbit Flex and Jawbone UP Move had low accuracy, particularly when a gait aid was used.

Physical activity patterns of patients immediately after lumbar surgery.

Purpose: To describe the physical activity patterns of patients in the first week after lumbar surgery, and to investigate factors that potentially limit walking time early after surgery.Materials and methods: Adults undergoing lumbar decompression, discectomy and/or fusion surgery (N = 216, mean age 62 years, SD 13.9) were invited to participate. Walking time and step count were recorded for the first seven post-operative days, using an ActivPAL accelerometer. Participants recorded daily pain scores, supervision requirements while walking, and any complications that prevented walking.Results: On the first post-operative day, participants spent an average of 17 min (SD 20) walking, by Day 6, participants spent an average of 53 min (SD 38) walking. Participants who reported minor post-operative complications had a significantly lower step count than those without complications (p < 0.01). A lower step count was associated with a longer time to achieve independent mobility (r= -0.60, 95% CI -0.68 to -0.50), and a longer hospital admission (r= -0.70, 95% CI -0.76 to -0.63).Conclusions: This study found that patients walk for less than an hour a day over the week after lumbar surgery. Further research is required to investigate whether intervention designed to increase walking time improves post-operative activity and longer-term patient outcome.IMPLICATIONS FOR REHABILITATIONWhile resuming walking after lumbar surgery is a common focus of early rehabilitation, little is known about how much walking patients do, or how walking impacts recovery.The findings from this study describe activity patterns early after lumbar surgery, which may be used to inform patients about normal post-operative recovery.A lower post-operative step count was associated with several patient factors, including a fusion procedure and more severe post-operative pain, which may be used to guide peri-operative care and rehabilitation protocols.

Predictors of substantial improvement in physical function six months after lumbar surgery: is early post-operative walking important? A prospective cohort study.

BACKGROUND: Resuming walking after lumbar surgery is a common focus of early post-operative rehabilitation, however there is no knowledge about whether increased walking is associated with better functional outcomes. This study aimed to determine whether time spent walking in the week after lumbar surgery, along with co-morbidities, pre-operative pain duration, pre-operative physical activity or function, or surgical variables predict substantial improvement in physical function six months after lumbar surgery. METHODS: A prospective cohort study design was utilized. Participants undergoing lumbar surgery (discectomy, decompression, fusion) were recruited between April and November 2016. Predictor variables were collected pre-operatively (age, sex, smoking status, obesity, diabetes, depression, anxiety, pre-operative pain duration, neurological deficit, physical activity levels, mobility restriction, function) and early post-operatively (post-operative walking time, surgical procedure, single/multi-level surgery). Outcome variables (physical function, back pain and leg pain severity) were measured pre-operatively and six-months post-operatively. Logistic regression analysis was used to establish prediction of substantial improvement in outcome at six months. RESULTS: Participants (N = 233; 50% female; age 61 (SD = 14) years) who walked more in the first post-operative week were more likely to have substantially improved function on the Oswestry Disability Questionnaire at six months (OR 1.18, 95%CI 1.02-1.37), as were participants with < 12 months pre-operative pain (OR 2.71, 95%CI 1.28-5.74), and those with lower pre-operative function (OR 4.02, 95%CI 2.33-6.93). Age < 65 years (OR 2.36, 95%CI 1.14-4.85), and < 12 months pre-operative pain (OR 3.52 95%CI 1.69-7.33) predicted substantial improvement on the SF-36 Physical Component Summary. There were no significant predictors for substantial improvement in either leg or back pain. CONCLUSIONS: Walking time in the week after lumbar surgery is one of several predictors of substantial improvement in function at six months. Further research is required to determine whether intervention designed to increase walking early after lumbar surgery results in improved longer-term recovery of function. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry (ANZCTR), registration number 12616000747426 . Retrospectively registered on the 7th of June 2016.

Individualised functional restoration plus guideline-based advice vs advice alone for non-reducible discogenic low back pain: a randomised controlled trial.

OBJECTIVES: To evaluate the effectiveness of individualised functional restoration plus guideline-based advice compared to advice alone in people with non-reducible discogenic pain (NRDP). DESIGN: Subgroup analysis within a multicentre, parallel group randomised controlled trial. SETTING: Fifteen primary care physiotherapy clinics. PARTICIPANTS: Ninety-six participants with clinical features indicative of NRDP (6 week to 6 month duration of injury). INTERVENTIONS: Over a 10 week period physiotherapists provided 10 sessions of individualised functional restoration plus guideline-based advice or two sessions of advice alone MAIN OUTCOME MEASURES: Primary outcomes were back and leg pain (separate numerical rating scales) and activity limitation (Oswestry Disability Index). RESULTS: Between-group differences favoured individualised functional restoration over advice for back pain (1.1, 95% CI 0.1 to 2.1), leg pain (1.5, 95% CI 0.4 to 2.6) and Oswestry (6.3, 95% CI 1.3 to 11.4) at 10 weeks as well as Oswestry at 26 weeks (6.6, 95% CI 1.4 to 11.8). Secondary outcomes and responder analyses also favoured physiotherapy functional restoration suggesting the differences were clinically important. CONCLUSIONS: In people with NRDP of ≥6 weeks and ≤6 months duration, individualised functional restoration was more effective than advice for all primary outcomes at 10 weeks and sustained at 26 weeks for activity limitation. Our results suggest that for people with NRDP not recovering after 6 weeks, an individualised physiotherapy functional restoration program should be considered. CONTRIBUTION OF PAPER: (1) A physiotherapist delivered functional restoration program individualised to pathoanatomical, psychosocial and neurophysiological barriers and incorporating guideline-based advice was more effective than advice alone in people with non-reducible discogenic low back pain of ≥6 weeks and ≤6 months duration. (2) This trial differs significantly from other studies on individualised physiotherapy, as it investigates a conservative management program that specifically targets the pathoanatomical subgroup non-reducible discogenic pain. ACTRN numbers: ACTRN12609000412235; ACTRN12609000834257.

Does walking after lumbar spinal surgery predict recovery of function at six months? Protocol for a prospective cohort study.

BACKGROUND: Physiotherapists are commonly involved in the management of patients immediately following lumbar spinal surgery. There is however, very little research to guide physiotherapy intervention in the acute post-operative period, and the advice provided to patients regarding post-operative walking and physical activity has been shown to be highly variable. The primary aim of this research is to establish whether the amount of walking patients perform in the week following lumbar spinal surgery predicts improvement in function at 6 months. METHODS: This study will be a prospective cohort study design, with a projected sample size of 250 participants. Patients undergoing surgery for the management of a disc prolapse, degenerative disc disease, lumbar spinal stenosis and/or degenerative spondylolysthesis will be invited to participate in this study. Outcome measurement will take place pre-operatively and at six months post-operatively. The primary outcome variable will be self-reported function, measured using the Modified Oswestry Disability Questionnaire and the physical component summary of the SF-36. Each participant will be fitted with an activPAL3 accelerometer to be worn for the first seven post-operative days. This accelerometer will record time spent in active versus sedentary postures, step count and time spent walking. Multivariable logistic regression analysis will be used to investigate the relationship between the total time spent walking over the first seven post-operative days, and outcome at six months. DISCUSSION: The results from this research will help to guide patient management during the inpatient phase, by identifying patients who are at risk of poorer outcome due to limited walking time. These patients may benefit from ongoing rehabilitation and outpatient physiotherapy services. This information will also provide a foundation for further research into interventions designed to optimise post-operative activity. TRIAL REGISTRATION: ACTRN12616000747426 , retrospectively registered 7th June 2016.

The Shoulder Function Index (SFInX): evaluation of its measurement properties in people recovering from a proximal humeral fracture.

BACKGROUND: Concerns about test administration, reliability estimations, content and internal structure (dimensionality) of available shoulder measures for people with proximal humeral facture led to the development of a new clinician-observed outcome measure: the Shoulder Function Index (SFInX). The SFInX measures shoulder function by judgement of actual ability to perform daily tasks in which the shoulder is involved. Patients and health professionals had input into the instrument development, and Rasch analysis was used to create a unidimensional, interval-level scale. This study comprehensively evaluated the measurement properties of the SFInX in people recovering from a proximal humeral fracture. METHODS: Data were collected on 92 people [79 women, mean age 63.5 years (SD13.9)] who sustained a proximal humeral fracture within the previous year on three occasions to allow for evaluation of the following measurement properties: construct validity (convergent, discriminant and known-groups validity), longitudinal validity (responsiveness), intra-rater reliability (one week retest interval), and inter-rater reliability (n = 20 subgroup; two independent raters). Comparative measures were Constant Score and Disabilities of the Arm Shoulder and Hand (DASH) and discriminative measure was a mental status questionnaire. Minimal clinically important difference, floor and ceiling effects and feasibility of the SFInX were also evaluated. A priori hypotheses were formulated where applicable. RESULTS: Results for construct validity testing supported hypothesised relationships (convergent validity r = 0.75-0.89 (Constant Score and DASH); discriminant validity r = -0.08 (mental status); known-groups validity r = 0.50). For longitudinal validity, lower correlations (r = 0.40-0.49) than hypothesised (r = 0.50-0.70) were found. The SFInX scores changed more (10.3 points) than other scales, which could indicate that the SFInX is more responsive than the comparative measures. Intra-rater and inter-rater reliability found ICCs of 0.96 (95 % CI 0.94-0.97) and 0.91 (95 % CI 0.63-0.97) respectively, with low measurement error (SEM = 3.9-5.8/100). A change of 11-12 points (out of 100) was indicative of a clinically important difference. CONCLUSIONS: The SFInX is a feasible outcome measure which clinicians can use to reliably measure and detect clinically important changes in the construct of 'shoulder function', the ability to perform activities in which the shoulder is involved, in people recovering from a proximal humeral fracture.

Individualised physiotherapy as an adjunct to guideline-based advice for low back disorders in primary care: a randomised controlled trial.

BACKGROUND: Many patients with low-back disorders persisting beyond 6 weeks do not recover. This study investigates whether individualised physiotherapy plus guideline-based advice results in superior outcomes to advice alone in participants with low-back disorders. METHODS: This prospective parallel group multicentre randomised controlled trial was set in 16 primary care physiotherapy practices in Melbourne, Australia. Random assignment resulted in 156 participants receiving 10 sessions of physiotherapy that was individualised based on pathoanatomical, psychosocial and neurophysiological barriers to recovery combined with guideline-based advice, and 144 participants receiving 2 sessions of physiotherapist-delivered advice alone. Primary outcomes were activity limitation (Oswestry Disability Index) and numerical rating scales for back and leg pain at 5, 10, 26 and 52 weeks postbaseline. Analyses were by intention-to-treat using linear mixed models. RESULTS: Between-group differences showed significant effects favouring individualised physiotherapy for back and leg pain at 10 weeks (back: 1.3, 95% CI 0.8 to 1.8; leg: 1.1, 95% CI 0.5 to 1.7) and 26 weeks (back: 0.9, 95% CI 0.4 to 1.4; leg: 1.0, 95% CI 0.4 to 1.6). Oswestry favoured individualised physiotherapy at 10 weeks (4.7; 95% CI 2.0 to 7.5), 26 weeks (5.4; 95% CI 2.6 to 8.2) and 52 weeks (4.3; 95% CI 1.4 to 7.1). Responder analysis at 52 weeks showed participants receiving individualised physiotherapy were more likely to improve by a clinically important amount of 50% from baseline for Oswestry (relative risk (RR=1.3) 1.5; 95% CI 1.2 to 1.8) and back pain (RR 1.3; 95% CI 1.2 to 1.8) than participants receiving advice alone. CONCLUSIONS: 10 sessions of individualised physiotherapy was more effective than 2 sessions of advice alone in participants with low-back disorders of ≥6 weeks and ≤6 months duration. Between-group changes were sustained at 12 months for activity limitation and 6 months for back and leg pain and were likely to be clinically significant. CLINICAL TRIAL REGISTRATION: ACTRN12609000834257.

Gender-responsiveness in corrections: Estimating female inmate misconduct risk using the Personality Assessment Inventory (PAI).

Proper inmate assessment is critical to correctional management and institutional security. While many instruments have been developed to assist with this process, most of these tools have not been validated using samples of female inmates although distinct gender differences have been identified in the inmate population in terms of adaptation and misconduct. The Personality Assessment Inventory (PAI) is a multiscale measure of psychopathology that is being increasingly utilized in the correctional setting to assist with the inmate classification process. The current study contributes to the dearth of literature surrounding gender-responsive inmate classification by utilizing a sample of 2,000 female inmates to examine the incremental and predictive validity of the PAI in association with general and assaultive disciplinary infractions. Findings from this study reveal that the PAI scales presenting the strongest relationship to general and assaultive disciplinary infractions among this female sample included Aggression (AGG), Antisocial Features (ANT), Paranoia (PAR), and the Violence Potential Index (VPI). Moreover, findings derived from this study suggest that certain PAI measures, specifically ARD-T, DRU, and more general substance abuse and mental health indicators may be useful in gender-responsive assessments during the female inmate classification process.

Testing the predictive validity of the Personality Assessment Inventory (PAI) in relation to inmate misconduct and violence.

The Personality Assessment Inventory (PAI) has been widely employed in correctional settings as a screening tool to assess inmates' risk for committing various types of institutional misconduct. Evaluations have generally found the PAI scales Antisocial Features (ANT), Aggression (AGG), and the Violence Potential Index (VPI) to be modestly related to institutional misbehavior, thus supporting its construct validity. The current study provides the most comprehensive examination of the predictive and incremental validity of the PAI and its subscales among a large sample of imprisoned offenders to date. In particular, the size of the sample (n = 15,546) and follow-up period (mean time at risk of 2.2 years) allowed for the disaggregation of institutional misconduct by levels of seriousness and separate examinations by conviction offense and criminal history variables. The 3 scales most strongly related to general rule infractions were ANT, AGG, and the VPI. After controlling for age at intake, violent conviction history, prior violent arrests, and time at risk, the PAI scales were shown to add incremental validity to the classification of 4 types of disciplinary infractions ranging from 2 to 4 percentage points. The study also explored the relationship of the PAI's response bias scales to institutional misconduct. (PsycINFO Database Record

Patient-Reported Outcome (PRO) questionnaires for people with pain in any spine region. A systematic review.

BACKGROUND/OBJECTIVE: This systematic review investigates the measurement properties of Patient-Reported Outcome (PRO) questionnaires which evaluate disability associated with pain in any area of the spine. METHOD: PRO questionnaires for people with pain in any spinal region were identified from existing systematic reviews and recent studies. Databases were searched for studies which evaluated the measurement properties of the included questionnaires to August 2015. Data synthesis used a levels of evidence approach which considered study methodological quality. RESULTS: The Extended Aberdeen Back Pain Scale (EA), Functional Rating Index (FRI) and Spine Functional Index (SFI) were identified as eligible for this review. The FRI was evaluated in 15 studies, with positive results for internal consistency, structural validity, hypothesis testing and responsiveness, negative results for measurement error and conflicting results for reliability. The SFI was evaluated in 3 studies with positive results for internal consistency, reliability, content validity, and structural validity. Conflicting results were found for hypothesis testing. The EA was evaluated in 3 studies which found negative results for internal consistency and structural validity. CONCLUSIONS: The FRI is provisionally recommended for the assessment of disability in people with multi-area spinal pain. This conclusion is based on studies of mainly fair methodological quality.

Motivational strategies for returning patients with low back pain to usual activities: A survey of physiotherapists working in Australia.

Timely resumption of usual activities is integral to successful functional outcomes in individuals with low back pain (LBP). Little is known about how physiotherapists motivate their patients achieve this. This study examined physiotherapists' knowledge, reported usage and training in a set of 12 motivational strategies. The results of an online cross sectional survey of 170 Australian physiotherapists were compared descriptively, and potential associations between therapist training and strategy use, confidence and perceived effectiveness analysed. Participants considered it extremely important to motivate individuals with LBP to return to usual activities and most commonly reported managing this aspect of treatment exclusively. Active goal setting was the most recognised motivational strategy and transtheoretical based counselling the least recognised. Provision of verbal information and praise/encouragement were reported as the most frequently used strategies. The most common reasons for not using a familiar motivational strategy were time constraints and lack of training. Training in active goal setting was associated with greater use, confidence and perceived effectiveness and was most commonly perceived as moderately effective. Cognitive behavioural therapy was well recognised and training associated with greater use and confidence but not perceived effectiveness. Motivational interviewing was known to approximately half of respondents, consistent with its infancy in LBP and training was not associated with use, confidence or perceived effectiveness. Further research into clearly defined, time efficient and physiotherapy specific motivational interventions for individuals ambivalent to returning to usual activities following an episode of low back pain, may help address the issues identified by the current survey.

Reliability and validity of the German translation of the de Morton Mobility Index (DEMMI) performed by physiotherapists in patients admitted to a sub-acute inpatient geriatric rehabilitation hospital.

BACKGROUND: Mobility is a key outcome in geriatric rehabilitation. The de Morton Mobility Index (DEMMI) is an internationally well-established, unidimensional measure of mobility with good psychometric properties. The aim of this study was to examine the reliability and construct validity of the German translation of the DEMMI in geriatric inpatients. METHODS: This cross-sectional study included patients admitted to a sub-acute inpatient geriatric rehabilitation hospital (reliability sample: N = 33; validity sample: N = 107). Reliability, validity, and unidimensionality were investigated. RESULTS: Inter-rater reliability between two graduate physiotherapists was excellent, with intra-class correlation coefficient of 0.94 (95% confidence interval: 0.88-0.97). The minimal detectable change with 90% confidence was 9 points. Construct validity for the DEMMI was evidenced by significant moderate to strong correlations with other measures of mobility and related constructs (Performance Oriented Mobility Assessment: rho = 0.89; Functional Ambulation Categories: rho = 0.70; six-minute walk test: rho = 0.73; gait speed: rho = 0.67; Falls Efficacy Scale International: rho = -0.68). Known-groups validity was indicated by significant DEMMI mean group differences between independent versus dependent walkers and walking aid users versus non-users. Unidimensionality of the German DEMMI translation was confirmed by Rasch analysis. CONCLUSIONS: The German translation of the DEMMI is a unidimensional instrument producing valid and reproducible measurement of mobility in an inpatient geriatric rehabilitation setting.

The Shoulder Function Index (SFInX): a clinician-observed outcome measure for people with a proximal humeral fracture.

BACKGROUND: Proximal humeral fractures are amongst the most common fractures. Functional recovery is often slow and many people have ongoing disability during activities of daily life. Unidimensional measurement of activity limitations is required to monitor functional progress during rehabilitation. However, current shoulder measures are multidimensional incorporating constructs such as activities, range of motion and pain into a single scale. Psychometric information of these measures is scarce in this population, and indicate measurement issues with reliability. Therefore, the aim was to develop the clinician-observed Shoulder Function Index (SFInX), a unidimensional, interval-level measure of 'shoulder function' based on actual performance of activities, reflecting activity limitations following a proximal humeral fracture. METHODS: An outcome measure development study was performed including item generation (existing shoulder measures, focus groups) and item selection (selection criteria, importance and feasibility ratings, pilot testing, Rasch analysis). Clinicians (n=15) and people with a proximal humeral fracture (n=13) participated in focus groups. Items were pilot tested (n=12 patients) and validated in a Rasch study. The validation study sample (n=92, 86% female) were recruited between 5 and 52 weeks post-fracture and had a mean age of 63.5 years (SD13.9). Measurements at recruitment and 6 and 7 weeks later were taken in three public metropolitan hospitals or during home visits. Raw SFInX data were analysed with WINSTEPS v3.74 using polytomous Rasch models. RESULTS: From 282 generated items, 42 items were selected to be rated by clinicians and patients; 34 items were pilot tested and 16 items were included for Rasch analysis. The final SFInX, developed with the Partial Credit Model, contains 13 items and has the response categories: 'unable', 'partially able' and 'able'. It is unidimensional measuring 'shoulder function', and can measure from early functional use (drinking from a cup) to independence around the house (lifting items above head, carrying heavy items). CONCLUSIONS: The SFInX is a promising outcome measure of shoulder function for people with a proximal humeral fracture. It has content relevant to patients and clinicians, is unidimensional and feasible for use in clinical and home settings. In its current form, the SFInX is ready for further psychometric evaluation, and for subsequent use in clinical settings and research.

Efficacy of Mechanical versus Non-Mechanical Sterile Preoperative Skin Preparation With Chlorhexidine Gluconate 4% Solution.

OBJECTIVE: To compare the efficacy of sterile preoperative skin antisepsis using either a 5-minute mechanical preparation or 5-minute non-mechanical preparation with chlorhexidine gluconate 4% solution. STUDY DESIGN: Matched design, ANOVA. ANIMALS: Healthy adult Thoroughbred horses (n = 30). METHODS: Each horse had both surgical preparation methods randomly assigned to identical sites on the left or right upper thigh. Prepared sites were sampled and cultured for bacteria after each preparation step. RESULTS: Mechanical and non-mechanical preparation techniques significantly reduced bacteria isolated from surface swab samples compared with samples taken from unprepared skin and after the preliminary rough prepared skin (P < 0.05). No difference in the number of skin-associated bacteria was detected between the mechanical and non-mechanical sterile preoperative preparation techniques (P = 0.77). Ten species of bacteria were identified by 16s PCR after final skin preparation. CONCLUSIONS: Pre-surgical skin preparation without repeated mechanical scrubbing using chlorhexidine gluconate 4% solution (total contact time, 225 seconds) is effective in reducing bacterial counts.

A critical appraisal of instruments to measure outcomes of interprofessional education.

CONTEXT: Interprofessional education (IPE) is believed to prepare health professional graduates for successful collaborative practice. A range of instruments have been developed to measure the outcomes of IPE. An understanding of the psychometric properties of these instruments is important if they are to be used to measure the effectiveness of IPE. OBJECTIVES: This review set out to identify instruments available to measure outcomes of IPE and collaborative practice in pre-qualification health professional students and to critically appraise the psychometric properties of validity, responsiveness and reliability against contemporary standards for instrument design. METHODS: Instruments were selected from a pool of extant instruments and subjected to critical appraisal to determine whether they satisfied inclusion criteria. The qualitative and psychometric attributes of the included instruments were appraised using a checklist developed for this review. RESULTS: Nine instruments were critically appraised, including the widely adopted Readiness for Interprofessional Learning Scale (RIPLS) and the Interdisciplinary Education Perception Scale (IEPS). Validity evidence for instruments was predominantly based on test content and internal structure. Ceiling effects and lack of scale width contribute to the inability of some instruments to detect change in variables of interest. Limited reliability data were reported for two instruments. Scale development and scoring protocols were generally reported by instrument developers, but the inconsistent application of scoring protocols for some instruments was apparent. CONCLUSIONS: A number of instruments have been developed to measure outcomes of IPE in pre-qualification health professional students. Based on reported validity evidence and reliability data, the psychometric integrity of these instruments is limited. The theoretical test construction paradigm on which instruments have been developed may be contributing to the failure of some instruments to detect change in variables of interest following an IPE intervention. These limitations should be considered in any future research on instrument design.

Randomized controlled trial of the effect of additional functional exercise during slow-stream rehabilitation in a regional center.

OBJECTIVE: To evaluate whether adding functional exercise training to standard physiotherapy during residential slow-stream rehabilitation (SSR) improves discharge outcomes and functional ability. DESIGN: Randomized controlled trial. SETTING: A regional hospital. PARTICIPANTS: Older people (N=60) admitted to SSR. INTERVENTION: All participants received standard physiotherapy. An individualized functional incidental training (FIT) program was implemented for intervention participants consisting of 4 extra episodes of functional exercise daily for the period of SSR. Research assistants visited twice weekly to practice and progress FIT programs. MAIN OUTCOME MEASURES: Outcome measures included discharge destination, participant-expected discharge destination, and functional tests of the Berg Balance Scale (BBS), de Morton Mobility Index (DEMMI), and 5 times sit-to-stand test (FTSTS) at admission and discharge. RESULTS: Fifty-two participants completed the study. At baseline, the SSR group achieved higher scores on the BBS, DEMMI, and FTSTS. There was no significant difference in discharge destination between groups (P=.305). The difference in functional change between groups from admission to discharge on the BBS, DEMMI, and FTSTS was not significant. Participant-expected discharge destination was significantly associated with eventual discharge destination (χ1(2)=8.40, P=.004). CONCLUSIONS: Adding FIT to standard physiotherapy did not improve discharge outcomes and did not have a statistically significant effect on function, but may have a small effect on balance. Patient expected and actual discharge destinations were associated.

An effective coaching intervention for people with low recovery expectations and low back pain: a content analysis.

BACKGROUND: A health coaching intervention in addition to usual physiotherapy care increased recovery expectation and activity in people with non-chronic NSLBP and low recovery expectation. OBJECTIVE: We aimed to fully describe the coaching intervention to allow replication and enable a deeper understanding of the mechanisms behind health coaching in this setting. METHODS: A qualitative analysis was conducted using notes taken by the coach during the health coaching intervention. Two researchers independently applied open coding and content analysis, using the factors of low recovery expectation identified in a previous qualitative investigation as a framework. RESULTS: For the majority of participants coaching rapidly progressed to goal setting and action planning, with less time spent on increasing the importance and confidence to return to activity. The factors of the person, progression, pain, performance and treatment were addressed across all phases of the coaching intervention. CONCLUSION: This effective health coaching intervention for people with non-chronic NSLBP and low recovery expectation concentrated on goal setting and action planning and addressed the essential factors of recovery expectations. This study suggests that coaching interventions are likely to be different in this population compared to similar interventions in chronic conditions due to pre-existing levels of readiness to change.