Characteristics of goal-setting tools in adult rehabilitation: A scoping review.

OBJECTIVES: This scoping review aims to map the literature on goal-setting tools in adult rehabilitation, exploring their characteristics, target users and supporting evidence to inform practice and future research in this area. METHODS: We completed a comprehensive search of four databases to identify relevant articles on tools for goal setting in rehabilitation. We followed Arkey and O'Malley's scoping review process to guide article selection, data extraction and data analysis. RESULTS: We identified a total of 165 studies that reported on 55 different goal-setting tools, including tools for goal selection and goal documentation (n = 31), goal setting and intervention planning (n = 15), and for measuring the quality of the goal-setting process (n = 9). Over half of the tools were primarily designed for use in rehabilitation of physical disabilities (n = 32). Some tools fell under multiple sub-categories based on their characteristics as follows: 22 framework tools, 12 interview tools, 9 outcome measurement tools for goal achievement, 6 outcome measurement tools for goal quality and 25 documentation tools. The majority of goal-setting instruments targeted goals at the level of activity and participation (n = 51) and aimed to facilitate a client-centred or shared decision-making approach to rehabilitation planning (n = 46). CONCLUSIONS: This study provides a comprehensive overview of existing goal-setting tools, highlighting their characteristics, target users and identified needs. These findings can enhance practitioners' awareness of the range of goal-setting tools available and can enable more effective utilization of these tools in clinical practice. Further research should investigate how clinicians can combine multiple tools to deliver goal setting.

Comparison of Stroke Care Costs in Urban and Nonurban Hospitals and Its Association With Outcomes in New Zealand: A Nationwide Economic Evaluation.

BACKGROUND: Although geographical differences in treatment and outcomes after stroke have been described, we lack evidence on differences in the costs of treatment between urban and nonurban regions. Additionally, it is unclear whether greater costs in one setting are justified given the outcomes achieved. We aimed to compare costs and quality-adjusted life years in people with stroke admitted to urban and nonurban hospitals in New Zealand. METHODS: Observational study of patients with stroke admitted to the 28 New Zealand acute stroke hospitals (10 in urban areas) recruited between May and October 2018. Data were collected up to 12 months poststroke including treatments in hospital, inpatient rehabilitation, other health service utilization, aged residential care, productivity, and health-related quality of life. Costs in New Zealand dollars were estimated from a societal perspective and assigned to the initial hospital that patients presented to. Unit prices for 2018 were obtained from government and hospital sources. Multivariable regression analyses were conducted when assessing differences between groups. RESULTS: Of 1510 patients (median age 78 years, 48% female), 607 presented to nonurban and 903 to urban hospitals. Mean hospital costs were greater in urban than nonurban hospitals ($13 191 versus $11 635, P=0.002), as were total costs to 12 months ($22 381 versus $17 217, P<0.001) and quality-adjusted life years to 12 months (0.54 versus 0.46, P<0.001). Differences in costs and quality-adjusted life years remained between groups after adjustment. Depending on the covariates included, costs per additional quality-adjusted life year in the urban hospitals compared to the nonurban hospitals ranged from $65 038 (unadjusted) to $136 125 (covariates: age, sex, prestroke disability, stroke type, severity, and ethnicity). CONCLUSIONS: Better outcomes following initial presentation to urban hospitals were associated with greater costs compared to nonurban hospitals. These findings may inform greater targeted expenditure in some nonurban hospitals to improve access to treatment and optimize outcomes.

Learning from clinicians' positive inclination to suicidal patients: A grounded theory model.

Despite experts' contention that clinicians' positive inclination is essential to successful treatment of patients at risk for suicide (PRS), research in the area is lacking. This study used grounded theory to develop a model of clinicians' positive inclination based on interviews with 12 clinicians who "liked" working with PRS. The core process identified, a state of emotional synchrony through deep connection between clinicians and PRS, appeared to provide an intersubjective emotion regulation, associated with distress reduction in patients and deep satisfaction in clinicians. Findings suggest clinicians' deep sense of satisfaction and PRS' clinical improvement in treatment could be interdependent.

Aldosterone antagonists for people with chronic kidney disease requiring dialysis.

BACKGROUND: People with chronic kidney disease (CKD) requiring dialysis are at a particularly high risk of cardiovascular death and morbidity. Several clinical studies suggested that aldosterone antagonists would be a promising treatment option for people undergoing dialysis. However, the clinical efficacy and potential harm of aldosterone antagonists for people with CKD on dialysis has yet to be determined. OBJECTIVES: This review aimed to evaluate the benefits and harms of aldosterone antagonists, both non-selective (spironolactone) and selective (eplerenone), in comparison to control (placebo or standard care) in people with CKD requiring haemodialysis (HD) or peritoneal dialysis (PD). SEARCH METHODS: We searched the Cochrane Kidney and Transplant Register of Studies up to 5 August 2020 using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. SELECTION CRITERIA: We included parallel randomised controlled trials (RCTs), cross-over RCTs, and quasi-RCTs (where group allocation is by a method that is not truly random, such as alternation, assignment based on alternate medical records, date of birth, case record number, or other predictable methods) that compared aldosterone antagonists with placebo or standard care in people with CKD requiring dialysis. DATA COLLECTION AND ANALYSIS: Two review authors independently extracted data and assessed risk of bias for included studies. We used a random-effects model meta-analysis to perform a quantitative synthesis of the data. We used the I² statistic to measure heterogeneity among the studies in each analysis. We indicated summary estimates as a risk ratio (RR) for dichotomous outcomes, mean difference (MD) for continuous outcomes, or standardised mean differences (SMD) if different scales were used, with their 95% confidence interval (CI). We assessed the certainty of the evidence for each of the main outcomes using the GRADE (Grades of Recommendation, Assessment, Development, and Evaluation) approach. MAIN RESULTS: We included 16 studies (14 parallel RCTs and two cross-over RCTs) involving a total of 1446 participants. Thirteen studies compared spironolactone to placebo or standard care and one study compared eplerenone to a placebo. Most included studies had an unclear or high risk of bias. Compared to control, aldosterone antagonists probably reduced the risk of death (any cause) for people with CKD requiring dialysis (9 studies, 1119 participants: RR 0.45, 95% CI 0.30 to 0.67; I² = 0%; moderate certainty of evidence). Aldosterone antagonist probably decreased the risk of death due to cardiovascular disease (6 studies, 908 participants: RR 0.37, 95% CI 0.22 to 0.64; I² = 0%; moderate certainty of evidence) and cardiovascular and cerebrovascular morbidity (3 studies, 328 participants: RR 0.38, 95% CI 0.18 to 0.76; I² = 0%; moderate certainty of evidence). While aldosterone antagonists probably increased risk of gynaecomastia compared with control (4 studies, 768 participants: RR 5.95, 95% CI 1.93 to 18.3; I² = 0%; moderate certainty of evidence), aldosterone antagonists may make little or no difference to the risk of hyperkalaemia (9 studies, 981 participants: RR 1.41, 95% CI 0.72 to 2.78; I² = 47%; low certainty of evidence). Aldosterone antagonists had a marginal effect on left ventricular mass among participants undergoing dialysis (8 studies, 633 participants: SMD -0.42, 95% CI -0.78 to 0.05; I² = 77%). In people with CKD requiring dialysis received aldosterone antagonists compared to control, there were 72 fewer deaths from all causes per 1000 participants (95% CI 47 to 98) with a number needed to treat for an additional beneficial outcome (NNTB) of 14 (95% CI 10 to 21) and for gynaecomastia were 26 events per 1000 participants (95% CI 15 to 39) with a number need to treat for an additional harmful outcome (NNTH) of 38 (95% CI 26 to 68). AUTHORS' CONCLUSIONS: Based on moderate certainty of the evidence, aldosterone antagonists probably reduces the risk of all-cause and cardiovascular death and probably reduces morbidity due to cardiovascular and cerebrovascular disease in people with CKD requiring dialysis. For the adverse effect of gynaecomastia, the risk was increased compared to control. For this outcome, the absolute risk was lower than the absolute risk of death. It is hoped the three large ongoing studies will provide better certainty of evidence.

Why we need an internationally shared rehabilitation definition for clinical research purposes.

PURPOSE: Responding to a recent editorial arguing against defining rehabilitation, we discuss the reasons for developing a classification of rehabilitation for research purposes, its philosophical background and some of the possible risks. WHY DEFINE: Science requires the definition and classification of phenomena to allow replication of experiments and studies, and to allow interpretation and use of the findings. As understanding increases, the definitions can be refined. Defining rehabilitation does run the risk of excluding some interventions or practices that are either considered rehabilitation (perhaps wrongly) or are rehabilitation interventions; when identified, these errors in definition can be remedied. Defining rehabilitation for research purposes should not inhibit but could (possibly) orient research. RISK OF NOT: Without a definition, rehabilitation will remain in a permanent limbo. Experts will (apparently) know what it is, while others are left guessing or failing to comprehend or recognise it. This uncertainty may reassure some people, because all possible interventions are included; we argue that it downgrades the understanding of our field because interventions that are not rehabilitation are, nonetheless, called rehabilitation. In an era of international collaboration, and of undertaking systematic reviews with metanalysis, we need a shared definition. CONCLUSION: Terminology is often controversial, but definition enables progress in understanding such that terms themselves can evolve over time.

What would 'upscaling' involve? A qualitative study of international variation in stroke rehabilitation.

BACKGROUND: Demand for stroke rehabilitation is expected to grow dramatically; with the estimated prevalence of stroke survivors rising to 70 million worldwide by 2030. The World Health Organization's (WHO) report - Rehabilitation 2030: A call for action - has introduced the objective of 'upscaling' rehabilitation globally to meet demand. This research explored what upscaling stroke rehabilitation might mean for health professionals from countries at different stages of economic development. METHODS: Qualitative descriptive study design using semi-structured interviews was employed. Purposively sampled, clinical leaders in stroke rehabilitation were recruited for interviews from low through to high-income countries. RESULTS: Twelve rehabilitation professionals (medicine, physical therapy, occupational therapy, and speech and language therapy) from high (United States of America, Germany, United Kingdom, United Arab Emirates, New Zealand), upper-middle (Colombia and Turkey), lower-middle (Vietnam, Pakistan, Ghana), and low-income countries (Nepal and Sierra Leone) were interviewed. Upscaling was seen as a necessity. Successful scaling up will require initiatives addressing: political governance and managerial leadership, increasing knowledge and awareness of the value of rehabilitation, financial support, workforce developments, physical space and infrastructure, and the development of community services and reintegration. CONCLUSION: Although there have been many gains within the development of stroke rehabilitation internationally, further investment is required to ensure that this patient population group continues to receive the best quality services. For the WHO to be successful in implementing their objective to upscale rehabilitation, specific attention will need to be paid to political, professional, economic, and sociocultural issues at global and local levels.

Engaging Maori with qualitative healthcare research using an animated comic.

This article reports an effective strategy for recruiting patients with asthma to a qualitative study using an animated comic advertised on social media. An ad spend of NZ$432 on Facebook resulted in 101 study enquiries, and 27 participants taking part in the focus groups, of which 16 (56%) were Maori, the Indigenous Peoples of New Zealand. Representation of Maori amongst participants was over five times higher than their proportion in the local population (9.7%), resulting in data fulfilling the principle of equal explanatory power, an approach to research which can help advance Maori health development and address inequity. The success of this campaign is of particular interest for health researchers in New Zealand where Maori continue to be disproportionately affected by poorer health outcomes compared with non-Maori, particularly those with asthma. Approaches that better engage and support participation of under-represented communities in clinical research are of wider global interest. We reflect on the recruitment strategy and outcomes within a Kaupapa Maori framework, explore how this can be applied more widely in healthcare, and suggest direction for future study and implementation. Lay summary We designed an animated comic to advertise a study for patients with asthma. This was shared locally with a Facebook ad. The approach was highly engaging with the public, and resulted in rapid recruitment. Interestingly, participation of Maori (the Indigenous People of New Zealand) was over five times higher than their proportion in the local population. Maori have poorer health outcomes and increased barriers to healthcare access compared with non-Maori, particularly those with asthma. Approaches which can engage and support under-represented communities to participate in clinical research are of wider global interest. In this article, we reflect on the recruitment strategy and outcomes, and suggest direction for future study and implementation.

Retractions in Rehabilitation and Sport Sciences Journals: A Systematic Review.

OBJECTIVE: To identify the characteristics of retracted publications in rehabilitation and sport sciences journals. DATA SOURCES: The Web of Science, PubMed, and Retraction Watch databases were searched from inception to August 2019. STUDY SELECTION: Retracted publications published in rehabilitation or sport sciences journals, indexed in the Science Citation Index Expanded (SCIE) and Social Sciences Citation Index (SSCI) were included. DATA EXTRACTION: One author extracted the data. Two other authors checked the data. DATA SYNTHESIS: A total of 37 and 52 retracted publications and their retraction notices were identified for rehabilitation and sport sciences, respectively. The majority of retracted publications (68% of all retracted papers in rehabilitation and 54% of all retracted papers in sport sciences) were published in the past decade. Retracted publications in rehabilitation and sport sciences were published in 21 and 22 different journals and originated from 18 and 21 different countries, respectively. The full-text of the retracted publications was available with a retraction watermark or note for 59% of cases in rehabilitation and 58% in sport sciences. The reasons for the retractions were more often attributed to misconduct (79% and 61%) than to honest error (21% and 39%) in rehabilitation and sport sciences, respectively. However, a reason was not stated for 15% of the publications. The median time interval between publication and retraction was 622 days in rehabilitation and 607 days in sport sciences publications. CONCLUSIONS: The total number of retracted publications in rehabilitation and sport sciences journals was small. The retracted publications have been published in a variety of rehabilitation and sport sciences journals and came from different countries across the world. Several retracted publications and retraction notices failed to adhere to The Committee on Publication Ethics guidelines in the handling of full-text (retain with a watermark or note) or stating the underlying reasons for the retraction.

Participation-focused practices in paediatric rehabilitation for children with neurodisability in New Zealand: An observational study using MAPi audit tool.

BACKGROUND: Participation outcomes and family-centred services are now widely agreed standards of care in paediatric rehabilitation. Evidence suggests that adoption of these practices into usual care has been slow internationally, and no studies of participation-focused or family-centred practices in New Zealand have been undertaken to date. The aims of this study were to identify the extent that goal setting in paediatric rehabilitation services is participation focused and family centred and to profile clinicians' beliefs about these foci. METHODS: Observational study including a retrospective case note audit and questionnaire. Case notes ('charts') were audited for participation-focused goal-related practice. Subgroup analysis of audit data by service, profession and child ethnicity were completed using weighted mean differences. Clinicians whose case notes were audited completed a 42-item questionnaire on factors related to practice behaviour including text responses with each item. Numerical and text data were analysed descriptively. RESULTS: Five services were recruited (N = 46 clinicians) with case notes for 220 children audited. Auditors extracted 368 potentially participation-related goals (Mdn = 2 goals per child) with no goals extracted for 43 (20%) of case notes. Subsequent coding of extracted goals identified 61% reflected participation (225/368). Subgroup analysis revealed significant differences between services (p = 0.006) and professions (p < 0.001). Clinicians' reported valuing participation outcomes and family involvement and largely felt they did target participation. Skill gaps, absence of self-monitoring strategies and unsupportive professional and work cultures were cited as key challenges. CONCLUSIONS: Although valued by clinicians, participation-focused practice is unusual care in paediatric rehabilitation in New Zealand. Substantial gains in the quality of care for children with disabilities could be afforded through training in collaborative goal setting to target participation outcomes.

One in 11 Cochrane Reviews Are on Rehabilitation Interventions, According to Pragmatic Inclusion Criteria Developed by Cochrane Rehabilitation.

OBJECTIVE: To identify all published protocols and reviews in the Cochrane Library relevant to the scope of practice of rehabilitation; to test pragmatic criteria to identify rehabilitation interventions; to begin categorizing reviews according to the professionals involved in delivering the intervention and broad areas of clinical practice. DATA SOURCES: Cochrane Database of Systematic Reviews. STUDY SELECTION: We screened all published reviews and protocols in the Cochrane library. DATA EXTRACTION: We built an online relational database into which we imported titles and abstracts of all reviews and protocols published in the Cochrane Library from 1996 to August 2018. We recruited rehabilitation professionals worldwide through Cochrane Rehabilitation's social media to find and tag rehabilitation reviews in this database. One rehabilitation physician and 1 allied health professional independently tagged each title against prespecified criteria. The Cochrane Rehabilitation Review Committee examined disagreements between contributors for any uncertainties about how to categorize a review. We revised and improved our preliminary criteria for identifying rehabilitation interventions as the work progressed. DATA SYNTHESIS: We identified that 9.4% of all Cochrane publications (894/9471 reviews and protocols) are directly relevant to the practice of rehabilitation. The professional groups whose interventions were most frequently the subject of rehabilitation reviews and protocols were rehabilitation physicians and physical therapists. We also identified a final list of inclusion and exclusion criteria for reviews on rehabilitation interventions. CONCLUSION: Many Cochrane Reviews are directly relevant to rehabilitation. Cochrane needs to consider the rehabilitation community a major stakeholder in all its work. The pragmatic criteria we tested are offered for future discussions on the identification and categorization of rehabilitation interventions by stakeholders worldwide. This work will support the spread of content from the Cochrane Library to rehabilitation professionals and guide future research.

Living Life After Traumatic Brain Injury: Phase 1 of a Longitudinal Qualitative Study.

OBJECTIVE: To explore what helps and hinders recovery and adaptation after disabling traumatic brain injury (TBI) and make recommendations for improving service responsiveness. DESIGN: A longitudinal qualitative descriptive study across all TBI severities. SETTING: Community. PARTICIPANTS: Forty people with TBI, and 22 significant others, 6 to 9 months following a TBI. MAIN MEASURES: Semistructured interviews, analyzed using qualitative description, focused on (a) key areas of importance or concern and (b) strategies or actions that people found helpful or that hindered recovery. RESULTS: Traumatic brain injury produced a complex set of challenges in keeping up with life, and understanding what having a TBI means for, and to, me. This period encompassed a tangled fit and misfit in life as brain injury did not occur in isolation. People had to actively change some aspects of life and yet allow other changes to happen. Valued supports from others included being looked out for and having someone to help drive the process. CONCLUSION: Improved services delivery and better outcomes may result if we respond to the person within his or her context; listen, believe, and acknowledge the person's story through our actions; and avoid assumptions about aspects of life that mean most to people and who/what may help best.

What Do Final Year Medical Students Understand by the Concept of Recovery? A Descriptive Qualitative Study.

OBJECTIVE: Traditional teaching in psychiatry does little to address recovery concepts. The aim of this study was to evaluate the incorporation of a recovery-focused teaching program for medical students in psychiatry. METHODS: Recovery, as understood by medical students who had participated in a recovery-focused teaching program, was assessed by thematic analysis of recovery-focused assessment reflections. RESULTS: Six major themes emerged from the recovery reflections from final year medical students are as follows: (1) recovery as a person-centered approach, (2) the need for social integration, (3) non-diagnostic framing of mental illness, (4) tensions between the medical model and personal recovery, (5) a patient's willingness to engage with mental health services, and (6) the development of a positive sense of self. CONCLUSIONS: A recovery teaching program was associated with students expressing knowledge of recovery principles and positive attitudes towards people with experience of mental illness. Psychiatric placements for medical students may benefit from a recovery focus.

The 'wayfinding' experience of family carers who learn to manage technical health procedures at home: a grounded theory study.

BACKGROUND: With more care taking place in the home, family carers play an important role in supporting patients. Some family carers undertake technical health procedures generally managed by health professionals in hospital settings (e.g. managing a tracheostomy or enteral feeding). AIM: To explore how family carers learn to manage technical health procedures in order to help health professionals better understand and support this process. DESIGN AND METHODS: A grounded theory study using data from interviews with 26 New Zealand family carers who managed technical health procedures including nasogastric or gastrostomy feeding, stoma care, urinary catheterisation, tracheostomy management, intravenous therapy, diabetes management and complex wound dressings. Most (20 participants) were caring for their child and the remaining six for their spouse, parent or grandparent. Following grounded theory methods, each interview was coded soon after completion. Additional data were compared with existing material, and as analysis proceeded, initial codes were grouped into higher order concepts until a core concept was developed. Interviewing continued until no new ideas emerged and concepts were well defined. FINDINGS: The core concept of 'wayfinding' indicates that the learning process for family carers is active, individualised and multi-influenced, developing over time as a response to lived experience. Health professional support was concentrated on the initial phase of carers' training, reducing and becoming more reactive as carers took responsibility for day-to-day management. CONCLUSION: Wayfinding involves self-navigation by carers, in contrast to patient navigator models which provide continuing professional assistance to patients receiving cancer or chronic care services. Wayfinding by carers raises questions about how carers should be best supported in their initial and ongoing learning as the management of these procedures changes over time.

Becoming an expert carer: the process of family carers learning to manage technical health procedures at home.

AIMS: To describe the learning process of family carers who manage technical health procedures (such as enteral tube feeding, intravenous therapy, dialysis or tracheostomy care) at home. BACKGROUND: Increasingly, complex procedures are being undertaken at home but little attention has been paid to the experiences of family carers who manage such procedures. DESIGN: Grounded theory, following Charmaz's constructivist approach. METHODS: Interviews with 26 family carers who managed technical health procedures and 15 health professionals who taught carers such procedures. Data collection took place in New Zealand over 19 months during 2011-2013. Grounded theory procedures of iterative data collection, coding and analysis were followed, with the gradual development of theoretical ideas. FINDINGS: The learning journey comprised three phases: (1) an initial, concentrated period of training; (2) novice carers taking responsibility for day-to-day care of procedures while continuing their learning; and (3) with time, experience and ongoing self-directed learning, the development of expertise. Teaching and support by health professionals (predominantly nurses) was focussed on the initial phase, but carers' learning continued throughout, developed through their own experience and using additional sources of information (notably the Internet and other carers). CONCLUSION: Further work is needed to determine the best educational process for carers, including where to locate training, who should teach them, optimal teaching methods and how structured or individualized teaching should be. Supporting carers well also benefits patient care.

Enabling people, not completing tasks: patient perspectives on relationships and staff morale in mental health wards in England.

BACKGROUND: Mental health inpatient wards are stressful places to work and concerns have been raised regarding quality of patient care and staff wellbeing on these wards. Recent research has suggested that robust support systems and conditions that allow staff to exercise professional autonomy in their clinical work result in better staff morale. Staff value having a voice in their organisations, and say that they would like more interaction with patients and processes to reduce violent incidents on wards. There has been little research into patients' views on staff morale and on how it may impact on their care. This study aimed to explore staff morale and staff-patient relationships from a patient perspective. METHODS: A qualitative investigation was conducted using purposive sampling to select seven inpatient wards in England representing various subspecialties. Semi-structured interviews were carried out with three patients on each ward. A thematic approach to analysis was used, supported by NVivo 10 software. RESULTS: Patients valued staff who worked together as a cohesive team, treated them as individuals, practised in a collaborative way and used enabling approaches to support their recovery. Participating patients described observing staff closely and feeling concerned at times about their well-being and the impact on them of stress and adverse incidents. They tended to perceive ward staff and patients as closely and reciprocally linked, with staff morale having a significant impact on patient well-being and vice versa. Some participants also described modifying their own behaviour because of concerns about staff well-being. Administrative duties, staff shortages and detrimental effects of violent incidents on the ward were seen as compromising staff members' ability to be involved with patients' lives and care. CONCLUSION: Patient views about the factors impacting on staff morale on inpatient wards are similar to those of staff in qualitative studies. Their accounts suggest that staff and patient morale should be seen as interlinked, suggesting there is scope for interventions to benefit both.

Interventions for sexual dysfunction in people with chronic obstructive pulmonary disease (COPD).

BACKGROUND: People with chronic obstructive pulmonary disease (COPD) are believed be at higher risk of problems with sexual function than age-matched peers. Problems with sexuality or sexual function associated with COPD may arise as a results of hormonal, physiological, or psychological problems, or as a result of changes in intimate relationships arising from the chronic nature of the condition. OBJECTIVES: To evaluate the effectiveness of interventions for sexual dysfunction in people with COPD. SEARCH METHODS: We searched the Cochrane Airways Group's Specialised Register on 8 July 2015 and conducted supplementary searches of the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, four other databases, and two trials registers to July 2015, together with reference checking, citation searching, and contact with study authors to identify additional studies. We used no language or date restrictions. SELECTION CRITERIA: Randomised controlled trials (RCTs), cluster RCTs, and quasi-RCTs evaluating the effects of pharmacological, mechanical, psychological, or educational interventions to address problems with sexual well-being in people with COPD and their partners. DATA COLLECTION AND ANALYSIS: Two review authors independently reviewed search results against predetermined inclusion criteria. Two review authors independently extracted data and assessed risk of bias for included studies. We contacted study authors for additional information. MAIN RESULTS: We included two studies involving a total of 48 participants. One of these studies (an RCT) investigated the effect of a pharmacological intervention (testosterone therapy) compared to a placebo over a four-month period. The other study (a quasi-RCT) compared one month of long-term oxygen therapy to a single 24-hour dose of oxygen therapy over a one-month period. Both studies only included men with moderate to very severe COPD (mean FEV1% across both studies 41%; standard deviation (SD) 11.7%) who were under the age of 74 (mean age across both studies 65 years; SD 7.1). We found low-quality evidence that testosterone therapy for men with COPD results in improvements in erectile function, but no evidence of effect regarding overall satisfaction with sexual function. There is insufficient data to draw conclusions regarding the possibility of adverse events arising from testosterone therapy for COPD or the effect of oxygen therapy on erectile dysfunction. Neither study provided additional data on sexual function, other than erectile function. AUTHORS' CONCLUSIONS: There is currently insufficient evidence from clinical trials at present to inform the best way of providing interventions to improve sexual function and sexual satisfaction for people with COPD and their partners. Consequently, clinicians need to rely on clinical trials involving people without COPD and expert opinion in order to guide clinical practice in this area. Considerably more trials need to be conducted in this area of clinical practice.

ANTECEDENTES: Se considera que los pacientes con enfermedad pulmonar obstructiva crónica (EPOC) tienen un mayor riesgo de problemas con la función sexual que sus pares igualados por la edad. Los problemas con la sexualidad o la función sexual asociados con la EPOC pueden surgir como resultado de problemas hormonales, fisiológicos o psicológicos, o como resultado de los cambios en las relaciones íntimas que aparecen por la naturaleza crónica de la afección. OBJETIVOS: Evaluar la efectividad de las intervenciones para la disfunción sexual en los pacientes con EPOC. MÉTODOS DE BÚSQUEDA: Se buscó en el registro especializado del Grupo Cochrane de Vías Respiratorias (Cochrane Airways Group) el 8 de julio de 2015 y se realizaron búsquedas suplementarias en el Registro Cochrane Central de Ensayos Controlados (Cochrane Central Register of Controlled Trials) (CENTRAL), MEDLINE, EMBASE, en otras cuatro bases de datos y en otros dos registros hasta julio 2015, junto con la verificación de las referencias, la búsqueda de citas y el contacto con autores de estudios para identificar estudios adicionales. No se aplicó ninguna restricción de idioma o de fecha. CRITERIOS DE SELECCIÓN: Ensayos controlados aleatorios (ECA), ECA grupales y ensayos controlados cuasialeatorios que evaluaron los efectos de las intervenciones farmacológicas, mecánicas, psicológicas o educacionales para enfrentar los problemas con el bienestar sexual en pacientes con EPOC y sus parejas. OBTENCIÓN Y ANÁLISIS DE LOS DATOS: Dos revisores de manera independiente examinaron los resultados de la búsqueda contra los criterios predeterminados de inclusión. Dos autores de la revisión, de forma independiente, extrajeron los datos y evaluaron el riesgo de sesgo de los estudios incluidos. Se contactó con los autores de los estudios para obtener información adicional. RESULTADOS PRINCIPALES: Se incluyeron dos estudios con un total de 48 participantes. Uno de estos estudios (un ECA) investigó el efecto de una intervención farmacológica (tratamiento con testosterona) comparada con placebo durante un período de cuatro meses. El otro estudio (un ensayo controlado cuasialeatorio) comparó un mes de oxigenoterapia a largo plazo con una dosis única de 24 horas de oxigenoterapia durante un período de un mes. Ambos estudios solamente incluyeron hombres con EPOC moderada a muy grave (VEF1% medio en ambos estudios 41%; desviación estándar [DE] 11,7%) que tenían menos de 74 años (edad promedio en ambos estudios 65 años; DE 7,1). Se encontraron pruebas de baja calidad de que el tratamiento con testosterona en los hombres con EPOC da lugar a mejorías en la función eréctil, pero no se obtuvieron pruebas del efecto con respecto a la satisfacción general con la función sexual. No hay datos suficientes para establecer conclusiones con respecto a la posibilidad de eventos adversos con el tratamiento con testosterona para la EPOC o el efecto de la oxigenoterapia sobre la disfunción eréctil. Ningún estudio proporcionó datos adicionales sobre la función sexual, aparte de la función eréctil. CONCLUSIONES DE LOS AUTORES: Actualmente no hay pruebas suficientes de ensayos clínicos que informen la mejor manera de proporcionar intervenciones para mejorar la función sexual y la satisfacción sexual de los pacientes con EPOC y sus parejas. Por lo tanto, los médicos deben depender de ensayos clínicos que incluyen pacientes sin EPOC y de la opinión de expertos para guiar la práctica clínica en esta área. Es necesario realizar muchos más ensayos en esta área de la práctica clínica.

Goal setting and strategies to enhance goal pursuit for adults with acquired disability participating in rehabilitation.

BACKGROUND: Goal setting is considered a key component of rehabilitation for adults with acquired disability, yet there is little consensus regarding the best strategies for undertaking goal setting and in which clinical contexts. It has also been unclear what effect, if any, goal setting has on health outcomes after rehabilitation. OBJECTIVES: To assess the effects of goal setting and strategies to enhance the pursuit of goals (i.e. how goals and progress towards goals are communicated, used, or shared) on improving health outcomes in adults with acquired disability participating in rehabilitation. SEARCH METHODS: We searched CENTRAL, MEDLINE, EMBASE, four other databases and three trials registers to December 2013, together with reference checking, citation searching and contact with study authors to identify additional studies. We did not impose any language or date restrictions. SELECTION CRITERIA: Randomised controlled trials (RCTs), cluster-RCTs and quasi-RCTs evaluating the effects of goal setting or strategies to enhance goal pursuit in the context of adult rehabilitation for acquired disability. DATA COLLECTION AND ANALYSIS: Two authors independently reviewed search results for inclusion. Grey literature searches were conducted and reviewed by a single author. Two authors independently extracted data and assessed risk of bias for included studies. We contacted study authors for additional information. MAIN RESULTS: We included 39 studies (27 RCTs, 6 cluster-RCTs, and 6 quasi-RCTs) involving 2846 participants in total. Studies ranged widely regarding clinical context and participants' primary health conditions. The most common health conditions included musculoskeletal disorders, brain injury, chronic pain, mental health conditions, and cardiovascular disease.Eighteen studies compared goal setting, with or without strategies to enhance goal pursuit, to no goal setting. These studies provide very low quality evidence that including any type of goal setting in the practice of adult rehabilitation is better than no goal setting for health-related quality of life or self-reported emotional status (8 studies; 446 participants; standardised mean difference (SMD) 0.53, 95% confidence interval (CI) 0.17 to 0.88, indicative of a moderate effect size) and self-efficacy (3 studies; 108 participants; SMD 1.07, 95% CI 0.64 to 1.49, indicative of a moderate to large effect size). The evidence is inconclusive regarding whether goal setting results in improvements in social participation or activity levels, body structure or function, or levels of patient engagement in the rehabilitation process. Insufficient data are available to determine whether or not goal setting is associated with more or fewer adverse events compared to no goal setting.Fourteen studies compared structured goal setting approaches, with or without strategies to enhance goal pursuit, to 'usual care' that may have involved some goal setting but where no structured approach was followed. These studies provide very low quality evidence that more structured goal setting results in higher patient self-efficacy (2 studies; 134 participants; SMD 0.37, 95% CI 0.02 to 0.71, indicative of a small effect size) and low quality evidence for greater satisfaction with service delivery (5 studies; 309 participants; SMD 0.33, 95% CI 0.10 to 0.56, indicative of a small effect size). The evidence was inconclusive regarding whether more structured goal setting approaches result in higher health-related quality of life or self-reported emotional status, social participation, activity levels, or improvements in body structure or function. Three studies in this group reported on adverse events (death, re-hospitalisation, or worsening symptoms), but insufficient data are available to determine whether structured goal setting is associated with more or fewer adverse events than usual care.A moderate degree of heterogeneity was observed in outcomes across all studies, but an insufficient number of studies was available to permit subgroup analysis to explore the reasons for this heterogeneity. The review also considers studies which investigate the effects of different approaches to enhancing goal pursuit, and studies which investigate different structured goal setting approaches. It also reports on secondary outcomes including goal attainment and healthcare utilisation. AUTHORS' CONCLUSIONS: There is some very low quality evidence that goal setting may improve some outcomes for adults receiving rehabilitation for acquired disability. The best of this evidence appears to favour positive effects for psychosocial outcomes (i.e. health-related quality of life, emotional status, and self-efficacy) rather than physical ones. Due to study limitations, there is considerable uncertainty regarding these effects however, and further research is highly likely to change reported estimates of effect.

Self-Reflective Meaning Making in Troubled Times: Change in Self-Identity After Traumatic Brain Injury.

Our aim with this article is to clarify the concept of change in self-identity following traumatic brain injury (TBI). We used concept analysis methodology-predominantly concept clarification. We identified 110 articles using a systematic literature search, and used critical appraisal, content analysis, and analytical questioning to explore attributes and boundaries. A reported change in self-identity is the ultimate expression of a variety of cognitive, psychological, and social sequelae of TBI. We present an integrative model of this process, identifying three potential levels of change: (a) component parts (egocentric self, sociocentric self, and "identity as shared with others"); (b) integral processes (self-awareness and expression via meaningful occupation and narratives); and (c) whole-system disruption. Change in self-identity after TBI is a highly individualistic process. The driver of this process is "self-reflective meaning making," giving a purpose and direction in life, providing motivation and goals for future behavior.

Improving the quality of evidence production in rehabilitation. Results of the 5th Cochrane Rehabilitation Methodological Meeting.

The paper introduces the Special Sections of the European Journal of Physical and Rehabilitation Medicine dedicated to the 5th Methodological Meeting of Cochrane Rehabilitation. It introduces Cochrane Rehabilitation; its vision, mission and goals; discusses why the Methodological Meetings were created; and reports on their organisation and previous outcomes. The core content of this editorial is the 5th Methodological Meeting held in Milan in September 2023. The original title for this meeting was "The Rehabilitation Evidence Ecosystem: useful study designs." The focus of the Milan meeting was informed by the lessons learned by Cochrane Rehabilitation in the past few years, by the new rehabilitation definition for research purposes, by the collaboration with the World Health Organization (WHO), and by the REH-COVER (Rehabilitation COVID-19 Evidence-Based Response) action. During the Meeting, participants discussed the current methodological evidence on the following: RCTs in rehabilitation coming from meta-epidemiological studies; observational study designs - specifically the IDEAL Framework (Idea, Development, Exploration, Assessment, Long-term study) and its potential implementation in rehabilitation and the Target Trial Emulation framework: Single Case Experimental Designs; complex intervention studies: health services research studies, and studies using qualitative approaches. The Meeting culminated in the development of a first version of a "road map" to navigate the evidence production in rehabilitation according to the previous discussions. The Special Sections' papers present all topics discussed at the meeting, and a methodological paper about choosing the right research question, presenting final results and the "road map" for evidence production in rehabilitation.

Designing studies and reviews to produce informative, trustworthy evidence about complex interventions in rehabilitation: a narrative review and commentary.

According to Cochrane Rehabilitation's recently published definition for research purposes, rehabilitation is inherently complex. Rehabilitation teams frequently implement multiple strategies concurrently, draw on input from a range of different health professionals, target multiple outcomes, and personalize therapeutic plans. The success of rehabilitation lies not only in the specific therapies employed, but also in how they are delivered, when they are delivered, and the capability and willingness of patients to engage in them. In 2021, the UK Medical Research Council (MRC) and the National Institute of Health Research (NIHR) released the second major update of its framework for developing and evaluating complex interventions. This framework has direct relevance to the development and implementation of evidence-based practice in the field of rehabilitation. While previous iterations of this framework positioned complex interventions as anything that involved multiple components, multiple people, multiple settings, multiple targets of effect, and behavior change, this latest framework expanded on this concept of complexity to also include the characteristics and influence of the context in which interventions occur. The revised MRC-NIHR framework presents complex intervention research as comprising the following four inter-related and overlapping phases: 1) development or identification of the intervention; 2) feasibility; 3) evaluation; and 4) implementation, with different methods and tools required to address each of these phases. This paper provides an overview of the MRC-NIHR framework and its application to rehabilitation, with examples from past research. Rehabilitation researchers are encouraged to learn about the MRC-NIHR framework and its application. Funders of rehabilitation research are also encouraged to place greater emphasis on supporting studies that involve the right design to address key uncertainties in rehabilitation clinical practice. This will require investment into a broader range of types of research than simply individual-level randomized controlled trials. Rehabilitation research can both learn from and contribute to future iterations of the MRC-NIHR framework as it is an excellent environment for exploring complexity in clinical practice.