Exploring the Safewards Programme to Reduce Restrictive Practices in Residential Aged Care: Protocol for a Pilot and Feasibility Study.

INTRODUCTION: Restrictive practice use in residential aged care homes internationally is unacceptably high. Although policies and legislation mandate the reduction or elimination of restrictive practices, there remains a gap in knowledge regarding strategies that have been effective in achieving a sustained reduction in restraint use. There is an urgent need to identify effective and feasible interventions that aged care staff can implement in everyday practice to reduce restraint use. Safewards is an evidence-based programme that has demonstrated effectiveness in reducing conflict and restrictive practice use in inpatient psychiatric settings and has the potential to address the issue of restraint use in aged care homes. This study aims to evaluate the feasibility of Safewards in reducing restrictive practices in residential aged care homes. METHODS: This pilot and feasibility study will adopt a mixed methods process and outcomes evaluation. Safewards will be implemented in two Australian residential aged care homes. The Reach, Effectiveness, Adoption, Implementation and Maintenance framework will be used to evaluate implementation outcomes. Additionally, the Consolidated Framework for Implementation Research will be used to guide qualitative data collection (including semi-structured interviews with residents/family members, aged care leaders and staff) and explain the facilitators and barriers to effective implementation. CONCLUSION: This study will provide pilot evidence on the feasibility of the Safewards programme in residential aged care homes. Understanding the processes and adaptations for implementing and evaluating Safewards in residential aged care will inform a future trial in aged care to assess its effectiveness. More broadly, the findings will support the implementation of an international aged care policy of reducing restrictive practices in residential aged care. PATIENT OR PUBLIC CONTRIBUTION: A person with lived experience of caring for someone with dementia is employed as a Safewards facilitator and is a member of the steering committee. Residents and family members will be invited to participate in the project steering committee and provide feedback on their experience of Safewards. TRIAL REGISTRATION: ACTRN12624000044527.

Sustaining our rural allied health workforce: experiences and impacts of the allied health rural generalist pathway.

INTRODUCTION: Rural and remote communities face significant disadvantages accessing health services and have a high risk of poor health outcomes. Workforce challenges in these areas are multifaceted, with allied health professionals requiring broad skills and knowledge to provide vital services to local communities. To develop the expertise for rural and remote practice, the allied health rural generalist pathway (AHRGP) was introduced to develop and recognise specialist skills and knowledge required for rural and remote practice, however the experiences of professionals has not been explored. This study gained the experiences and perceptions of allied health professionals undertaking the pathway as well as their clinical supervisors, line managers, profession leads and consumer representatives. METHODS: A qualitative study was undertaken drawing on pragmatic approaches across four research phases. This study was one component of a larger mixed methods study investigating the experience, impact and outcomes of the AHRGP across six regional Local Health Networks in South Australia (SA). Interviews, surveys and focus groups were conducted to explore the perceptions and experiences of participants. Data was analysed thematically across participant groups and research phases. RESULTS: A total of 54 participants including 15 trainees, 13 line managers, nine clinical supervisors, six profession leads, four program managers and seven consumer representatives informed this study. Five themes were generated from the data; gaining broad skills and knowledge for rural practice, finding the time to manage the pathway, implementing learning into practice, the AHRGP impacts the whole team and confident, consistent, skilled allied health professionals positively impact consumers. CONCLUSION: The AHRGP is offering allied health professionals the opportunity to develop skills and knowledge for rural and remote practice. It is also having positive impacts on individuals' ability to manage complexity and solve problems. Findings indicated consumers and organisations benefited through the provision of more accessible, consistent, and high quality services provided by trainees. Trainees faced challenges finding the time to manage study and to implement learning into practice. Organisations would benefit from clearer support structures and resourcing to support the pathway into the future. Incentives and career advancement opportunities for graduates would strengthen the overall value of the AHRPG.

Care biography: A concept analysis.

In this article, we investigate how the concept of Care Biography and related concepts are understood and operationalised and describe how it can be applied to advancing our understanding and practice of holistic and person-centred care. Walker and Avant's eight-step concept analysis method was conducted involving multiple database searches, with potential or actual applications of Care Biography identified based on multiple discussions among all authors. Our findings demonstrate Care Biography to be a novel overarching concept derived from the conjunction of multiple other concepts and applicable across multiple care settings. Concepts related to Care Biography exist but were more narrowly defined and mainly applied in intensive care, aged care, and palliative care settings. They are associated with the themes of Meaningfulness and Existential Coping, Empathy and Understanding, Promoting Positive Relationships, Social and Cultural Contexts, and Self-Care, which we used to inform and refine our concept analysis of Care Biography. In Conclusion, the concept of Care Biography, can provide a deeper understanding of a person and their care needs, facilitate integrated and personalised care, empower people to be in control of their care throughout their life, and help promote ethical standards of care.

The allied health rural generalist pathway: a cost consequence analysis.

INTRODUCTION: Rural and remote health workforces face longstanding challenges in Australia. Little is known about the economic effectiveness of workforce initiatives to increase recruitment and retention. A two-level allied health rural generalist pathway was introduced as a workforce strategy in regional local health networks (LHNs) in South Australia in 2019. This research measured the resources and outcomes of the pathway following its introduction. METHODS: A multi-phase, mixed-methods study was conducted with a 3-year follow-up period (2019-2022). A cost-consequence analysis was conducted as part of this study. Resources measured included tuition, time for quarantined study, supervision and support, and program manager salary. Outcomes measured included length of tenure, turnover data, career progression, service development time, confidence and competence. RESULTS: Fifteen allied health professional trainees participated in the pathway between 2019 and 2022 and seven completed during this time. Trainees participated for between 3 and 42 months. The average total cost of supporting a level 1 trainee was $34,875 and level 2 was $70,469. The total return on investment within the evaluation period was $317,610 for the level 1 program and $58,680 for the level 2 program. All seven completing trainees continued to work in regional LHNs at the 6-month follow-up phase and confidence and competence to work as a rural generalist increased. CONCLUSION: This research found that the allied health rural generalist pathway has the potential to generate multiple positive outcomes for a relatively small investment and is therefore likely to be a cost-effective workforce initiative.

Common home hazards among healthy older aged adults and potential modifications required for age-friendly housing.

INTRODUCTION: The creation of age-friendly home environments enables middle-aged and older aged people to live independently at home while adapting to age-related changes. Little is currently known about existing home hazards that may potentially hinder healthy older people as they age. METHODS: Prospective cohort study of healthy adults who received an age-friendly home environment assessment conducted by an occupational therapist. Adults aged 60 and over, without significant disability, living in homes within metropolitan Adelaide, South Australia were recruited through community advertising. RESULTS: Sixty age-friendly home environment assessments were conducted. Common areas where potential hazards were identified, and modifications recommended were bathrooms, toilets and backyards. Gardens were commonly identified as potentially requiring modifications in the future. Participants were more likely to consider moving to new housing if additional modifications were needed to their homes. CONCLUSION: Affordable and accessible age-friendly housing is required to support an ageing population. Education on age-friendly housing for healthy middle and older aged people is required enabling proactive planning rather than awaiting health crises.

Middle aged and older adult's perspectives of their own home environment: a review of qualitative studies and meta-synthesis.

BACKGROUND: Most people prefer to remain in their homes and communities as long as possible. Staying at home is widely beneficial as ageing within the home promotes independence and costs less than residential aged care. Understanding meanings and drivers of remaining at home is an area of importance. OBJECTIVE: The objective of this systematic review of qualitative studies was to synthesise middle and older aged adult's perspective of their home environment and determine the factors that are important when making decisions about future housing. METHODS: This review and meta-synthesis was conducted in accordance with JBI (formally known as the Joanna Briggs Institute) methodology for systematic reviews of qualitative evidence. Meta-aggregation was used as the method of synthesis. Included qualitative studies involved middle and older aged adults and their views about ageing and housing. Published studies were identified in four electronic databases and grey literature. Critical appraisal and extraction were conducted using JBI tools and findings were categorised and synthesised into findings. RESULTS: A total of 46 papers with 5183 participants on the concept of home were included. Most of the participants were older (> 65 years old) and the perspectives of middle-aged people were largely absent. Factors impacting on future housing decisions among individuals were identified. Seven synthesized findings emerged-independence, finances, stigma, attitudes towards ageing, attachments with home, aesthetics, and family connection. CONCLUSION: Older people have a greater sense of independence and autonomy if they remain in their own home. Multiple external factors impacted on their perspectives including a sense of stigma about ageing, fear of being a burden to others and their own financial position which in some cases restricted their options. This review provides a comprehensive description of the different factors that need to be considered when planning future housing needs; both for individuals and for communities.

Older adults' community participation, physical activity, and social interactions during and following COVID-19 restrictions in Australia: a mixed methods approach.

BACKGROUND: With the increasing age of the global population, key components of healthy ageing including community, physical, and social participation continue to gain traction. However, management of the COVID-19 pandemic aimed to protect older adults and reduce the spread of the virus, this restricted community participation and reduced the opportunities for social interaction. METHODS: This mixed methods study investigates community dwelling older adults' community participation; physical activity and social interaction prior to, during, and following the COVID-19 lockdown in Adelaide, Australia. Twenty-six community dwelling older adults were monitored over three time-points between November 2018 and October 2020, with Global Positioning Systems, accelerometry and self-reported diaries. In addition, nineteen participants completed semi-structured interviews. RESULTS: Community participation varied across the three time points, with significant reduction in the number of trips taken out-of-home (p = 0.021), social interactions (p = 0.001) and sleep quality (p = 0.008) during restrictions. Five themes were identified to explain personal experiences of community participation during restrictions: (1) Reframing of meaning, (2) Redefining to maintain activities, (3) Revision of risk, (4) Reflection and renewal and (5) Future planning. CONCLUSION: During COVID-19 the physical and social activities of community dwelling older adults changed. Services that support older adults to adapt their activities   , considering their capacities and preferences, to facilitate community participation are required.

Barriers and enablers to managing challenging behaviours after traumatic brain injury in the acute hospital setting: a qualitative study.

BACKGROUND: Challenging behaviours after traumatic brain injury (TBI) in the acute setting are associated with risk of harm to the patient and staff, delays in commencing rehabilitation and increased length of hospital stay. Few guidelines exist to inform practice in acute settings, and specialist services providing multi-disciplinary expertise for TBI behaviour management are predominantly based in subacute inpatient services. This study aims to investigate acute and subacute staff perspectives of barriers and enablers to effectively managing challenging behaviours after TBI in acute hospital settings. METHODS: Qualitative focus groups were conducted with 28 staff (17 from acute setting, 11 from subacute setting) across two sites who had experience working with patients with TBI. Data were analysed using inductive-deductive reflexive thematic analysis. Data were applied to the constructs of the integrated-Promoting Action on Research Implementation in Health Services (i-PARIHS) framework to generate themes representing barriers and enablers to managing challenging behaviours after TBI in the acute hospital setting. RESULTS: Four barriers and three enablers were identified. Barriers include (1) Difficulties with clinical decision making; (2) Concerns for risks to staff and patients; (3) Hospital environment; (4) Intensive resources are required. Enablers were (1) Experienced staff with practical skills; (2) Incorporating person-centred care; and (3) Supportive teams. CONCLUSION: These findings can inform pre-implementation planning for future improvements to TBI behaviour management in acute hospital settings. Difficulties with clinical decision making, concerns for risks of injury, the hospital environment and lack of resources are major challenges. Implementation strategies developed to address barriers will need to be trialled, with multi-disciplinary team approaches, and tailored to the acute setting.

Implementing a Screen-Clean-Hydrate bundle of care for improving swallow screening, oral health, and hydration in acute stroke: Protocol for a Type 2 hybrid-effectiveness pre-post study.

Stroke clinical guidelines recommend care processes that optimize patient outcomes and minimize hospital-acquired complications. However, audits and surveys illustrate that recommended care is not always consistently or thoroughly implemented. This paper outlines the methods for implementing and evaluating a new bundle of care. Screen-Clean-Hydrate bundles together recommendations from the Australian Clinical Guidelines for Stroke Management and supplements these with evidence-informed best practice from the literature for: swallow screening within 4 h of presentation to hospital (Screen); oral health assessment and delivery of oral care (Clean); and hydration assessment and management (Hydrate). The study is a pre-post Type 2 hybrid effectiveness/implementation design with an embedded process evaluation, which will be conducted in two acute stroke units in a capital city of Australia. The integrated-Promoting Action on Research Implementation in Health Services (iPARIHS) framework will be used to guide study design, conduct, and evaluation. Clinical effectiveness will be measured by rates of hospital-acquired complications and proxy measures of cost (length of stay, procedure costs) for 60 patient participants pre- and postimplementation. Implementation outcomes will focus on acceptability, feasibility, uptake and fidelity, and identification of barriers and enablers to implementation through staff interviews, medical record audits, and researcher field notes. Due to its design as a hybrid effectiveness/implementation study, once completed, the study will provide information on both intervention and implementation effectiveness, including details of successful and unsuccessful multidisciplinary implementation strategies. This will inform a larger multisite effectiveness/implementation trial for future upscale, leading to improved compliance with stroke guidelines and therefore stroke outcomes.

The Use of Digital Technologies in the Inpatient Setting to Promote Communication During the Early Stage of an Infectious Disease Outbreak: A Scoping Review.

Background: Infectious disease outbreaks disrupt inpatient clinical care and have an impact on staff and patients' ability to communicate with each other and with the wider community. Digital technology may offer opportunities for communication in the inpatient setting during infectious disease outbreaks. Aim: This scoping review aimed to investigate the use of digital technology in the inpatient setting to promote communication in the early stages of an infectious disease outbreak. Methods: There were three aspects to this scoping review: (1) a database search of Ovid MEDLINE (MEDLINE), Cumulative Index of Nursing and Allied Health Literature (CINAHL), Association for Computing Machinery Digital Library (ACM) and IEEE Xplore (IEEE) exploring peer-reviewed articles, (2) a gray literature search, and (3) a media search. Results: Results focused on the early stages of the COVID-19 pandemic. Thirty-eight peer-reviewed articles were extracted from the database search. There were three main areas of investigation: study characteristics, technology features, and benefits and barriers. Forty-four websites were searched for the gray literature search focusing on policy and guidance. Eighteen media articles were retrieved focusing on patients' use of technology and community involvement. Conclusion: Results demonstrate the diverse use of digital technology in the inpatient setting to facilitate communication during the early stages of the COVID-19 pandemic. However, the articles provide limited data to allow readers to fully understand and reproduce described actions. Furthermore, there was limited guidance to support clinicians to communicate using digital technology to create trusting therapeutic relationships. Areas for future development include standard reporting process for technology hardware, software, and content; and structured reporting and evaluation of the implementation of technologies.

Experiences of working as early career allied health professionals and doctors in rural and remote environments: a qualitative systematic review.

BACKGROUND: Maintaining a health professional workforce in rural and remote areas poses a significant challenge internationally. A range of recruitment and retention strategies have had varying success and these are  generally developed from the collective experience of all health professions, rather than targeted to professional groups with differing educational and support contexts. This review explores, compares and synthesises the evidence examining the experience of early career rural and remote allied health professionals and doctors to better understand both the profession specific, and common factors that influence their experience. METHODS: Qualitative studies that include early career allied health professionals' or doctors' experiences of working in rural or remote areas and the personal and professional factors that impact on this experience were considered. A systematic search was completed across five databases and three grey literature repositories to identify published and unpublished studies. Studies published since 2000 in English were considered. Studies were screened for inclusion and critically appraised by two independent reviewers. Data was extracted and assigned a level of credibility. Data synthesis adhered to the JBI meta-aggregative approach. RESULTS: Of the 1408 identified articles, 30 papers were eligible for inclusion, with one rated as low in quality and all others moderate or high quality. A total of 23 categories, 334 findings and illustrations were aggregated into three synthesised findings for both professional groups including: making a difference through professional and organisational factors, working in rural areas can offer unique and rewarding opportunities for early career allied health professionals and doctors, and personal and community influences make a difference. A rich dataset was obtained and findings illustrate similarities including the need to consider personal factors, and differences, including discipline specific supervision for allied health professionals and local supervision for doctors. CONCLUSIONS: Strategies to enhance the experience of both allied health professionals and doctors in rural and remote areas include enabling career paths through structured training programs, hands on learning opportunities, quality supervision and community immersion. SYSTEMATIC REVIEW REGISTRATION NUMBER: PROSPERO CRD42021223187.

Implementing a behavior management approach in the hospital setting for individuals with challenging behaviors during acute traumatic brain injury.

PRIMARY OBJECTIVE: This study aimed to determine if implementing a clinically pragmatic behavior management approach for challenging behaviors during acute TBI reduces use of restraints, security incidences, acute length of stay admission and cost, thereby improving progress to rehabilitation. RESEARCH DESIGN: This pilot study involved a behavior management group (n = 27), compared with a historical control group (n = 74). METHOD AND PROCEDURES: The behavior management group received care following the implementation of a behavior management approach for challenging behaviors during acute TBI at two hospitals in South Australia. MAIN OUTCOMES AND RESULTS: Fidelity results demonstrated high level of adherence to the implemented behavior management approach. The behavior management group had significant lower use of mechanical restraints (p = 0.03), and significantly lower acute admission costs (p = 0.034). Trends in lower pharmacological restraint usage, lower acute hospital length of stay and time from admission to rehabilitation acceptance were recorded. CONCLUSIONS: These pilot results contribute to improving quality of health care but methodological limitations make outcomes difficult to interpret as a direct result of the intervention. Future studies are required to investigate evidence-based behavior management interventions for acute TBI patients using more rigorous knowledge translation implementation designs.

Professional reasoning of occupational therapy driver rehabilitation interventions.

INTRODUCTION: Driver-trained occupational therapists are advanced practitioners who work with people to help maintain their independence and autonomy through driving. There is a lack of investigation of professional reasoning processes for why interventions are recommended by driver-trained occupational therapists. This research project sought to explore the reasoning of driver-trained occupational therapists when they plan, implement, and reflect on driver rehabilitation interventions. METHODS: In-depth semistructured interviews (n = 7) and one focus group (n = 5) were conducted with 12 experienced driver-trained occupational therapists, comprising a wide range of experience, client populations, and licensing jurisdictions. Data were analysed using a modified template analysis approach. RESULTS: Seven higher order modes that reflect professional reasoning theory and hierarchical models were evident in the work of the driver-trained occupational therapists, with no new modes of reasoning emerging. Ethical reasoning regarding the balance of safety versus client independence was an overarching shared framework, with therapists mostly using interactive and conditional reasoning in practice. Twenty-three second-level themes were identified that exemplify how the reasoning modes operate in practice. Therapists described assessment activity even when solely asked about intervention, indicating the importance of assessment to intervention design. The full hierarchy of reasoning was evident during the rehabilitation phase. CONCLUSION: These findings elucidate the application of professional reasoning in advanced occupational therapy practices and could support driver-trained occupational therapists in making driving rehabilitation recommendations if used in reflective practices.

Contemporary occupational priorities at the end of life mapped against Model of Human Occupation constructs: A scoping review.

INTRODUCTION: People with end-of-life care needs are seen in an increasingly diverse range of health and community settings. Opportunity for continued occupational participation is highly valued by people at the end of life. This scoping review sought to identify the priorities and preferences for participation at the end of life and to map findings using the model of human occupation. METHODS: A search strategy informed by the research question was developed in collaboration with a research librarian. Data sources used were Ovid Medline(R), CINAHL, Ovid Emcare, Scopus, Web of Science and PsychInfo. Studies that focused on clinician perspectives, clinical care, grief and loss, did not clearly identify end-stage diseases, <18 years and written in languages other than English were excluded. FINDINGS: Forty-four studies were included with a total of 1,070 study participants. Inductively developed themes were mapped against the model of human occupation constructs of volition (personal causation, values, interests), habituation (habits of occupational performance and routine), performance capacity and the lived body within the physical, social and occupational environment. The majority of findings sat within the construct of volition, particularly around sense of personal capacity, self-efficacy and values. At the end of life, people prioritise ongoing engagement in valued occupations even if participation is effortful. As disease progresses, opportunity to exert influence and control over this participation and engagement increases in importance. Personal causation plays an important role in the experience of occupational participation at this time. CONCLUSION: This review provides important insights into the occupational priorities of people at the end of life and the importance of supporting agency and volition at this time. The model of human occupation and its client-centred focus offer a framework for a more robust examination of ways to enhance volitional capacity and enable occupational participation for people at the end of life.

Community participation of community dwelling older adults: a cross-sectional study.

BACKGROUND: With the advancing age of the population, and increasing demands on healthcare services, community participation has become an important consideration for healthy ageing. Low levels of community participation have been linked to increased mortality and social isolation. The extent to which community participation has been measured objectively in older adults remains scarce. This study aims to describe where and how older adults participate in the community and determine the feasibility of measurement methods for community participation. METHODS: This observational cross-sectional study obtained data from 46 community dwelling older adults. A combination of Global Positioning Systems (GPS), accelerometry, and self-reported diaries were used over a 7-day monitoring period. Feasibility of methods were determined by calculating the loss of GPS data, questionnaires, and comparison of self-reported locations with GPS co-ordinates. Relationships between community participation, physical activity, social interactions, health related quality of life, sleep quality and loneliness were explored. RESULTS: Older adults took a median (IQR) of 15 (9.25-18.75) trips out of home over the 7-day monitoring period, most frequently visiting commercial and recreational locations. In-home activities were mainly sedentary in nature, with out of home activities dependent on location type. Self-reported and GPS measures of trips out of home and the locations visited were significantly correlated (self-report 15.7 (5.6) GPS 14.4 (5.8) (r = 0.94)). Significant correlations between both the number of trips taken from home, with social interactions (r = 0.62) and the minutes of moderate to vigorous physical activity (MVPA) (r = 0.43) were observed. Daily MVPA was higher in participants who visited local walk/greenspaces (r = 0.48). CONCLUSION: Participants performed more activities with social interactions out of home and visited commercial locations most frequently. The combination of GPS, accelerometry and self-report methods provided a detailed picture of community participation for older adults. Further research is required with older adults of varying health status to generalise the relationships between community participation, location and physical activity. TRIAL REGISTRATION: Ethical approval was gained from the Flinders University Social and Behavioural Research Ethics Committee (protocol no. 8176).

Occupational Therapy Interventions to Improve Driving Performance in Older People With Mild Cognitive Impairment or Early-Stage Dementia: A Systematic Review.

IMPORTANCE: For a person with mild cognitive impairment (MCI) or early-stage dementia, driving is important for independence. However, driving presents safety concerns for both the person and family members. It is important to determine whether occupational therapy interventions can prolong safe driving for this population. OBJECTIVE: To determine the effectiveness of occupational therapy interventions to improve driving performance in older people with MCI or early-stage dementia. DATA SOURCES: We conducted a search of MEDLINE, PsycINFO, CINAHL, and gray literature using Google Scholar. Study Selection and Data Collection: Studies were included if they evaluated interventions that (1) aimed to improve the driving performance of older people (M age ≥60 yr) with MCI or early-stage dementia and (2) could be designed or delivered by an occupational therapy practitioner who specializes in driving. Citations were reviewed independently by two authors, and quality appraisal was conducted using the Cochrane risk-of-bias guidelines. FINDINGS: One Level I randomized controlled trial (RCT) and 4 Level III quasi-experimental studies were included; these studies had 231 participants in total with reported M ages of 65.6-72.5 yr. One study evaluated a compensatory approach, whereas the others evaluated a remedial approach. The studies used different measures to assess outcomes and reported mixed effects. CONCLUSIONS AND RELEVANCE: Low strength of evidence suggests that occupational therapy interventions may improve the driving performance of older people with MCI or early-stage dementia. More RCTs are needed that include long-term follow-up measures and address clinically important outcomes. What This Article Adds: In the absence of conclusive evidence from research studies and best practice guidelines, occupational therapy practitioners must rely on their clinical experience and their clients' abilities. Development of evidence and guidelines in this area is critical. It is also important for practitioners to work closely with clients, families, and interdisciplinary team members to carefully monitor fitness to drive.

Telerehabilitation services for stroke.

BACKGROUND: Telerehabilitation offers an alternate way of delivering rehabilitation services. Information and communication technologies are used to facilitate communication between the healthcare professional and the patient in a remote location. The use of telerehabilitation is becoming more viable as the speed and sophistication of communication technologies improve. However, it is currently unclear how effective this model of delivery is relative to rehabilitation delivered face-to-face or when added to usual care. OBJECTIVES: To determine whether the use of telerehabilitation leads to improved ability to perform activities of daily living amongst stroke survivors when compared with (1) in-person rehabilitation (when the clinician and the patient are at the same physical location and rehabilitation is provided face-to-face); or (2) no rehabilitation or usual care. Secondary objectives were to determine whether use of telerehabilitation leads to greater independence in self-care and domestic life and improved mobility, balance, health-related quality of life, depression, upper limb function, cognitive function or functional communication when compared with in-person rehabilitation and no rehabilitation. Additionally, we aimed to report on the presence of adverse events, cost-effectiveness, feasibility and levels of user satisfaction associated with telerehabilitation interventions. SEARCH METHODS: We searched the Cochrane Stroke Group Trials Register (June 2019), the Cochrane Central Register of Controlled Trials (the Cochrane Library, Issue 6, 2019), MEDLINE (Ovid, 1946 to June 2019), Embase (1974 to June 2019), and eight additional databases. We searched trial registries and reference lists. SELECTION CRITERIA: Randomised controlled trials (RCTs) of telerehabilitation in stroke. We included studies that compared telerehabilitation with in-person rehabilitation or no rehabilitation. In addition, we synthesised and described the results of RCTs that compared two different methods of delivering telerehabilitation services without an alternative group. We included rehabilitation programmes that used a combination of telerehabilitation and in-person rehabilitation provided that the greater proportion of intervention was provided via telerehabilitation. DATA COLLECTION AND ANALYSIS: Two review authors independently identified trials on the basis of prespecified inclusion criteria, extracted data and assessed risk of bias. A third review author moderated any disagreements. The review authors contacted investigators to ask for missing information. We used GRADE to assess the quality of the evidence and interpret findings. MAIN RESULTS: We included 22 trials in the review involving a total of 1937 participants. The studies ranged in size from the inclusion of 10 participants to 536 participants, and reporting quality was often inadequate, particularly in relation to random sequence generation and allocation concealment. Selective outcome reporting and incomplete outcome data were apparent in several studies. Study interventions and comparisons varied, meaning that, in many cases, it was inappropriate to pool studies. Intervention approaches included post-hospital discharge support programs, upper limb training, lower limb and mobility retraining and communication therapy for people with post-stroke language disorders. Studies were either conducted upon discharge from hospital or with people in the subacute or chronic phases following stroke. PRIMARY OUTCOME: we found moderate-quality evidence that there was no difference in activities of daily living between people who received a post-hospital discharge telerehabilitation intervention and those who received usual care (based on 2 studies with 661 participants (standardised mean difference (SMD) -0.00, 95% confidence interval (CI) -0.15 to 0.15)). We found low-quality evidence of no difference in effects on activities of daily living between telerehabilitation and in-person physical therapy programmes (based on 2 studies with 75 participants: SMD 0.03, 95% CI -0.43 to 0.48). SECONDARY OUTCOMES: we found a low quality of evidence that there was no difference between telerehabilitation and in-person rehabilitation for balance outcomes (based on 3 studies with 106 participants: SMD 0.08, 95%CI -0.30 to 0.46). Pooling of three studies with 569 participants showed moderate-quality evidence that there was no difference between those who received post-discharge support interventions and those who received usual care on health-related quality of life (SMD 0.03, 95% CI -0.14 to 0.20). Similarly, pooling of six studies (with 1145 participants) found moderate-quality evidence that there was no difference in depressive symptoms when comparing post-discharge tele-support programs with usual care (SMD -0.04, 95% CI -0.19 to 0.11). We found no difference between groups for upper limb function (based on 3 studies with 170 participants: mean difference (MD) 1.23, 95% CI -2.17 to 4.64, low-quality evidence) when a computer program was used to remotely retrain upper limb function in comparison to in-person therapy. Evidence was insufficient to draw conclusions on the effects of telerehabilitation on mobility or participant satisfaction with the intervention. No studies evaluated the cost-effectiveness of telerehabilitation; however, five of the studies reported health service utilisation outcomes or costs of the interventions provided within the study. Two studies reported on adverse events, although no serious trial-related adverse events were reported. AUTHORS' CONCLUSIONS: While there is now an increasing number of RCTs testing the efficacy of telerehabilitation, it is hard to draw conclusions about the effects as interventions and comparators varied greatly across studies. In addition, there were few adequately powered studies and several studies included in this review were at risk of bias. At this point, there is only low or moderate-level evidence testing whether telerehabilitation is a more effective or similarly effective way to provide rehabilitation. Short-term post-hospital discharge telerehabilitation programmes have not been shown to reduce depressive symptoms, improve quality of life, or improve independence in activities of daily living when compared with usual care. Studies comparing telerehabilitation and in-person therapy have also not found significantly different outcomes between groups, suggesting that telerehabilitation is not inferior. Some studies reported that telerehabilitation was less expensive to provide but information was lacking about cost-effectiveness. Only two trials reported on whether or not any adverse events had occurred; these trials found no serious adverse events were related to telerehabilitation. The field is still emerging and more studies are needed to draw more definitive conclusions. In addition, while this review examined the efficacy of telerehabilitation when tested in randomised trials, studies that use mixed methods to evaluate the acceptability and feasibility of telehealth interventions are incredibly valuable in measuring outcomes.

Using social return on investment analysis to calculate the social impact of modified vehicles for people with disability.

INTRODUCTION: Returning to driving is often a goal for people with acquired disabilities. Vehicle modifications make it possible for people with both acquired and lifelong disabilities to drive yet can be costly. There has been no financial evaluation of vehicle modifications in Australia or internationally. METHODS: A social return on investment analysis of vehicle modifications was undertaken. Primary data were collected via qualitative interviews with consumers and other stakeholders (e.g. driver-trained occupational therapists, rehabilitation physicians, driving instructors, vehicle modifiers) (n = 23). Secondary data were collected from literature searches and used to identify suitable financial proxies and make estimations of the proportion of drivers with vehicle modifications experiencing each outcome. A co-investment model was adopted to estimate social return on investment and payback period for funder and consumer. Five scenarios were developed to illustrate social return for low-cost modifications (Scenario 1) through to high-cost modifications (Scenario 5). RESULTS: Social return on investment ratios was positive for funder and consumer investment in all five scenarios. Social return on investment calculations based on co-investment ranged from $17.32 for every $1 invested (Scenario 1) to $2.78 for every $1 invested (Scenario 5). Consumers' payback periods were between 5.4 and 7.1 months, and funders between 3.5 weeks and 2 years 8.4 months. CONCLUSION: Vehicle modifications represent sound investments for both funders and consumers. Given the short payback periods, funders should reconsider age restrictions on vehicles considered suitable for modifications, especially for low- to medium-cost modifications.

A pilot study: Can the UFOV assessment be used as a repeated measure to determine timing of on-road assessment in stroke?

BACKGROUND/AIMS: Useful Field of View scores are predictive of on-road performance post-stroke. No objective data exist to determine if the Useful Field of View (UFOV) assessment can be used as a repeated measure in the post-stroke population to determine timing of occupational therapy on-road assessment as recovery occurs. The aims of this study were to determine whether there is a practice effect if the UFOV is administered at one, two and three months' post-stroke and to assess optimal time post-stroke to refer to an on-road assessment. METHOD: Forty-two participants, 17 men (40.5%), with a mean age of 71 years (SD 9.33) were randomly allocated to 1. Assessment group - UFOV at one, two and three months' post-stroke, 2. Control group-UFOV at three months' post-stroke. Parametric and non-parametric tests were utilised depending on data distribution. RESULTS: No significance was found between; three months' subtest 1 (P = 0.463), three months' subtest 2 (P = 0.729) and three months' subtest 3 (P = 0.534) between the assessment and control groups. Both group's scores were combined to examine pass/fail rates of UFOV assessment to indicate timing of referral to on-road assessments. At one month, 16.9% stroke survivors passed the UFOV, when reassessed at three months 69.1% passed and 28.6% again failed. CONCLUSION: Improvements in scores at one month intervals over three months are due to improvements in abilities assessed by the UFOV as no practice effect was found to influence scores. UFOV scores performed at monthly intervals post-stroke can be used to guide the timing of an occupational therapy on-road assessment, with an increased likelihood of passing, as recovery occurs. This repeated use of the UFOV assessment can assist referral practices that best utilise driving rehabilitation programmes. Larger studies need to be conducted to confirm these results.