Establishing the efficacy of interventions to improve health literacy and health behaviours: a systematic review.

BACKGROUND: The primary aim of this review was to establish whether health literacy interventions, in adults, are effective for improving health literacy. Two secondary aims assessed the impact of health literacy interventions on health behaviours and whether health literacy interventions have been conducted in cardiovascular patients. METHODS: A systematic review (Prospero registration: CRD42018110772) with no start date running through until April 2020. Eligible studies were conducted in adults and included a pre/post measure of health literacy. Medline, Embase, Eric, PsychINFO, CINAHL, Psychology and Behavioural Science, HMIC, Web of Science, Scopus, Social Care Online, NHS Scotland Journals, Social Policy and Practice, and Global Health were searched. Two thousand one hundred twenty-seven papers were assessed, and 57 full text papers screened to give 22 unique datasets from 23 papers. Risk of bias was assessed regarding randomisation, allocation sequence concealment, blinding, incomplete outcome data, selective outcome reporting and other biases. Intervention reporting quality was assessed using the TIDieR checklist. RESULTS: Twenty-two studies were included reporting on 10,997 participants in nine countries. The majority of studies (14/22) were published in 2018 or later. Eight studies (n = 1268 participants) also reported on behavioural outcomes. Health literacy interventions resulted in improvements in at least some aspect of health literacy in 15/22 studies (n = 10,180 participants) and improved behavioural outcomes in 7/8 studies (n = 1209 participants). Only two studies were conducted with cardiovascular patients. All studies were at risk of bias with 18 judged as high risk. In addition, there was poor reporting of intervention content with little explication of the theoretical basis for the interventions. CONCLUSIONS: Health literacy interventions can improve health literacy and can also lead to changes in health behaviours. Health literacy interventions offer a way to improve outcomes for populations most at risk of health inequalities. Health literacy is a developing field with very few interventions using clear theoretical frameworks. Closer links between health literacy and behaviour change theories and frameworks could result in higher quality and more effective interventions. PROSPERO REGISTRATION: Prospero registration: CRD42018110772.

Sleep duration and physical function in people with severe obesity: a prospective cross-sectional study.

BACKGROUND: Subjects with severe obesity (BMI > 40 kg/m2) have worse physical function and sleep less than lean people (BMI 18.5-25 kg/m2). METHODS: In 554 subjects with severe obesity, we compared physical function in those with normal sleep duration (NSD, 6-9 h/night), short sleep duration (SSD, ≤ 6 h/night) and long sleep duration (LSD, ≥ 9 h/night). RESULTS: The mean (±SD) age and BMI were 43.1 (± 11.1) years and 50.9 ± 8.6 kg/m2 respectively. One hundred ninety-six (35.4%) were male. More subjects in the NSD group (n = 256) were able to ascend and descend a step 50 times than in the SSD group (n = 247) or the LSD group (n = 51, 75.5% vs 62.8% vs 56.9%, p = 0.002). A similar observation was made for step speed (0.45 ± 0.11 vs 0.43 ± 0.10 vs 0.40 ± 0.11 steps/s respectively, p = 0.001). NSD participants were less likely to have fallen in the preceding year compared to LSD participants (21.1% vs 39.2%, p = 0.007) and also reported less low back pain compared to SSD participants (60.8% vs 75.9%, p = 0.004). CONCLUSIONS: In conclusion, abnormal sleep duration is associated with reduced physical function in non-elderly severely obese subjects. The effects of sleep hygiene interventions in this cohort warrant further assessment and may be beneficial to their physical function.

Leveraging Interdisciplinary Education Toward Securing the Future of Connected Health Research in Europe: Qualitative Study.

BACKGROUND: Connected health (CH) technologies have resulted in a paradigm shift, moving health care steadily toward a more patient-centered delivery approach. CH requires a broad range of disciplinary expertise from across the spectrum to work in a cohesive and productive way. Building this interdisciplinary relationship at an earlier stage of career development may nurture and accelerate the CH developments and innovations required for future health care. OBJECTIVE: This study aimed to explore the perceptions of interdisciplinary CH researchers regarding the design and delivery of an interdisciplinary education (IDE) module for disciplines currently engaged in CH research (engineers, computer scientists, health care practitioners, and policy makers). This study also investigated whether this module should be delivered as a taught component of an undergraduate, master's, or doctoral program to facilitate the development of interdisciplinary learning. METHODS: A qualitative, cross-institutional, multistage research approach was adopted, which involved a background study of fundamental concepts, individual interviews with CH researchers in Greece (n=9), and two structured group feedback sessions with CH researchers in Ireland (n=10/16). Thematic analysis was used to identify the themes emerging from the interviews and structured group feedback sessions. RESULTS: A total of two sets of findings emerged from the data. In the first instance, challenges to interdisciplinary work were identified, including communication challenges, divergent awareness of state-of-the-art CH technologies across disciplines, and cultural resistance to interdisciplinarity. The second set of findings were related to the design for interdisciplinarity. In this regard, the need to link research and education with real-world practice emerged as a key design concern. Positioning within the program context was also considered to be important with a need to balance early intervention to embed integration with later repeat interventions that maximize opportunities to share skills and experiences. CONCLUSIONS: The authors raise and address challenges to interdisciplinary program design for CH based on an abductive approach combining interdisciplinary and interprofessional education literature and the collection of qualitative data. This recipe approach for interdisciplinary design offers guidelines for policy makers, educators, and innovators in the CH space. Gaining insight from CH researchers regarding the development of an IDE module has offered the designers a novel insight regarding the curriculum, timing, delivery, and potential challenges that may be encountered.

The Influence of a Cognitive Dual Task on the Gait Parameters of Healthy Older Adults: A Systematic Review and Meta-Analysis.

This review examines the effect of a dual task on the gait parameters of older adults with a mean gait speed of 1.0 m/s or greater, and the effect of type and complexity of task. A systematic review of Web of Science, PubMed, SCOPUS, Embase, and PsycINFO was performed in July 2016. Twenty-three studies (28 data sets) were reviewed and pooled for meta-analysis. The effect size on seven gait parameters was measured as the raw mean difference between single- and dual-task performance. Gait speed significantly reduced with the addition of a dual task, with increasing complexity showing greater decrements. Cadence, stride time, and measures of gait variability were all negatively affected under the dual-task condition. In older adults, the addition of a dual task significantly reduces gait speed and cadence, with possible implications for the assessment of older people, as the addition of a dual task may expose deficits not observed under single-task assessment.

Standing on the Precipice: Evaluating Final-Year Physiotherapy Students' Perspectives of Their Curriculum as Preparation for Primary Health Care Practice.

Purpose: To explore final-year physiotherapy students' perceptions of primary health care practice to determine (1) aspects of their curriculum that support their learning, (2) deficiencies in their curriculum, and (3) areas that they believe should be changed to adequately equip them to make the transition from student to primary health care professional. Methods: Framework analysis methodology was used to analyze group opinion obtained using structured group feedback sessions. Sixty-eight final-year physiotherapy students from the four higher education institutions in Ireland participated. Results: The students identified several key areas that (1) supported their learning (exposure to evidence-based practice, opportunities to practise with problem-based learning, and interdisciplinary learning experiences); (2) were deficient (primary health care placements, additional active learning sessions, and further education and practice opportunities for communication and health promotion), and (3) required change (practice placements in primary health care, better curriculum organization to accommodate primary health care throughout the programme with the suggestion of a specific primary health care module). Conclusion: This study provides important insights into physiotherapy students' perceptions of primary health care. It also provides important indicators of the curriculum changes needed to increase graduates' confidence in their ability to take up employment in primary health care.

Objectif : Explorer les perceptions qu'ont les étudiants de dernière année en physiothérapie des soins primaires afin de déterminer (1) les aspects du curriculum qui favorisent leur apprentissage, (2) les lacunes dans le curriculum et (3) les changements nécessaires pour mieux les préparer à la profession en soins primaires. Méthodes : Les opinions du groupe ont été recueillies lors de séances de groupe structurées et analysées au moyen d'un cadre méthodologique analytique. Soixante-huit étudiants de dernière année en physiothérapie des quatre établissements d'enseignement supérieur d'Irlande ont pris part à l'étude. Résultats : Les étudiants ont relevé des (1) éléments favorables à leur apprentissage (exposition à la pratique fondée sur les données probantes, apprentissage par problèmes, expériences d'apprentissage interdisciplinaire); (2) des lacunes (manque de stages en soins primaires, de séances d'apprentissage actif et de formation en communication et en promotion de la santé); (3) et des changements nécessaires (stages en soins primaires, réorganisation du curriculum afin d'intégrer les soins primaires tout au long du programme, inclusion d'un module spécifique sur les soins primaires). Conclusion : Cette étude apporte un éclairage utile sur les perceptions qu'ont les étudiants en physiothérapie des soins primaires. Elle met également au jour les changements qui s'imposent afin d'améliorer la confiance des diplômés en leur capacité de pratiquer en soins primaires.

Expert opinion regarding the preparation of entry-level physiotherapists for primary healthcare practice, examined using Biggs 3P's model of teaching learning.

INTRODUCTION: The scope of contemporary physiotherapy practice is a critical factor in determining the appropriate educational preparation for physiotherapists now and into the future. The world-wide shift from secondary to primary healthcare has, and is, continuing to result in new and different ways of working. It is crucial that curricular changes reflect these developments. In this study a qualitative approach using Biggs 3P's - Pressage, Process and Product model to discuss curriculum design. OBJECTIVE: The aim of the study was to explore the perspectives of both national and international physiotherapy educators/practitioners in primary healthcare, on the key elements required in physiotherapy education programmes to prepare future primary healthcare practitioners. METHODS: Snowball sampling was used to identify experts in education and/or primary healthcare practice. Semi-structured interviews were conducted using an interview guide based on the Biggs 3P's model. PARTICIPANTS: Twelve participants were recruited from Ireland (n = 2), the UK (n = 4), Canada (n = 3), New Zealand (n = 2) and Australia (n = 1) using snowball sampling. RESULTS: Interviews were analysed using thematic analysis. Themes identified included; understanding the philosophy of physiotherapy practice, cultural competence, inter-disciplinary team working and communication skills. Contextual factors and teaching and learning strategies were discussed. CONCLUSIONS: There is an urgent need for physiotherapy education programmes to adopt the concept of primary healthcare as the basis for the physiotherapy curriculum and illuminate key components for consideration.

The effect of a dual task on gait speed in community dwelling older adults: A systematic review and meta-analysis.

BACKGROUND AND PURPOSE: Reduced walking speed in older adults is associated with adverse health outcomes. This review aims to examine the effect of a cognitive dual-task on the gait speed of community-dwelling older adults with no significant pathology affecting gait. DATA SOURCES AND STUDY SELECTION: Electronic database searches were performed in, Web of Science, PubMed, SCOPUS, Embase and psychINFO. Eligibility and methodological quality was assessed by two independent reviewers. The effect size on gait speed was measured as the raw mean difference (95% confidence interval) between single and dual-task performance. Pooled estimates of the overall effect were computed using a random effects method and forest plots generated. DATA EXTRACTION AND DATA SYNTHESIS: 22 studies (27 data sets) with a population of 3728 were reviewed and pooled for meta-analysis. The mean walking speed of participants included in all studies was >1.0m/s and all studies reported the effect of a cognitive dual-task on gait speed. Sub-analysis examined the effect of type of cognitive task (mental-tracking vs. verbal-fluency). Mean single-task gait speed was 1.21 (0.13)m/s, the addition of a dual-task reduced speed by 0.19 m/s to 1.02 (0.16)m/s (p<0.00001), both mental-tracking and verbal-fluency tasks resulted in significant reduction in gait speed. LIMITATIONS AND CONCLUSION: The cross-sectional design of the studies made quality assessment difficult. Despite efforts, high heterogeneity remained, possibly due to participant characteristics and testing protocols. This meta-analysis shows that in community-dwelling older adults, the addition of a dual-task significantly reduces gait speed and may indicate the value of including dual-task walking as part of the standard clinical assessment of older people.

Family-Mediated Exercises (FAME): an exploration of participant's involvement in a novel form of exercise delivery after stroke.

BACKGROUND: Family members and caregivers play a significant supporting role in the rehabilitation process after stroke, a role that may increase with the growing trend of providing stroke rehabilitation in the individual's own home after discharge from the hospital. OBJECTIVE: To explore the impact of family involvement in exercise delivery after stroke from the perspective of the individual with stroke and his or her family member. METHODS: A qualitative research design was used in which in-depth semi-structured interviews were carried out with participants who had taken part in an 8-week family-mediated exercise program (FAME). A phenomenological theoretical framework and a grounded theory methodology were used to inform the data analysis. RESULTS: Fifteen individuals with acute stroke and 15 designated "family" members participated in the study after completion of an 8-week, individually tailored, family-mediated exercise intervention. An overarching concept of patient-centeredness emerged after data analysis, which detailed the extent to which individuals with stroke and their families felt that their rehabilitation was enhanced by the active role of their families. Four key themes that expanded the concept of patient-centeredness were identified: personalized nature of the reported benefits, therapeutic value of the program, family involvement, and caregiver commitment to program. CONCLUSION: This research serves to increase our understanding of the role of family members in the rehabilitation process after stroke, particularly in relation to exercise delivery, from the perspective of the individuals with stroke and their family members.

Predictors of short-term outcome to exercise and manual therapy for people with hip osteoarthritis.

BACKGROUND: Physical therapy for hip osteoarthritis (OA) has shown short-term effects but limited long-term benefit. There has been limited research, with inconsistent results, in identifying prognostic factors associated with a positive response to physical therapy. OBJECTIVES: The purpose of this study was to identify potential predictors of response to physical therapy (exercise therapy [ET] with or without adjunctive manual therapy [MT]) for hip OA based on baseline patient-specific and clinical characteristics. DESIGN: A prognostic study was conducted. METHODS: Secondary analysis of data from a multicenter randomized controlled trial (RCT) (N=131) that evaluated the effectiveness of ET and ET+MT for hip OA was undertaken. Treatment response was defined using OMERACT/OARSI responder criteria. Ten baseline measures were used as predictor variables. Regression analyses were undertaken to identify predictors of outcome. Discriminative ability (sensitivity, specificity, and likelihood ratios) of significant variables was calculated. RESULTS: The RCT results showed no significant difference in most outcomes between ET and ET+MT at 9 and 18 weeks posttreatment. Forty-six patients were classified as responders at 9 weeks, and 36 patients were classified as responders at 18 weeks. Four baseline variables were predictive of a positive outcome at 9 weeks: male sex, pain with activity (<6/10), Western Ontario and McMaster Universities Osteoarthritis Index physical function subscale score (<34/68), and psychological health (Hospital Anxiety and Depression Scale score <9/42). No predictor variables were identified at the 18-week follow-up. Prognostic accuracy was fair for all 4 variables (sensitivity=0.5-0.58, specificity=0.57-0.72, likelihood ratios=1.25-1.77), indicating fair discriminative ability at predicting treatment response. LIMITATIONS: The short-term follow-up limits the interpretation of results, and the low number of identified responders may have resulted in possible overfitting of the predictor model. CONCLUSIONS: The authors were unable to identify baseline variables in patients with hip OA that indicate those most likely to respond to treatment due to low discriminative ability. Further validation studies are needed to definitively define the best predictors of response to physical therapy in people with hip OA.

Exercise and manual physiotherapy arthritis research trial (EMPART) for osteoarthritis of the hip: a multicenter randomized controlled trial.

OBJECTIVES: To determine the effectiveness of exercise therapy (ET) compared with ET with adjunctive manual therapy (MT) for people with hip osteoarthritis (OA); and to identify if immediate commencement of treatment (ET or ET+MT) was more beneficial than a 9-week waiting period for either intervention. DESIGN: Assessor-blind randomized controlled trial with a 9-week and 18-week follow-up. SETTING: Four academic teaching hospitals in Dublin, Ireland. PARTICIPANTS: Patients (N=131) with hip OA recruited from general practitioners, rheumatologists, orthopedic surgeons, and other hospital consultants were randomized to 1 of 3 groups: ET (n=45), ET+MT (n=43), and waitlist controls (n=43). INTERVENTIONS: Participants in both the ET and ET+MT groups received up to 8 treatments over 8 weeks. Control group participants were rerandomized into either ET or ET+MT groups after 9 week follow-up. Their data were pooled with original treatment group data: ET (n=66) and ET+MT (n=65). MAIN OUTCOME MEASURES: The primary outcome was the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) physical function (PF) subscale. Secondary outcomes included physical performance, pain severity, hip range of motion (ROM), anxiety/depression, quality of life, medication usage, patient-perceived change, and patient satisfaction. RESULTS: There was no significant difference in WOMAC PF between the ET (n=66) and ET+MT (n=65) groups at 9 weeks (mean difference, .09; 95% confidence interval [CI] -2.93 to 3.11) or 18 weeks (mean difference, .42; 95% CI, -4.41 to 5.25), or between other outcomes, except patient satisfaction with outcomes, which was higher in the ET+MT group (P=.02). Improvements in WOMAC, hip ROM, and patient-perceived change occurred in both treatment groups compared with the control group. CONCLUSIONS: Self-reported function, hip ROM, and patient-perceived improvement occurred after an 8-week program of ET for patients with OA of the hip. MT as an adjunct to exercise provided no further benefit, except for higher patient satisfaction with outcome.

Functional exercise after total hip replacement (FEATHER): a randomised control trial.

BACKGROUND: Prolonged physical impairments in range of movement, postural stability and walking speed are commonly reported following total hip replacement (THR). It is unclear from the current body of evidence what kind of exercises should be performed to maximize patient function and quality of life. METHODS/DESIGN: This will be a single blind multi centre randomized control trial with two arms. Seventy subjects post primary total hip arthroplasty will be randomized into either an experimental group (n=35), or to a control group (n=35). The experimental group will attend a functional exercise class twice weekly for a six week period from week 12 to week 18 post surgery. The functional exercise group will follow a circuit based functional exercise class supervised by a chartered Physiotherapist. The control group will receive usual care. The principal investigator (BM) will perform blinded outcome assessments on all patients using validated measures for pain, stiffness, and function using the Western Ontario and Mc Master Universities Osteoarthritis index (WOMAC). This is the primary outcome measurement tool. Secondary outcome measurements include Quality of life (SF-36), 6 min walk test, Visual Analogue Scale, and the Berg Balance score. The WOMAC score will be collated on day five post surgery and repeated at week twelve and week eighteen. All other measurements will be taken at week 12 and repeated at week eighteen. In addition a blinded radiologist will measure gluteus medius cross sectional area using real time ultrasound for all subjects at week 12 and at week 18 to determine if the functional exercise programme has any effect on muscle size. DISCUSSION: This randomised controlled trial will add to the body of evidence on the relationship between muscle size, functional ability, balance, quality of life and time post surgery in patients following total hip arthroplasty. The CONSORT guidelines will be followed to throughout. Ethical approval has been gained from the Ethics committee Health Services Executive Dublin North East.

The introduction of an interprofessional education module: students' perceptions.

AIM: The purpose of this study was to examine health science students' perceptions of an interprofessional education (IPE) module delivered by means of problem-based learning (PBL). METHODS: Ninety-two students from four health science disciplines (medicine, physiotherapy, nursing and diagnostic imaging) elected to participate in this IPE PBL module. An evaluation was undertaken using a questionnaire with quantitative and qualitative components completed at the end of the module. Students were asked to evaluate aspects of the module relating to learning objectives, intellectual stimulation, resources, library information skills, work load and overall satisfaction. Open-ended questions asked students to comment on the best aspects of the module and areas for improvement. Quantitative data were analysed using SPSS version 18 and qualitative data using framework analysis methodology. RESULTS: Of the 92 students that participated in the module, 70 (78%) completed the questionnaire. Over 70% (n = 49) of students positively endorsed the module in terms of the statements posed. Overall satisfaction with the module was high, with 63 (91%) students reporting that they agreed or strongly agreed that they were satisfied with the module. Analysis of qualitative data revealed the following emerging themes in relation to the module: (1) collaboration (learning together with others from different professions); (2) structure (small group work, discussion, teamwork assessment procedures); and (3) content (problem diversity). CONCLUSIONS: The introduction of this IPE module for health science students was well received. Students valued the opportunity to work in small groups with individuals from other health science disciplines. Students highlighted module structure and content as being important elements for consideration when developing IPE. Further research is required in order to define whether improving communication and collaboration skills will ultimately lead to improved quality in patient care.

Contemporary undergraduate physiotherapy education in terms of physical activity and exercise prescription: practice tutors' knowledge, attitudes and beliefs.

OBJECTIVES: Practice tutors' evaluation to (i) establish current physical activity and exercise promotion and prescription curriculum content and (ii) their knowledge, attitudes and beliefs concerning physical activity and exercise prescription in clinical education, in terms of contemporary and emerging health trends and priorities. DESIGN: A cross sectional survey employing a questionnaire and focus groups. PARTICIPANTS: All practice tutors delivering physiotherapy undergraduate education in four physiotherapy schools in Ireland (n=38) were invited to participate. Thirty participated giving a response rate of 79%. METHODS: Two methods of data collection were employed. Clinical content questionnaires were administered, the results of which informed follow-up focus groups. Focus group transcriptions were analysed using the 'Framework Analysis' method. RESULTS: 66% of practice tutors were unhappy with their own knowledge and felt they required further training in the following areas: strategies for changing physical activity behaviour; exercise promotion and prescription for public health; exercise prescription for lifestyle related disease. Main themes emerging from the focus groups were (i) perceptions of the physiotherapist's role, (ii) perceptions of the practice tutor's role and (iii) facilitators and barriers to change. CONCLUSION: In terms of physical activity and exercise prescription education, practice tutors identified a need for further education to improve their knowledge base. However, their attitudes and beliefs relating to physiotherapists' and educators' role in terms of teaching contemporary and emerging health trends and priorities were mixed. Results of this study provide useful data to inform future physiotherapy curricula development in terms of physical activity and exercise content.

Physical activity and exercise promotion and prescription in undergraduate physiotherapy education: content analysis of Irish curricula.

BACKGROUND: Overwhelming evidence shows that physical activity and exercise promotion and prescription are effective in preventing and managing numerous chronic conditions. With physiotherapists commonly referred to as 'exercise prescription experts', an in-depth knowledge of exercise promotion and prescription is assumed. However, to date, no information exists about what is or should be included in terms of undergraduate physiotherapy physical activity and exercise education, nor whether the content prepares graduates to be exercise experts for contemporary practice. OBJECTIVES: To provide an accurate, contemporary picture of physical activity and exercise promotion and prescription content within Irish undergraduate physiotherapy curricula. METHOD: Content analysis was used to explore physical activity and exercise inclusion within four of the five programmes in Ireland. Seven categories were generated. Frequency analysis for each category was used to provide a guide to the extensiveness of physical activity and exercise promotion and prescription content. RESULTS: All curricula included varying quantities of basic exercise science and exercise testing and prescription. Physical activity and exercise promotion and prescription for conditions routinely referred to physiotherapy, such as cardio respiratory disease, were well represented. Three key areas were identified as being absent or needing further emphasis: physical activity/exercise for public health, strategies for changing physical activity behaviour, and physical activity/exercise for lifestyle-related diseases. CONCLUSION: Results indicate a strong need for re-evaluation of physical activity and exercise education in Irish physiotherapy curricula. There is a lack of explicit exercise content in relation to public health and lifestyle-related disease.

Family-mediated exercise intervention (FAME): evaluation of a novel form of exercise delivery after stroke.

BACKGROUND AND PURPOSE: Additional exercise therapy has been shown to have a positive impact on function after acute stroke and research is now focusing on methods to increase the amount of therapy that is delivered. This randomized controlled trial examined the impact of additional family-mediated exercise (FAME) therapy on outcome after acute stroke. METHODS: Forty participants with acute stroke were randomly assigned to either a control group who received routine therapy with no formal input from their family members or a FAME group, who received routine therapy and additional lower limb FAME therapy for 8 weeks. The primary outcome measure used was the lower limb section of the Fugl-Meyer Assessment modified by Lindmark. Other measures of impairment, activity, and participation were completed at baseline, postintervention, and at a 3-month follow-up. RESULTS: Statistically significant differences in favor of the FAME group were noted on all measures of impairment and activity postintervention (P<0.05). These improvements persisted at the 3-month follow-up but only walking was statistically significant (P<0.05). Participants in the FAME group were also significantly more integrated into their community at follow-up (P<0.05). Family members in the FAME group reported a significant decrease in their levels of caregiver strain at the follow-up when compared with those in the control group (P<0.01). CONCLUSIONS: This evidence-based FAME intervention can serve to optimize patient recovery and family involvement after acute stroke at the same time as being mindful of available resources.

Randomised controlled trial examining the effect of exercise in people with rheumatoid arthritis taking anti-TNFα therapy medication.

BACKGROUND: Substantial progress has been made in the medical management of rheumatoid arthritis (RA) over the past decade with the introduction of biologic therapies, including anti-tumour necrosis factor alpha (anti-TNFα) therapy medications. However, individuals with RA taking anti-TNFα medication continue to experience physical, psychological and functional consequences, which could potentially benefit from rehabilitation. There is evidence that therapeutic exercise should be included as an intervention for people with RA, but to date there is little evidence of the benefits of therapeutic exercise for people with RA on anti-TNFα therapy medication. A protocol for a multicentre randomised controlled three-armed study which aims to examine the effect of dynamic group exercise therapy on land or in water for people with RA taking anti-TNFα therapy medication is described. METHODS/DESIGN: Six hundred and eighteen individuals with RA, on anti-TNFα therapy medication, will be randomised into one of 3 groups: a land-based exercise group; a water-based exercise group or a control group. The land and water-based groups will exercise for one hour, twice a week for eight weeks. The control group will receive no intervention and will be asked not to alter their exercise habits for the duration of the study. The primary outcome measure, the Stanford Health Assessment Questionnaire Disability Index (HAQ-DI) which measures functional ability, and secondary measures of pain, fatigue and quality of life, will be assessed at baseline, eight and 24 weeks by an independent assessor unaware of group allocation. Changes in outcome from 0 to 8 weeks and 0 to 24 weeks in the 'land-based exercise group versus control group' and the 'water-based exercise group versus control group' will be examined. Analysis will be conducted on an intention to treat basis. DISCUSSION: This trial will evaluate the effectiveness of group exercise therapy on land or in water, for people with RA taking anti-TNFα therapy medication. If these exercise groups are found to be beneficial, they could be conducted in local community facilities thus making these forms of exercise more easily accessible for individuals and potentially reduce the burden on health services. TRIAL REGISTRATION: This trial is registered with ClinicalTrials.gov (a service of the United States National Institutes of Health) identifier: NCT00855322.

Physiotherapy after stroke in Ireland: a qualitative insight into the patients' and physiotherapists' experience.

The study aimed to examine the experience of inpatient physiotherapy intervention delivered after stroke in Ireland from two different perspectives: that of the person with stroke and that of the physiotherapist. A qualitative study was conducted involving semi-structured interviews with 10 people with stroke and two focus groups with 10 senior physiotherapists working in the area of neurology. All transcriptions were analysed using the grounded theory approach. People with stroke and physiotherapists agreed that people with stroke could benefit from more physiotherapy than is routinely provided in the rehabilitation setting. However, the timing of the intervention was disputed. Family-mediated exercise therapy was identified as an acceptable adjunct to routine physiotherapy after stroke. People with stroke identified walking and lower-extremity exercises as the most important components of their programme. Furthermore, they identified honesty and encouragement as two important traits in a physiotherapist working with people with stroke. Obtaining the perspective of patients is an important and valuable way of evaluating healthcare services. Physiotherapists need to be cognizant of the elements of rehabilitation that are important to people with stroke. Methods of delivery of stroke care need to evolve and incorporate families not only for practical purposes but also from a psychological aspect. Family-assisted exercise therapy after stroke may enhance the carry-over outside formal physiotherapy, giving patients and their families the opportunity to maximize recovery.

Exercise and manual physiotherapy arthritis research trial (EMPART): a multicentre randomised controlled trial.

BACKGROUND: Osteoarthritis (OA) of the hip is a major cause of functional disability and reduced quality of life. Management options aim to reduce pain and improve or maintain physical functioning. Current evidence indicates that therapeutic exercise has a beneficial but short-term effect on pain and disability, with poor long-term benefit. The optimal content, duration and type of exercise are yet to be ascertained. There has been little scientific investigation into the effectiveness of manual therapy in hip OA. Only one randomized controlled trial (RCT) found greater improvements in patient-perceived improvement and physical function with manual therapy, compared to exercise therapy. METHODS AND DESIGN: An assessor-blind multicentre RCT will be undertaken to compare the effect of a combination of manual therapy and exercise therapy, exercise therapy only, and a waiting-list control on physical function in hip OA. One hundred and fifty people with a diagnosis of hip OA will be recruited and randomly allocated to one of 3 groups: exercise therapy, exercise therapy with manual therapy and a waiting-list control. Subjects in the intervention groups will attend physiotherapy for 6-8 sessions over 8 weeks. Those in the control group will remain on the waiting list until after this time and will then be re-randomised to one of the two intervention groups. Outcome measures will include physical function (WOMAC), pain severity (numerical rating scale), patient perceived change (7-point Likert scale), quality of life (SF-36), mood (hospital anxiety and depression scale), patient satisfaction, physical activity (IPAQ) and physical measures of range of motion, 50-foot walk and repeated sit-to stand tests. DISCUSSION: This RCT will compare the effectiveness of the addition of manual therapy to exercise therapy to exercise therapy only and a waiting-list control in hip OA. A high quality methodology will be used in keeping with CONSORT guidelines. The results will contribute to the evidence base regarding the clinical efficacy for physiotherapy interventions in hip OA.

To what extent are family members and friends involved in physiotherapy and the delivery of exercises to people with stroke?

PURPOSE: To examine the views of people with stroke, their 'family members/friends' and physiotherapists on the role of the family in physiotherapy and the delivery of exercises following stroke. METHODS: A self-report questionnaire was administered to 100 'family members/friends' and 75 people with stroke. Two focus groups were conducted with 10 expert physiotherapists working in the area of stroke rehabilitation. RESULTS: Family members of people with stroke are willing to participate in the delivery of unsupervised exercises in the hospital and the home setting (n = 91). Furthermore, this is also acceptable to people with stroke (n = 65) as an adjunct to routine physiotherapy. Physiotherapists highlighted a number of factors that influenced participation in physiotherapy such as; level of interest and motivation of the family (n = 5), availability (n = 3) and importance of education (n = 2). 'Family members/friends' identified reasons that would also limit participation such as work commitments (n = 24), lack of confidence (n = 20) and unsuitable treatment times (n = 13). The expert practitioners outlined a number of areas that family involvement can have an impact, such as treatment carry-over, assisting the family unit to cope on discharge and improving handling skills. CONCLUSIONS: Our study identifies an under-utilised role for 'family members/friends' in the rehabilitation of people with stroke. Family mediated exercises can maximise the carry-over outside formal physiotherapy giving patients the opportunity for informal practice. This study highlights the need to examine the value of a structured programme of exercises that can be delivered to people with stroke by their 'family members/friends'.

The impact of increased duration of exercise therapy on functional recovery following stroke--what is the evidence?

This article focuses on the impact of increased duration of exercise therapy on functional recovery after stroke. A comprehensive literature search using multiple databases was used to identify all relevant randomized controlled trials. Their quality was reviewed by two independent assessors, and a narrative systematic review and meta-analysis was completed. Methodological quality of all the 20 randomized controlled trials (RCTs) identified had a median of 6 points (range 5-8) on the 10-point PEDro scale. A meta-analysis was completed for studies that had a common outcome measure. For each outcome measure, the estimated effect size (ES) and the summary effect size (SES) were expressed as standardized mean differences (SMD). The results of the meta-analysis demonstrated that increased duration of exercise therapy time has a small but positive effect on activities of daily living as measured by the Barthel Index (SES 0.13; CI 0.01-0.25; Z = 2.15; p = .03) and that these improvements are maintained over a 6-month period (SES 0.15; CI 0.05-0.26; Z = 2.8; p = .00). Pooling reported differences in the various upper and lower extremity outcome measures demonstrated no significant SESs. However, the meta-analysis is supportive of the hypothesis that additional, focused exercise on the lower extremity has a favourable effect on lower extremity impairment and walking speed. The narrative review raises a number of issues that need to be considered in the development of future RCTs.