Non-invasive ventilation for people with neuromuscular disorders in Australia and New Zealand: a qualitative study of clinician perspectives.

OBJECTIVES: To explore the experiences of Australian and New Zealand clinicians with respect to care pathways, their awareness and use of non-invasive ventilation guidelines, and their perspectives on delivering quality non-invasive ventilation services to people with neuromuscular disorders. DESIGN, SETTING, PARTICIPANTS: Qualitative study; semi-structured focus groups and individual interviews with Australian and New Zealand clinicians who provide non-invasive ventilation services to people with neuromuscular disorders, recruited from participants at a 2017 sleep medicine conference. Interviews were conducted during 1 October 2017 - 31 May 2018. MAIN OUTCOME MEASURES: Major themes identified by an iterative, semantic, and inductive analysis. RESULTS: A total of 28 participants attended the four focus group sessions and five individual interviews; fourteen each from New Zealand and Australia, seventeen women and eleven men, eighteen physicians and ten other clinicians. Two major themes were identified: decision making for current practice, and resource constraints. Participants noted variable use of clinical guidelines and limited training to meet the needs of people with neuromuscular disorders who require non-invasive ventilation. They described a lack of dedicated funding, unstructured care pathways, equipment supply levels that do not meet need, low staff-to-patient ratios and staff shortages, and the inability to deliver quality multidisciplinary care. The need for clinical guidelines and service specifications was highlighted as requisite for reducing variation in clinical care. CONCLUSIONS: Systemic factors influence the needs-based provision of non-invasive ventilation for people with neuromuscular disorders. Development of clinical guidelines for Australia and New Zealand, dedicated funding for respiratory services for people with neuromuscular disorders, and specialist clinician training are important for equitable and high quality non-invasive ventilation care.

Health System Factors Affecting the Experience of Non-Invasive Ventilation Provision of People with Neuromuscular Disorders in New Zealand.

Non-invasive ventilation (NIV) is a critical therapy for many patients with neuromuscular disorders (NMD), supporting those with respiratory failure to achieve adequate respiration and improve their quality of life. The aim of this study was to explore the experiences of access to, consent, uptake, maintenance and safe use of non-invasive ventilation by people with NMD. Semi-structured individual interviews were conducted with 11 people with NMD, each using NIV for more than 12 months. A critical realism ontological paradigm with contextualism epistemology guided the Reflexive Thematic Analysis. An Equity of Health Care Framework underpinned the analysis. Three themes were interpreted: Uptake and informed consent for NIV therapy; Practicalities of NIV; and Patient-clinician relationships. We identified issues at the system, organization and health professional levels. Conclusions: We recommend the development of national service specifications with clear standards and dedicated funding for patients with NMD and call on the New Zealand Ministry of Health to proactively investigate and monitor the variations in service delivery identified. The specific areas of concern for patients with NMD suggest the need for NMD-related NIV research and service provision responsive to the distinct needs of this population.

"Me and 'that' machine": the lived experiences of people with neuromuscular disorders using non-invasive ventilation.

PURPOSE: Neuromuscular disorders (NMD) encompasses a wide range of conditions, with respiratory weakness a common feature. Respiratory care can involve non-invasive ventilation (NIV) resulting in fewer hospital admissions, a lower mortality rate and improved quality of life. The aim of this study was to explore the 'lived experience' of NIV by people with NMD. METHODS: Interpretive Phenomenological Analysis (IPA) with semi-structured, face to face interviews with 11 people with NMD, using bi-level positive airway pressure for NIV for more than 12 months. RESULTS: Three themes were interpreted: (i) Alive, with a life; (ii) Me and 'that' machine; and (iii) Precariousness of this life. NIV enabled hope, independence and the opportunity to explore previously perceived unattainable life experiences. Yet, participants felt dependent on the machine. Furthermore, practical considerations and fear of NIV failure created a sense of precariousness to life and a reframing of personal identity. CONCLUSION: The findings highlight the broad ranging positive and negative effects that may occur for people with NMD when using this important therapy. Ongoing non-judgemental support and empathy are required from health professionals as the use of NIV challenged concepts such as 'living life well' for people with NMD. IMPLICATIONS FOR REHABILITATIONNeuromuscular disorders may result in respiratory weakness requiring non-invasive ventilation (NIV).When prescribed early, NIV can results in fewer hospital admissions, a lower mortality rate and improved quality of life.The relationship of people with NMD with their NIV machine is complex and impacts on and requires adjustment to their identity.NIV users acknowledged that NIV provided hope but simultaneously recognised the precariousness of NIV on their life.In order to better support people with NMD healthcare professionals need to better understand how the physical, psychological and social implications of NIV affect an individual's life.

iSelf-Help: a co-designed, culturally appropriate, online pain management programme in Aotearoa.

INTRODUCTION: Current best practice recommends group-based pain management programmes for long-term improvements in persistent pain-related disability. However, there are barriers for people to access in-person delivered pain management programmes in Aotearoa. AIMS: To develop a co-designed, culturally responsive, online group-based pain management programme (iSelf-help) for people with persistent pain. METHODS: A modified participatory action research (PAR) framework was used to co-design contents and cultural-appropriateness of iSelf-help. The PAR team included: (1) seven end-users living with persistent pain, who had previously attended an in-person delivered group pain management programme, (2) two pain management clinicians, (3) two health researchers, (4) two digital health experts, and (5) a health literacy expert. Five meetings were held with the PAR group and a Nominal Group Technique was used to rank order the preferred features of content delivery. In parallel, to ensure cultural appropriateness of iSelf-help, three focus groups (n = 15) were held with Maori (the Indigenous population of Aotearoa) living with persistent pain in collaboration with a Maori community health trust. All contents were reviewed by a Maori Health literacy expert and core contents were translated into Te Reo (Maori language). All contents were finalised by iterative discussion among the PAR team and consultation with Maori stakeholders. The preliminary version of iSelf-help was pilot tested with the PAR group participants and Maori community members living with persistent pain and their feedback was included. The iterative co-design process occurred over a period of nine months. RESULTS: The finalised version of iSelf-help included a total of 130 resources organised in to 12 content relevant online modules plus a dedicated welcoming page and an online community forum. Each module included: short videos, animations explaining main concepts, patient stories, written content to accompany visual content, podcasts of relaxation techniques, illustrated texts, and evidence-summaries. A dedicated module of videos demonstrating cardiovascular and strengthening exercises of varying intensity was also included. CONCLUSIONS: This is the first co-created, culturally appropriate, on-line group pain management programme for people with persistent pain, developed in Aotearoa. The next step is to evaluate the clinical and cost-effectiveness of iSelf-help compared to in-person delivered pain management programme.

Pain management programmes delivered in a group format are best practice to support people living with persistent non-cancer pain to live well. Some people can find accessing these programmes hard due to lack of referral, transportation costs and lack of trained health professionals. Further, people from Indigenous and non-Western backgrounds are poorly represented in these programmes despite having a high prevalence of persistent pain. One way of improving access is delivering services via technology. We aimed to co-design an online version of an existing hospital-based pain management programme (iSelf-help) and to ensure cultural appropriateness of the iSelf-help for Maori. Maori are the Indigenous population of Aotearoa (an accepted Maori word to describe New Zealand). We used a modified participatory action research (PAR) framework for our co-design process. This framework actively encouraged people with lived experience of pain and community partners to have a voice in the content design. The PAR team included: (1) seven end-users living with persistent pain, who had previously attended hospital-based pain management programme, (2) two pain management clinicians, (3) two health researchers, (4) two digital health experts, and (5) a health literacy expert. Five meetings were held with the PAR team. We used a Nominal Group Technique, whereby PAR team members ranked their preferences on content design and delivery, until concensus was reached. In parallel, three focus groups (n = 15) were held with Maori living with persistent pain in collaboration with a Maori community health trust. All contents were reviewed by a Maori Health literacy expert and core contents were translated into Te Reo (Maori language). The finalised version of iSelf-help included 130 resources, tested for accessibility, organised in to 12 online modules plus a dedicated welcoming page and an online community forum. Each module included: short videos, animations, patient stories, podcasts of relaxation techniques, illustrated texts, and evidence-summaries. This is the first co-created, culturally appropriate, on-line group pain management programme for people with persistent pain, developed in Aotearoa. We are currently evaluating if iSelf-help is acceptable to users, and clinically and cost effective as compared to the hospital-based pain management programme.

"A coalition of the willing": experiences of co-designing an online pain management programme (iSelf-help) for people with persistent pain.

BACKGROUND: Participatory approaches to developing health interventions with end-users are recommended to improve uptake and use. We aimed to explore the experiences of co-designing an online-delivered pain management programme (iSelf-help) for people with persistent pain. METHODS: A modified participatory action research (PAR) framework was used to co-design contents and delivery of iSelf-help. The PAR team included: (1) a patient advisory group consisting of people living with persistent pain (n = 8), (2) pain management service clinicians (n = 2), (3) health researchers (n = 3), (4) digital health experts (n = 2), (5) a health literacy expert, and (6) two Maori health researchers and our community partner who led the cultural appropriateness of iSelf-help for Maori (the Indigenous population of New Zealand). The iSelf-help co-design processes and activities of the 'PAR' team is reported in another paper. In this paper, all PAR team members were invited to share their experiences of the co-design process. Individual interviews were held with 12 PAR team members. Interview transcripts were analysed using the General Inductive Approach. RESULTS: Five common themes were identified from the interviews: (1) Shared understanding and values of the co-design process, (2) Mismatched expectations with content creation, (3) Flexibility to share power and decision making, (4) Common thread of knowledge, and (5) Shared determination. Sustaining these themes was an overarching theme of "A coalition of the willing". CONCLUSIONS: PAR team members valued the shared determination and responsibility to co-design iSelf-help. They also acknowledged the complexities and challenges during the process related to mismatched expectations, power sharing and establishing a common thread of knowledge. Successful co-design requires a shared commitment and responsibility as a coalition to meet the aspirations of end-users, within the boundaries of time and budget.

Persistent non-cancer pain affects one in five people globally. Maori (the Indigenous population of New Zealand) experience a higher persistent pain prevalence than non-Maori. People living with persistent pain in New Zealand experience significant challenges in accessing specialised pain services, such as long-waiting times for referral, delays in getting a persistent pain diagnosis, lack of specialised health professionals in pain management and services that do not provide culturally responsive care. In an increasingly digital world, one way of addressing such access barriers is to provide pain services remotely. Using a participatory action research (PAR) framework, we co-designed an online version of an existing hospital-based pain management programme. The PAR 'team' included patients living with persistent pain, who have previously completed the pain management programme and other stakeholders including pain management clinicians, health researchers, technology design experts, and a health literacy expert. The PAR 'team' also included two Maori researchers, and our Maori community partner who led the cultural adaptation process of the online programme with Maori community members living with persistent pain. We invited all the PAR team members asking their experiences of co-designing an online pain management programme (iSelf-help) that is culturally adapted for Maori. Our results from interviewing 12 PAR team members suggest the shared values and determination to co-design the online programme enabled team members' journey as a coalition to be successful, however, along the way, the process was complex and challenging at times both within and between the various teams. The key factors that caused such complexity were the mismatched expectations and understandings of the project, negotiating power sharing between the various teams and establishing a common thread of knowledge. We conclude that successful co-design requires a shared commitment and responsibility as a coalition to meet the aspirations of end-users, within the limits of time and budget.

Sociocultural factors influencing physiotherapy management in culturally and linguistically diverse people with persistent pain: a scoping review.

BACKGROUND: People with persistent pain from culturally and linguistically diverse (CALD) communities experience significant health inequities. OBJECTIVE: To synthesise the sociocultural factors influencing pain management between CALD patients with persistent pain and physiotherapists treating CALD patients. DATA SOURCES: Major electronic databases MEDLINE, AMED, Scopus, Web of Science, PsycINFO and Google Scholar were searched until July 2018. STUDY SELECTION: Studies were included if they explored clinical interactions between physiotherapists and patients with persistent pain from diverse ethnocultural backgrounds. STUDY APPRAISAL: The methodological quality of qualitative and quantitative studies were assessed using the Critical Appraisal Skills Programme (CASP) Checklist and Mixed Methods Appraisal Tool (MMAT) respectively. SYNTHESIS METHOD: A thematic synthesis approach was used to extract the common themes. RESULTS: Sixteen articles from 16 studies were included. Eleven studies were qualitative and five studies were quantitative. Ten explored patients' perspectives, four explored physiotherapists' perspectives, and two explored both. Key factors included: (a) language competence; (b) active vs passive coping strategies; (c) gendered influences; (d) cultural-spiritual beliefs, illness perceptions and expression of pain; (e) treatment satisfaction and; (f) barriers to access. CONCLUSION: Discordant perspectives on causation, pain management approaches, and patient autonomy in management are evident between CALD patients and physiotherapists. Such discordance potentially create stress in the therapeutic alliance and undermines the efficacy of pain management interventions. To mitigate such barriers, it is crucial to foster cultural competence in physiotherapy and equip physiotherapists with opportunities to maximise their sociocultural awareness, knowledge and skill practising physiotherapy in cultural plural societies.

Current practices of health care providers in recommending online resources for chronic pain self-management.

PURPOSE: Online health resources (websites, apps and social media) may be an adjunct to provide self-management support for people with persistent or chronic pain. Endorsement of online health resources by health care providers is crucial for uptake by end-users. The aim of this study was to investigate the current practices of New Zealand (NZ) health care providers in recommending online resources for persistent pain management, and to identify what factors predict health care providers' recommendations and to explore the common concerns. METHODS: An online survey of NZ health care providers (ie, chiropractors, general practitioners, nurses, occupational therapists, osteopaths, physiotherapists, psychologists, specialist consultants, and social workers) involved in the management of persistent pain was conducted. The recruitment strategy was tailored to each occupation via occupation-specific professional organizations, and by approaching multidisciplinary professional organizations. RESULTS: Data from 213 health care providers were used in the final analysis. Most of the health care providers were physiotherapists (n=71), followed by chiropractors (n=39) and general practitioners (n=31). Fifty three percent (111/210) of health care providers reported currently recommending online resources. A multivariate logistic regression model showed that specialist interest in treating pain (OR=3.84; 95% CI: 1.66, 8.87; P=0.002), and level of confidence in recommending online resources (OR=1.05; CI: 1.04, 1.07; P<0.001), positively influenced recommending online resources. The majority of the health care providers (65%, 138/213) were concerned about the safety issues related to the risk of patients misinterpreting online information and to the lack of evidence-based information. CONCLUSION: Half of the health care providers surveyed reported recommending online resources, which may suggest limited confidence in recommending, or knowledge of, existing online resources for persistent pain management. Ongoing education for health care providers on evidence-based online resources is required to recommend online resources as a self-management support tool for people with persistent pain.

Do pain management websites foster self-management support for people with persistent pain? A scoping review.

OBJECTIVES: To evaluate if the contents of pain management websites include the current best practice self-management support strategies for people with persistent pain, are cultural tailored and to determine the website quality. METHODS: Websites were searched from three major search engines (Google, Bing, and Yahoo). Websites providing information on self-management strategies and websites that were freely available to the public were included. The website contents were evaluated using a 14-item self-management support (SMS-14) checklist. Website quality was assessed using the Health On the Net code (HONcode) certification. RESULTS: Of the twenty-seven websites evaluated, the websites scored a median of nine items (range 1-13) from the SMS-14 checklist. The websites LivePlanBe, ACI Pain Management Network and MyJointPain top-scored (13/14) from the SMS-14 checklist. One website (ACI Pain Management Network) provided culturally tailored information and HONcode certification was present in six websites. CONCLUSIONS: The review identified 27 contemporary pain management websites that could be used for self-management skills training. PRACTICE IMPLICATIONS: Clinicians could refer people with persistent pain to top ranked websites - LivePlanBe, ACI Pain Management Network, and MyJointPain for enabling self-management skills, with the caveats that most websites lacked cultural tailoring, and have limited or no evidence of clinical efficacy.

Park-based physical activity interventions for persons with disabilities: A mixed-methods systematic review.

BACKGROUND: Park-based physical activity (PA) interventions improve health in the general population, but it is unknown if the evidence can be translated to persons with disabilities. OBJECTIVES: To conduct a mixed-methods systematic synthesis of the evidence for park-based physical activity interventions for persons with disabilities and secondarily, to consider the health benefits across the lifespan (children and adolescents, young, middle, and older adults). METHODS: All major electronic databases were searched from inception until 30th November 2016. Studies were eligible if the PA intervention was conducted in an urban park environment with people reporting a disability (e.g. physical, psychological and developmental impairments) and health outcomes were evaluated with biopsychosocial measures. Methodological quality was assessed using Crowes Critical Appraisal Tool (CCAT) and key findings extracted. RESULTS: Six quantitative and four qualitative papers, comprising of 446 participants (age range seven to ninety-one years), were included for qualitative synthesis; five in children/adolescents, none in adults, and five in older adults. There was limited, low level, preliminary evidence for short-term improvements in physical, psychological, and social health outcomes in children and older adults with disabilities as well as improvements in disability-related impairments. When accessible, parks fostered societal inclusion. CONCLUSIONS: Health benefits from park use in persons with disabilities were identified. Parks may provide an alternative environment for rehabilitation and management of disabilities. Further randomized controlled trials evaluating the long-term effectiveness of park-based interventions is necessary to corroborate our findings. Legislative commitment ensuring urban parks are accessible may mitigate some health disparities in persons with disabilities.

User perspective on receiving adaptive equipment after stroke: A mixed-methods study.

BACKGROUND.: Adaptive equipment (AE) is frequently provided during stroke rehabilitation by occupational therapists. PURPOSE.: This study aimed to identify the AE that people typically use after a stroke and the outcomes achieved as a result, and to explore people's experiences obtaining and using AE, to inform both practice and policy in this field. METHOD.: A mixed-methods study, involving a postal questionnaire and interviews, used descriptive statistics and grounded theory to analyze the quantitative and qualitative data, respectively. FINDINGS.: Questionnaire data ( n = 258) revealed mobility AE was issued most frequently, with increased safety as the primary reported outcome. Interview data ( n = 15) indicated relationships with health professionals and the hospital environment shaped early AE selection and use. Once home, making sense of AE and community participation were more influential. IMPLICATIONS.: Therapeutic relationships and reflection time are critical to maximize AE use after stroke. Policy and related funding for AE need to prioritize community participation.

Does physiotherapy prehabilitation improve pre-surgical outcomes and influence patient expectations prior to knee and hip joint arthroplasty?

INTRODUCTION: Evidence supporting physiotherapy prior to hip or knee replacement for decreasing pain and improving function pre and post-operatively is equivocal. This observational cohort study used a mixed-methods approach to investigate whether 8 weeks of physiotherapy led exercise and education ('prehabilitation') would change pain and functional outcomes prior to surgery, and if patients' expectations and satisfaction post-surgery were influenced. METHODS: Participants awaiting THR or TKR were recruited (n = 75). Fifty two opted into the 'prehabilitation' group while twenty three opted for usual care. The prehabilitation group included a 45 min exercise and 15 min education session twice weekly for 8 weeks. All participants completed the WOMAC, NRS, Health Thermometer, 5xSTS and TUG outcome measures. Data were collected before and after prehabilitation and 6 weeks after surgery. Qualitative data were collected from 22 participants via telephone interviews and analysed inductively. RESULTS: Both groups improved post surgery. The prehabilitation group showed statistically significant improvements in all outcome measures after prehabilitation (pre-surgery). Participants' felt prehabilitation prepared them well for surgery and influenced expectations post-operatively. Group education talks and the experience of friends and family appeared highly valued information sources. CONCLUSION: Prehabilitation improved patients' pain and function before hip or knee replacement surgery.

What Works and Does Not Work in a Self-Management Intervention for People With Chronic Pain? Qualitative Systematic Review and Meta-Synthesis.

Background: Self-management interventions fostering self-efficacy improve the well-being of people with chronic pain. Purpose: The purpose of this study was to synthesize the enablers (what works) and barriers (what does not) of incorporating self-management strategies for people in everyday life after completion of a pain self-management intervention. Data Sources: Major electronic databases (MEDLINE, AMED, PsycINFO, Cochrane Library, PubMed, CINAHL, Scopus, and Google Scholar) were searched from inception to July 2016. Study Selection: Study selection included qualitative and mixed-method studies that explored the perceptions of individuals with chronic pain after completion of a self-management intervention. Data Extraction: A thematic analysis approach was used to synthesize the review findings, and a Confidence in the Evidence from Reviews of Qualitative Research (CERQual) Approach was used to assess the level of confidence. Data Synthesis: Thirty-three studies with 512 participants were included. Enablers to self-management included self-discovery-the ability to distinguish self (ie, body, thoughts, and feelings) from pain; feeling empowered by incorporating self-management strategies into practice; and supportive ambience via collaborative relationships with clinicians and support from family and friends. Barriers to self-management included difficulty with sustaining motivation for pain self-management; distress experienced from ongoing pain, anxiety, and depression; and unsupportive relationships with clinicians, family, and friends. Limitations: This review only included interventions that involved at least 4 self-management skills; thus, informative studies may have been missed. The follow-up period varied from immediately after the intervention to 72 months following the intervention; therefore, it is uncertain which of the key enablers and barriers were most influential long term. Only articles published in the English language were included; studies conducted in low- and middle-income countries could not be located. Conclusions: The sustained effort to self-manage chronic pain could be exhausting, and motivation could wane over time following intervention. Providing intermittent support in the form of booster sessions and peer support groups may be important. Person-centered care via shared decision making and guided problem solving is essential to facilitating ongoing self-management.

Accessibility and usability of parks and playgrounds.

BACKGROUND: Public parks and playgrounds are an environment for leisure activity, which all generations can enjoy at low or no financial cost. Evaluating the accessibility and usability of parks and playgrounds is crucial because their design, environment (natural and built) and safety could restrict participation of persons with disabilities. OBJECTIVE: To evaluate the accessibility and usability of 21 public parks and playgrounds in three metropolitan cities of New Zealand. Secondary aims were to compare the accessibility and usability by park type (destination or neighborhood) and deprivation level (high and low). METHODS: Twenty-one parks were evaluated. A stratified random sampling was used to select 18 parks (six from each city). Three additional parks were purposely selected (one from each city) at the request of each respective city council. The parks and playgrounds were evaluated using a customized tool. Data were analyzed using descriptive statistics. RESULTS: None of the parks we evaluated met the national standards and/or international guidelines for park and playground design. We identified potential accessibility and usability issues with car parking spaces, path surfaces and play equipment as well as lack of lighting and fencing. The presence of amenities (e.g. toilets and drinking fountains) was more common in destination parks. Fewer parks in areas of higher deprivation had accessible car parking spaces and main paths wider than 1.5 m. CONCLUSION: Our evaluation identified potential design, environmental and safety barriers to park and playground based participation for persons with disabilities across the lifespan. A larger, more comprehensive evaluation of parks and playgrounds is required.

"Not always a straight path": patients' perspectives following anterior cruciate ligament rupture and reconstruction.

PURPOSE: To explore patients' perspectives following anterior cruciate ligament rupture and subsequent reconstructive surgery. METHODS: A qualitative study design was employed, using validated questionnaires, interviews and general inductive methodology. Semi-structured interviews were conducted with five men and four women who had undergone an anterior cruciate ligament reconstruction in the past 6-36 months. Participants completed the Knee Osteoarthritis Outcome Score and the Tegner Activity Score. Descriptive statistics were used to analyze quantitative data. Interviews were recorded, transcribed and analyzed using the general inductive approach to develop key themes. RESULTS: Participants had not returned to pre-injury knee-related activity levels (Tegner score: 7 pre-injury; 4 current). The theme of a disruptive "journey" emerged with two sub-themes of "loss of identity" and "life at the present," influenced positively and negatively by "support systems" and experience with the "care pathway." This unequivocally negative experience resulted in irrevocable changes to their lives, reflected by current lower knee-related quality of life. CONCLUSIONS: Anterior cruciate ligament injury and rehabilitation thereof have a profound influence in the individual's identity. The results imply that a broader approach is needed within the rehabilitation process to address psychosocial factors, in addition to physical impairments and function. Implications for rehabilitation Anterior cruciate ligament rupture has a profound influence on patients' understanding of their individual identity. Support systems the patients have in place influence the patients' experience of the care pathway. Understanding psychosocial responses and implementing appropriate strategies and interventions for these may be critical for rehabilitation of these patients.

Older adults' experiences regarding discharge from hospital following orthopaedic intervention: a metasynthesis.

PURPOSE: To identify and synthesise qualitative literature on the older adults' perspectives of being discharged from hospital following orthopaedic intervention. METHODS: A systematic search of nine databases, for qualitative research published between 1950 and December 2010, exploring the lived experience of older adults being discharged from hospital following orthopaedic surgery was undertaken. Included papers were evaluated using the Critical Appraisal Skills Programme (CASP) quality guidelines. Data were extracted and themes synthesised, using an EXCEL spreadsheet to assist with organisation of data. RESULTS: From the 16 papers included in the review, four themes were identified: 1) mental outlook; 2) loss of independence; 3) function and activity limitations; and 4) coping with pain. Mental outlook was central to the other three themes. CONCLUSIONS: Older adults' experiences around hospital discharge, collected through qualitative research, provide health authorities with valuable information that could be used in care pathway planning. Health professionals involved in in-patient and community care should be aware that a perceived loss of independence, function and activity limitations, and the ability to cope with pain can influence mental outlook and consequently rehabilitation.

"If I didn't have anybody, what would I have done?": Experiences of older adults and their discharge home after lower limb orthopaedic surgery.

OBJECTIVE: To explore the perceptions of being discharged home following lower limb orthopaedic surgery in older adults. METHODS: Qualitative interviews with 11 patients over the age of 65 years were conducted between 6 and 12 weeks afterdischarge home and analysed using interpretative phenomenological analysis (IPA). RESULTS: Three themes were identified from analysis of the participants' experiences of rehabilitation during the 6­12 weeks following discharge: (i) lack of a shared decision on when to go home; (ii) dependent on family to go home and to feel confident there; and (iii) trial and error rehabilitation.A further theme: a paternalistic medical model was also identified in participants' experiences of contact with health professionals. CONCLUSION: Participants had positive experiences of being discharged home from hospital. However, few participants played an active role in their discharge, all required the support of family to go home, and many were left unsure of how and when to return to usual activities. A paternalistic medical model was apparent. Family support, not without costs,was integral to discharge and rehabilitation at home.

Utility of the RT3 triaxial accelerometer in free living: an investigation of adherence and data loss.

There is strong evidence for the protective effects of physical activity on chronic health problems. Activity monitors can objectively measure free living occupational and leisure time physical activity. Utility is an important consideration when determining the most appropriate monitor for specific populations and environments. Hours of activity data collected, the reasons for activity hours not being recorded, and how these two factors might change over time when using an activity monitor in free living are rarely reported. This study investigated user perceptions, adherence to minimal wear time and loss of data when using the RT3 activity monitor in 21 healthy adults, in a variety of occupations, over three (7 day) repeated weeks of measurement in free living. An activity diary verified each day of monitoring and a utility questionnaire explored participant perceptions on the usability of the RT3. The RT3 was worn for an average of 14 h daily with 90% of participants having complete data sets. In total 6535.8 and 6092.5h of activity data were collected from the activity diary and the RT3 respectively. An estimated 443.3h (6.7%) of activity data were not recorded by the RT3. Data loss was primarily due to battery malfunction (45.2%). Non-adherence to wear time accounted for 169.5h (38.2%) of data loss, of which 14 h were due to occupational factors. The RT3 demonstrates good utility for free living activity measurement, however, technical issues and strategies to manage participant adherence require consideration with longitudinal and repeated measures studies.