Barriers and facilitators to physical activity in people with an inflammatory joint disease: a mixed methods study.

BACKGROUND: Physical activity has been shown to be of great benefit to people with an inflammatory joint disease (IJD), however people with an IJD have been shown to be very inactive compared to the general population. The aims of this study were to explore 1) whether the transition from a National Health Service (NHS)-run exercise programme into exercising in the community could be achieved successfully; and 2) the barriers and facilitators during the transition period. METHODS: This study adopted a complementary mixed-methods study design including a qualitative approach using focus groups and a prospective cohort study. Descriptive statistics were used to summarise the cohort study data. All variables were assessed for normality of distribution using the Sharpiro-Wilk test. Paired t-tests or Wilcoxon tests were undertaken for two consecutive assessment timepoints; one-way repeated measures ANOVAs or Friedman's tests for three consecutive assessment timepoints. Micro-interlocutor analysis was used to analyse the focus group data. Areas of congruence and incongruence were explored by confirming the statistical results against the qualitative results. The adapted ecological model of the determinants of physical activity was then used as a framework to describe the findings. RESULTS: A successful transition was defined as still exercising in the community 6-months post discharge from the NHS-run Inflammatory Arthritis Exercise Programme. This was self-reported to be 90% of the cohort. An individual barrier to physical activity in people with an IJD was found to be the unpredictable nature of their condition. Other barriers and facilitators found were similar to those found in the general population such as recreation facilities, locations, transportation and cost. Other facilitators were similar to those found in people living with other chronic long-term conditions such as the importance of peer support. CONCLUSIONS: 90% of the cohort data were defined as a successful transition. People with an IJD have similar barriers and facilitators to exercise as the general population and those living with other chronic long-term conditions. A barrier which appears to be unique to this population group is that of the unpredictable nature of their condition which needs to be considered whenever tailoring any intervention.

The clinical- and cost-effectiveness of functional electrical stimulation and ankle-foot orthoses for foot drop in Multiple Sclerosis: a multicentre randomized trial.

OBJECTIVE: To compare the clinical- and cost-effectiveness of ankle-foot orthoses (AFOs) and functional electrical stimulation (FES) over 12 months in people with Multiple Sclerosis with foot drop. DESIGN: Multicentre, powered, non-blinded, randomized trial. SETTING: Seven Multiple Sclerosis outpatient centres across Scotland. SUBJECTS: Eighty-five treatment-naïve people with Multiple Sclerosis with persistent (>three months) foot drop. INTERVENTIONS: Participants randomized to receive a custom-made, AFO (n = 43) or FES device (n = 42). OUTCOME MEASURES: Assessed at 0, 3, 6 and 12 months; 5-minute self-selected walk test (primary), Timed 25 Foot Walk, oxygen cost of walking, Multiple Sclerosis Impact Scale-29, Multiple Sclerosis Walking Scale-12, Modified Fatigue Impact Scale, Euroqol five-dimension five-level questionnaire, Activities-specific Balance and Confidence Scale, Psychological Impact of Assistive Devices Score, and equipment and National Health Service staff time costs of interventions. RESULTS: Groups were similar for age (AFO, 51.4 (11.2); FES, 50.4(10.4) years) and baseline walking speed (AFO, 0.62 (0.21); FES 0.73 (0.27) m/s). In all, 38% dropped out by 12 months (AFO, n = 21; FES, n = 11). Both groups walked faster at 12 months with device (P < 0.001; AFO, 0.73 (0.24); FES, 0.79 (0.24) m/s) but no difference between groups. Significantly higher Psychological Impact of Assistive Devices Scores were found for FES for Competence (P = 0.016; AFO, 0.85(1.05); FES, 1.53(1.05)), Adaptability (P = 0.001; AFO, 0.38(0.97); FES 1.53 (0.98)) and Self-Esteem (P = 0.006; AFO, 0.45 (0.67); FES 1 (0.68)). Effects were comparable for other measures. FES may offer value for money alternative to usual care. CONCLUSION: AFOs and FES have comparable effects on walking performance and patient-reported outcomes; however, high drop-outs introduces uncertainty.

Functional Electrical Stimulation for Foot Drop in Multiple Sclerosis: A Systematic Review and Meta-Analysis of the Effect on Gait Speed.

OBJECTIVE: To review the efficacy of functional electrical stimulation (FES) used for foot drop in people with multiple sclerosis (pwMS) on gait speed in short and long walking performance tests. DATA SOURCES: Five databases (Cochrane Library, CINAHL, Embase, MEDLINE, and PubMed) and reference lists were searched. STUDY SELECTION: Studies of both observational and experimental design where gait speed data in pwMS could be extracted were included. DATA EXTRACTION: Data were independently extracted and recorded. Methodologic quality was assessed using the Effective Public Health Practice Project tool. DATA SYNTHESIS: Nineteen studies (described in 20 articles) recruiting 490 pwMS were identified and rated as moderate or weak, with none gaining a strong rating. All studies rated weak for blinding. Initial and ongoing orthotic and therapeutic effects were assessed regarding the effect of FES on gait speed in short and long walking tests. Meta-analyses of the short walk tests revealed a significant initial orthotic effect (t=2.14, P=.016), with a mean increase in gait speed of .05m/s, and ongoing orthotic effect (t=2.81, P=.003), with a mean increase of .08m/s. There were no initial or ongoing effects on gait speed in long walk tests and no therapeutic effect on gait speed in either short or long walk tests. CONCLUSIONS: FES used for foot drop has a positive initial and ongoing effect on gait speed in short walking tests. Further fully powered randomized controlled trials comparing FES with alternative treatments are required.

Increasing physical activity in stroke survivors using STARFISH, an interactive mobile phone application: a pilot study.

BACKGROUND: Following stroke, people are generally less active and more sedentary which can worsen outcomes. Mobile phone applications (apps) can support change in health behaviors. We developed STARFISH, a mobile phone app-based intervention, which incorporates evidence-based behavior change techniques (feedback, self-monitoring and social support), in which users' physical activity is visualized by fish swimming. OBJECTIVE: To evaluate the potential effectiveness of STARFISH in stroke survivors. METHOD: Twenty-three people with stroke (12 women; age: 56.0 ± 10.0 years, time since stroke: 4.2 ± 4.0 years) from support groups in Glasgow completed the study. Participants were sequentially allocated in a 2:1 ratio to intervention (n = 15) or control (n = 8) groups. The intervention group followed the STARFISH program for six weeks; the control group received usual care. Outcome measures included physical activity, sedentary time, heart rate, blood pressure, body mass index, Fatigue Severity Scale, Instrumental Activity of Daily Living Scale, Ten-Meter Walk Test, Stroke Specific Quality of Life Scale, and Psychological General Well-Being Index. RESULTS: The average daily step count increased by 39.3% (4158 to 5791 steps/day) in the intervention group and reduced by 20.2% (3694 to 2947 steps/day) in the control group (p = 0.005 for group-time interaction). Similar patterns of data and group-time interaction were seen for walking time (p = 0.002) and fatigue (p = 0.003). There were no significant group-time interactions for other outcome measures. CONCLUSION: Use of STARFISH has the potential to improve physical activity and health outcomes in people after stroke and longer term intervention trials are warranted.

The relationship between urinary bladder control and gait in women.

AIMS: Urinary incontinence and OAB are associated with increased falls risk in older people suggesting a potential relationship between bladder functioning and control of gait. To begin to understand the possible interaction between gait and bladder control this exploratory study aimed to examine the effects of controlling the bladder on gait parameters in healthy adult women. METHODS: Thirty-six continent women (mean age 50.8 ± 15.8 years), participated in this observational cohort study. Subjects walked three times along an electronic walkway under three different bladder conditions; first desire to void (FDV), strong desire to void (SDV), and post void (PV). Spatial and temporal parameters of gait and continence status were recorded for each condition. RESULTS: A significant reduction in gait velocity (P < 0.025) was found at the SDV compared with the PV condition. Stride length decreased significantly (P < 0.001) at the SDV compared with the FDV and PV conditions. No significant differences were found between FDV and PV conditions. In addition, the variability of gait increased significantly with respect to cadence (P < 0.05) and stride times (P < 0.05) at the SDV compared to the PV condition. This was not observed between the FDV and the PV conditions, nor the FDV and the SDV. CONCLUSION: In healthy continent women, speed and rhythmicity of gait are different when a strong desire to void is experienced. This suggests an interaction may exist between urinary bladder control and control of gait. Further investigation is necessary to understand this relationship and begin to explain the increased risk of falls associated with urinary bladder functioning.

The effect of cueing therapy on single and dual-task gait in a drug naïve population of people with Parkinson's disease in northern Tanzania.

The incidence of Parkinson's disease (PD) in sub-Saharan Africa (SSA) is greater than thought however, is largely undiagnosed and untreated. This study aimed to evaluate a nonpharmacological approach using cueing therapy to improve gait in drug-naïve PD and the feasibility of delivering rehabilitation in northern Tanzania. In this study, twenty-one people with PD aged 76.4 years (12.9 SD) with varying disease severity participated. They received 9 x 30 min sessions of cueing therapy for gait problems over 3 weeks from a trained therapist delivered in their home environment. Cueing therapy consisted of walking in time to a metronome beat to correct step amplitude and step frequency during a range of functional activities. Gait was recorded on video before and after therapy, and videos were analyzed in the UK by an assessor not involved in data collection. Disease severity (UPDRS) and balance were also measured. Patients were assessed in their nearest clinic. Data were analyzed in Minitab and a P value of 0.05 was considered significant. Cueing therapy significantly improved single and dual task walking speed, step amplitude, and single task step frequency. There was also a significant improvement in motor impairment (UPDRS III) and activities of daily living (UPDRS II). The results provide promising evidence for the role of cueing therapy in PD for symptom management to reduce or delay medication onset. This study also supports the feasibility of rehabilitation in PD in community environments in SSA, which may be applicable to other developing regions.

An exploration of the experiences and utility of functional electrical stimulation for foot drop in people with multiple sclerosis.

Purpose: Functional electrical stimulation (FES) is effective in improving walking in people with multiple sclerosis (MS) with foot drop. There is limited research exploring people's experiences of using this device. This study aims to explore the utility, efficacy, acceptability, and impact on daily life of the device in people with MS.Methods: An interpretative phenomenological approach was employed. Ten participants who had used FES for 12 months were interviewed. Transcripts were analysed, and emergent themes identified.Results: Nine participants continued to use the device. Three relevant super-ordinate themes were identified; impact of functional electrical stimulation, sticking with functional electrical stimulation, and autonomy and control. Participants reported challenges using the device; however, all reported positive physical and psychological benefits. Intrinsic and external influences such as; access to professional help, the influence of others, an individual's ability to adapt, and experiences using the device, influenced their decisions to continue with the device. A thematic model of these factors was developed.Conclusions: This study has contributed to our understanding of people with MS experiences of using the device and will help inform prescribing decisions and support the continued, appropriate use of FES over the longer term.Implications for RehabilitationPeople with multiple sclerosis using functional electrical stimulation report benefits in many aspects of walking, improved psychological well-being and increased engagement in valued activities.A number of challenges impact on functional electrical stimulation use. Factors such as; a positive experience using the device, access to professional help, the influence of others, a strong sense of personal autonomy and an individual's ability to adapt, influence an individual's decision to continue using functional electrical stimulation.Clinicians prescribing functional electrical stimulation should be aware of these factors so that the right support and guidance can be provided to people with multiple sclerosis, thus improving outcomes and compliance over the long term.

Compliance with physical activity guidelines in a group of UK-based postal workers using an objective monitoring technique.

Compliance with physical activity (PA) recommendations was assessed using objective PA monitoring of ambulatory activity, in two healthy groups of individuals with active and sedentary occupations. The study showed generally low compliance with the guidelines (53% with 10,000 steps a day; 10% with 30 min of moderate activity a day; and 1% with 30 min of moderate activity a day in bouts of at least 10 min (ACSM)). Adherence to guidelines decreased as more rigorous conditions were applied to the PA data. Use of an objective monitor revealed that health enhancing bouts of activity were performed in periods of approximately 1-min duration, which may be due to unavoidable environmental interruptions. These bouts of activity are much shorter than those advocated in the ACSM guidelines, raising questions regarding how actual behaviour, based on objective monitoring, can be reconciled with guidelines based on self-reported PA.

Physiological cost of walking in those with chronic fatigue syndrome (CFS): a case-control study.

PURPOSE: To examine the physiological cost of walking in subjects with chronic fatigue syndrome (CFS) and a matched control group, walking at their preferred and at matched walking speeds. METHODS: Seventeen people with CFS and 17 matched-controls participated in this observational study of physiological cost during over-ground gait. Each subject walked for 5 min at their preferred walking speed (PWS). Controls then walked for 5 min at the same pace of their matched CFS subject. Gait speed and oxygen uptake, gross and net were measured and oxygen uptake was expressed per unit distance ambulated. CFS subjects completed the CFS-Activities and Participation Questionnaire (CFS-APQ). RESULTS: At PWS the CFS group walked at a slower velocity of 0.84 +/- 0.21 m s(-1) compared to controls with a velocity of 1.19 +/- 0.13 m s(-1) (p < 0.001). At PWS both gross and net oxygen uptake of CFS subjects was significantly less than controls (p = 0.023 and p = 0.025 respectively). At matched-velocity both gross and net physiological cost of gait was greater for CFS subjects than controls (p = 0.048 and p = 0.001, respectively). CONCLUSION: The physiological cost of walking was significantly greater for people with CFS compared with healthy subjects. The reasons for these higher energy demands for walking in those with CFS have yet to be fully elucidated.

Gait characteristics of subjects with chronic fatigue syndrome and controls at self-selected and matched velocities.

BACKGROUND: Gait abnormalities have been reported in individuals with Chronic Fatigue Syndrome (CFS) however no studies exist to date investigating the kinematics of individuals with CFS in over-ground gait. The aim of this study was to compare the over-ground gait pattern (sagittal kinematics and temporal and spatial) of individuals with CFS and control subjects at their self-selected and at matched velocities. METHODS: Twelve individuals with CFS and 12 matched controls participated in the study. Each subject walked along a 7.2 m walkway three times at each of three velocities: self-selected, relatively slow (0.45 ms-1) and a relatively fast (1.34 ms-1). A motion analysis system was used to investigate the sagittal plane joint kinematics and temporal spatial parameters of gait. RESULTS: At self-selected velocity there were significant differences between the two groups for all the temporal and spatial parameters measured, including gait velocity (P = 0.002). For the kinematic variables the significant differences were related to both ankles during swing and the right ankle during stance. At the relatively slower velocity the kinematic differences were replicated. However, the step distances decreased in the CFS population for the temporal and spatial parameters. When the gait pattern of the individuals with CFS at the relatively fast walking velocity (1.30 +/- 0.24 ms-1) was compared to the control subjects at their self-selected velocity (1.32 +/- 0.15 ms-1) the gait pattern of the two groups was very similar, with the exception of both ankles during swing. CONCLUSION: The self-selected gait velocity and/or pattern of individuals with CFS may be used to monitor the disease process or evaluate therapeutic intervention. These differences may be a reflection of the relatively low self-selected gait velocity of individuals with CFS rather than a manifestation of the condition itself.

A comparison of the initial orthotic effects of functional electrical stimulation and ankle-foot orthoses on the speed and oxygen cost of gait in multiple sclerosis.

BACKGROUND: Foot drop affects walking in people with multiple sclerosis (pwMS). This study compares the initial orthotic effects of two treatments for foot drop: ankle-foot orthoses (AFO) and functional electrical stimulation (FES), on the speed and oxygen cost of walking in MS. METHOD AND MATERIALS: Seventy-eight pwMS were randomised to receive AFO or FES (ODFS PACE (OML, Salisbury, UK)). Participants completed the 25-ft walk test (25ftWT) and 5-min self-selected walk test (5minSSWT), from which oxygen cost was determined, with and without their device. Between-, within- and sub-group analyses (based on baseline walking speed of <0.8 m/s (slow) or ≥0.8 m/s (fast)) were undertaken. RESULTS: No significant differences between baseline measures were observed. The AFO group walked significantly slower than the FES group (5minSSWT, p = 0.037, 0.11 m/s). The AFO group walked significantly slower with than without AFO (25ftWT, p = 0.037), particularly in the fast-walking group ( p = 0.011). The slow-walking FES group walked significantly faster with FES than without (25ftWT; p = 0.029, 5minSSWT; p = 0.037). There were no differences in the fast-walking FES group or in the oxygen cost for either device. CONCLUSION: AFO reduced walking speed, particularly in fast walkers. FES increased walking speed in slow, but not fast walkers.

Timing phases of the sit-to-walk movement: validity of a clinical test.

The sit-to-walk (STW) movement is a functional task that challenges balance and co-ordination. There is a paucity of literature investigating the phases of this movement and its significance in a clinical rehabilitation context. Measuring phases of this movement may provide clinically applicable data for screening subjects for mobility problems and evaluating interventions. Fifty-six subjects from three groups; young (<65 years old), elderly (>65 years old) and elderly at risk of falling (EARF), performed the STW movement freely from a chair. Switches placed on the backrest, chair seat and two on the floor identified the times of movement events: onset, seat-off, swing-off and stance-off. These events defined three phases: flexion, extension and stance. Timing of events and phase duration data derived from this switch system were correlated with those taken from a three-dimensional motion analysis system. All switch events closely matched the motion analysis events with ICC (model 2.1) scores ranging from 0.93 to 1.00. Duration of all STW phases were statistically longer in the EARF group compared to both unimpaired groups (p<0.05). Data from the four switch configuration demonstrated excellent concurrent validity when associated with data from a three-dimensional motion analysis system in identifying the phases of STW. Measurement of the phases of the STW task has potential in screening those at risk of falling and informing care strategies to prevent falls.

Consequences of short interruptions of bouts walking on estimates of compliance to physical activity guidelines.

Current guidelines on physical activity suggest that 30 min of moderate intensity physical activity can be accumulated in continuous bouts of at least 10 min. It has been shown by use of activity monitoring that it is difficult to achieve 10 min of completely uninterrupted walking in the free-living urban environment where we have obstacles such as roads to cross. The aim of this study was to examine the effect of short interruptions in walking on the rate of oxygen uptake (ml · kg · min-1) to determine if walking with short interruptions can still be considered continuous. This leads to a more meaningful understanding as to what is a physiological break in activity. This is an important consideration for measurement of physical activity especially when exploring measurement by accelerometry. In a laboratory setting a repeated measure design was used to replicate interrupted walking in urban setting. Healthy volunteers (N = 10) walked on a treadmill with walking interruptions of 10 s, 50 s and 100 s. Oxygen uptake was measured using a gas analysis system. 10 s interruptions in walking had no significant effect on the VO2 · kg · min-1. However two breaks of 50 s or 100 s introduced into a 5 min brisk walking bout showed a significant reduction in oxygen uptake requirements and metabolic equivalent of task (MET) (p < 0.001) compared to continuous walking for the same amount of effective walking, but only the 100 s walking period could not be considered greater than 3 MET during the interval. Short periods of brisk walking interrupted by 10 s breaks can be considered continuous physical activity, but when walking is interrupted by longer breaks e.g. 50 s, there is a significant reduction in oxygen uptake requirement suggesting that it is not continuous anymore and should be considered as fragmented.

Physical activity profiles and sedentary behaviour in people following stroke: a cross-sectional study.

PURPOSE: To measure and compare physical activity profiles and sedentary time between community dwelling stroke survivors and healthy volunteers. METHODS: Twenty-two stroke survivors (10 men, age 55.3 ± 9.9 years; 4.2 ± 4.0 years since their stroke) were recruited from local stroke support groups, and 22 controls were matched for sex, age and body mass index (BMI). All participants wore an ActivPAL™ physical activity monitor for seven days and from these data activity profiles, including the number of steps per day, time spent sedentary and time in different cadence bands, were recorded. RESULTS: Stroke survivors took significantly fewer steps per day than the controls (4035 ± 2830 steps/day versus 8394 ± 2941 steps/day, p < 0.001) and sedentary time (including sleep time) was significantly higher for stroke participants compared to the controls (20.4 ± 2.7 h versus 17.5 ± 3.8 h, p < 0.001). People with stroke spent a significantly higher proportion of their walking time in lower self-selected cadences compared to the controls. CONCLUSIONS: Community dwelling stroke survivors spent more time sedentary, took fewer steps and walked at a slower self-selected cadence. Interventions to increase walking and reduce sedentary time following stroke are required which may have the added benefit of reducing cardiovascular risk in this group. Implications for Rehabilitation Stroke survivors are predisposed to reduced physical activity and increased cardiovascular risk. This study showed that community dwelling stroke survivors spent more time sedentary, took fewer steps and walked at a slower self-selected cadence. Interventions are required which focus on reducing sedentary time as well as increasing step counts in people following stroke.

A comparison of the orthotic effect of the Odstock Dropped Foot Stimulator and the Walkaide functional electrical stimulation systems on energy cost and speed of walking in Multiple Sclerosis.

PURPOSE: Functional electrical stimulation (FES), an assistive device used for foot drop, has been found to improve the speed and energy cost of walking in people with multiple sclerosis (pwMS). This study aims to compare the immediate orthotic effect on walking of two different devices; the Odstock Dropped Foot Stimulator (ODFS) and Walkaide (WA). METHOD: Twenty pwMS (10 female, 10 male, mean age 50.4 ± 7.3 years) currently using ODFS were recruited. Participants walked for 5 min around an elliptical 9.5 m course at their preferred walking speed; once with ODFS, once with WA and once without FES on the same day of testing. Gait speed, distance and energy cost were measured. RESULTS: There was a statistically significant increase in walking speed for the ODFS (p = 0.043) and a near to significant increase for the WA (p = 0.06) in comparison to without FES. There were no differences between the ODFS and WA in terms of either walking speed (p = 0.596) or energy cost (p = 0.205). CONCLUSIONS: This is the first pilot study to compare the effects of two different FES devices on walking. Further research recruiting a larger cohort of FES naive participants is needed. Implications for Rehabilitation Functional electrical stimulation (FES) used for foot drop in multiple sclerosis (MS) is effective in improving the speed of walking. The Odstock Dropped Foot Stimulator and the Walkaide have similar orthotic effects on the speed and energy cost of walking in people with MS. Further research is urgently needed to compare FES devices, recruiting treatment of naive participants for a fully powered RCT.

Foot function is well preserved in children and adolescents with juvenile idiopathic arthritis who are optimally managed.

PURPOSE: The objective of this study was to compare disease activity, impairments, disability, foot function and gait characteristics between a well described cohort of juvenile idiopathic arthritis (JIA) patients and normal healthy controls using a 7-segment foot model and three-dimensional gait analysis. METHODS: Fourteen patients with JIA (mean (standard deviation) age of 12.4 years (3.2)) and a history of foot disease and 10 healthy children (mean (standard deviation) age of 12.5 years (3.4)) underwent three-dimensional gait analysis and plantar pressure analysis to measure biomechanical foot function. Localised disease impact and foot-specific disease activity were determined using the juvenile arthritis foot disability index, rear- and forefoot deformity scores, and clinical and musculoskeletal ultrasound examinations respectively. Mean differences between groups with associated 95% confidence intervals were calculated using the t distribution. RESULTS: Mild-to-moderate foot impairments and disability but low levels of disease activity were detected in the JIA group. In comparison with healthy subjects, minor trends towards increased midfoot dorsiflexion and reduced lateral forefoot abduction within a 3-5° range were observed in patients with JIA. The magnitude and timing of remaining kinematic, kinetic and plantar pressure distribution variables during the stance phase were similar for both groups. CONCLUSION: In children and adolescents with JIA, foot function as determined by a multi-segment foot model did not differ from that of normal age- and gender-matched subjects despite moderate foot impairments and disability scores. These findings may indicate that tight control of active foot disease may prevent joint destruction and associated structural and functional impairments.

Measuring foot placement and clearance during stair descent.

Falls during stair descent are a serious problem and can lead to accidental death. Inappropriate foot placement on, and clearance over, steps have been identified as causes for falls on stairs. This study investigated a new method for measuring placement and clearance during stair descent in 10 healthy young subjects. The effect of foot length was accounted for during the measurement of foot placement by calculating the percentage length of the foot overhanging the step. Foot clearance was measured as the resultant of the minimum vertical and horizontal distances from the heel of the foot to the edge of the step. Clearance was divided into landing and passing clearance depending on the planned placement of the foot in relation to the step edge being cleared. Each subject performed seven trials of stairs descent. Mean (SD) and CV (SD) were 16% (6), 0.28 (0.15) for placement; 45.88 (10.05), 0.21 (0.07) for landing clearance; 107.25 (5.59), 0.25 (0.08) for passing clearance. There was no statistically significant effect of trial on placement and clearance (p>0.05). There was a significant effect of step number on landing and passing clearance (p=0.01, p<0.001 respectively). Landing and passing clearances were greater for the third step compared to the second step. Passing clearance was also significantly greater than landing clearance (p<0.001). The repeatable methods and findings from this study might be useful in providing a technical background and normal values for the design of future gait studies on stairs.

A national framework for supporting improvements in the physiotherapy assessment and management of low back pain: the Scottish experience.

BACKGROUND: Similar to other countries worldwide, Scotland lacked a national view of whether the quality of the physiotherapy management of low back pain was compliant with national guidelines. Anecdotal evidence suggested that standards of care varied considerably despite the wide availability of clinical guidelines to clinicians. AIM: To develop a framework that supports National Health Service (NHS) Scotland in providing consistently applied high-quality physiotherapy assessment and management of low back pain in line with guideline recommendations. DESIGN: Prospective, multicentred national study, data collection and improvement phase. SETTING: All NHS boards in Scotland (n=14) plus two private provider sites. PARTICIPANTS: One hundred and eighty-six individual NHS sites and two private providers of services to patients with low back pain. METHOD: A national dataset was developed from evidence- and consensus-based guideline sources. All sites collected data (two 5-week periods) over 1 year (2008-2009) using a web-based database. This was interspersed by an improvement phase during which required improvements were considered and implemented. Issues were shared through a national network and national meeting. RESULTS: Data from 2147 patients showed improvements in the documented physiotherapy management of low back pain over the two cycles. All participants developed and implemented remedial action plans based on the results of the first cycle. CONCLUSION: It is possible to implement a framework, which is led nationally but driven and owned locally, supporting physiotherapists in an active programme of locally determined improvement. However, although process and outcome are linked, the direct impact of this initiative on patient outcome is not known.

Low back pain and physiotherapy use of red flags: the evidence from Scotland.

BACKGROUND: Red flags are recognised as indicators of possible serious spinal pathology, and their use is indicated by numerous guidelines. Similar to other countries worldwide, Scotland lacked a national view about the overall quality of the physiotherapy management of low back pain and the use of red flags. Anecdotal evidence suggested that practice varied considerably. AIM: To improve the use and documentation of red flags by physiotherapists during the assessment and management of low back pain. DESIGN: Prospective, multicentred, national data collection and improvement initiative. SETTING: National Health Service (NHS) health boards in Scotland (n=14) plus two private provider sites. PARTICIPANTS: One hundred and eighty-six individual NHS provider sites and two private provider sites, with in excess of 360 physiotherapists providing services to low back pain patients. METHOD: Measurement of documented practice in line with evidence- and consensus-based recommendations from guidelines collected via a web-based tool over two 5-week audit cycles interspersed with an improvement phase over 1 year (2008-2009). RESULTS: Data from 2147 patients showed improvement in the documentation of all red flags assessed from 33% (n=709) to 65% (n=1396), and improvement in the documentation of cauda equina syndrome from 60% (n=1288) to 84% (n=1804) over the two cycles. Only two regions provided evidence of 100% documentation of all components of cauda equina syndrome, with wide variation across the country. CONCLUSION: This national initiative resulted in considerable improvement in the documentation of red flags. Despite this, however, one in five patients did not receive optimal management as recommended by guidance. This has significant implications for patient safety and highlights the need for ongoing education of physiotherapists in this area.

A reliability study of biomechanical foot function in psoriatic arthritis based on a novel multi-segmented foot model.

The objective of this study was to determine the within-and between-day reliability of spatio-temporal, plantar pressure, kinematic and kinetic measurements based on a novel, seven segment foot model applied in patients with Psoriatic Arthritis (PsA). Nine PsA patients and matched healthy adult controls underwent three-dimensional gait analysis on two occasions, one week apart using a seven segment foot model. A core-set of functional variables including inter-segment kinematics, kinetics, spatio-temporal and plantar pressure distribution were analysed using the coefficient of multiple correlation (CMC), Bland-Altman plots, intraclass correlation coefficients (ICC) and the standard error of measurement (SEM). Results showed excellent within- and between-day reliability for intersegment kinematic and kinetic data patterns with CMC values typically greater than 0.950 in a clinically stable cohort of PsA patients. Between-day reliability ranged from poor to excellent for absolute CMC values. Corrected CMC values were consistently higher across all variables ranging from fair-to-good to excellent. ICC values indicated excellent reliability for discrete spatio-temporal, plantar pressure, and ankle moment and power variables for both groups. Reliability for ground reaction forces and kinematic discrete variables ranged from fair-to-good to excellent. Standard error of measurement values ranged from 0.7° to 3.0° for discrete kinematic variables across both groups with greater variability in the PsA patients. In conclusion, intersegment kinematics and kinetics as well as spatio-temporal and plantar pressure can be reliably measured in PsA patients using a novel seven segment foot model. Some discrete kinematic variables have poor reliability and should not be used in prospective cohort and intervention studies.