Prevalence of symptoms of anxiety and depression one year after intensive care unit admission for COVID-19.

BACKGROUND: To the best of our knowledge, the long term prevalence of symptoms of anxiety and depression in ICU admitted individuals after COVID-19 in Sweden during the first wave of the pandemic has not been investigated. Furthermore, no studies have exclusively investigated the risk factors for experiencing symptoms of anxiety and depression in this population. AIM: The aim of this study was to determine the prevalence of symptoms of anxiety and depression at one year after ICU admission for COVID-19. An additional aim was to identify any early predictors that are associated with symptoms of anxiety and depression, at one year following ICU admission for COVID-19. METHODS: This multicenter cohort study had a cross-sectional and a longitudinal design. The primary outcomes and dependent variables, symptoms of anxiety and depression, were assessed using the Hospital Anxiety and Depression Scale (HADS). The independent variables were related to demographic factors, comorbidities, and complications during COVID-19-related ICU admission. Logistic regression analyses were performed to identify any predictors of symptoms of anxiety and depression. RESULTS: Out of 182 eligible individuals, 105 participated in the study. Symptoms of anxiety was found in 40 (38.1%) and depression in 37 (35.2%) of the participants. Using univariable logistic regression analyses, female sex was identified as a predictor of depression as defined by HADS at one year following ICU admission for COVID-19 (odds ratio 2.53, 95% confidence intervals 1.01-6.34, p-value 0.048). CONCLUSIONS: The high prevalence of symptoms of anxiety and depression in ICU admitted individuals one year after COVID-19 is a public health issue of concern. Our findings imply that individuals who recovered after an ICU stay for COVID-19 may benefit from long-term follow-ups and continuous mental health support for more than a year following the ICU admission. For women specifically, this is true. TRIAL REGISTRATION: The study was registered at researchweb.org on 28 May 2020 (Project number: 274477).

Prevalence of pelvic floor dysfunction in recreational athletes: a cross-sectional survey.

INTRODUCTION AND HYPOTHESIS: Pelvic floor dysfunction (PFD) affects many women and participation in elite sport and high-impact exercise has been reported as a potential risk. However, few studies have investigated the effects of exercising at recreational levels on PFD. Our aim was to investigate levels of PFD in women exercising at, or above, UK guidelines for health and compare them with levels in non-exercisers. METHOD: Data on levels of PFD and potential risk factors (age, hormonal status, body mass index, constipation, parity, forceps delivery, and recreational exercise) were collected using a cross-sectional survey distributed via social media. The International Consultation Incontinence Questionnaire (ICIQ) Urinary Incontinence Short Form was used to estimate prevalence of urinary incontinence (UI). Selected questions from the ICIQ vaginal symptom and bowel symptom questionnaires were used to estimate prevalence of anal incontinence (AI) and pelvic organ prolapse (POP). Logistic regression analysis was used to compare exercisers and non-exercisers after adjusting for potential confounders. RESULTS: We recruited 1,598 adult women (1,141 exercisers and 457 non-exercisers). The majority were parous. High prevalence of UI (70%), AI (52%) and POP (18%) was reported. No significant association was found between recreational exercise and PFD despite adjustment for confounders, or further investigation regarding exercise involving impact, although some increased reporting of AI was seen in those exercising for over 10 hours per week. CONCLUSION: High levels of all PFD were reported but no significant association was found between recreational exercise and symptoms. However, data suggest that women modify their exercise regimes as required. Few symptomatic women sought professional help.

Developing a patient care pathway for emotional support around the point of multiple sclerosis diagnosis: A stakeholder engagement study.

BACKGROUND: Diagnosing multiple sclerosis (MS) can be a lengthy process, which can negatively affect psychological well-being, condition management, and future engagement with health services. Therefore, providing timely and appropriate emotional support may improve adjustment and health outcomes. PURPOSE: To develop a patient care pathway for providing emotional support around the point of diagnosing MS, and to explore potential barriers and facilitators to delivery and implementation. METHODS: Focus groups were conducted with 26 stakeholders, including 16 people living with MS, 5 carers/family members and 5 professionals working with people living with MS (3 MS nurses, 1 psychiatrist, and 1 charity staff member). Discussions were audio-recorded, transcribed verbatim and analyzed using framework analysis. RESULTS: Participants suggested that a patient care pathway should include comprehensive information provision as a part of emotional support at diagnosis, and follow-up sessions with a healthcare professional. Barriers including increasing staff workloads and financial costs to health services were acknowledged, thus participants suggested including peer support workers to deliver additional emotional support. All participants agreed that elements of a care pathway and embedded interventions should be individually tailored, yet provided within a standardized system to ensure accessibility. CONCLUSIONS: A patient care pathway was developed with stakeholders, which included an embedded MS Nurse support intervention supplemented with peer support sessions. Participants suggested that the pathway should be delivered within a standardized system to ensure equity of service provision across the country. PATIENT OR PUBLIC CONTRIBUTION: This research was conceptualized and designed collaboratively with Nottingham Multiple Sclerosis Patient and Public Involvement and Engagement (PPIE) group members. One member is a co-author and was actively involved in every key stage of the research process, including co-design of the pathway and research protocol, data collection (including presenting to participants and moderating group discussions), analysis and write-up. Authors consulted with PPIE members at two meetings (9 and 11 PPIE attendees per meeting) where they gave feedback on the research design, findings and the resulting pathway. People living with MS and carers of people with MS were included in the focus groups as participants.

How do stroke survivors and their caregivers manage post-stroke fatigue? A qualitative study.

OBJECTIVES: The primary objective was to gain insight into the lived experiences of using day-to-day strategies to manage post-stroke fatigue. DESIGN: Qualitative, descriptive study. SETTING: Community telephone interviews. PARTICIPANTS: A purposive sample of 20 stroke survivors with current, or previous, post-stroke fatigue, and 8 caregivers, who provided informal care or support, were recruited. MAIN MEASURES: Semi-structured telephone interviews were undertaken. Data were analysed using a framework approach. RESULTS: Most participants had found their own ways of coping and their personal strategies included acceptance of having fatigue; 'pacing' (spreading activities out and interspersing with rest periods); keeping a diary in order to plan activities and to identify 'trigger' activities which induced fatigue; talking to (and educating) others about having fatigue; using relaxation; and accessing professional advice and support. The burden placed on caregivers was considerable and they often had to oversee the post-stroke fatigue management strategies used. CONCLUSIONS: Post-stroke fatigue is managed in different ways and there was not one particular strategy that seemed effective for everyone. Most people in our study had had to devise their own ways of coping practically. Given the scale of this problem, which profoundly impacts the lives of both stroke survivors and caregivers, the management of post-stroke fatigue merits more attention and evaluation. However, this must be directly informed by those with lived experience.

Cognitive measures used in adults with multiple sclerosis: A systematic review.

Cognitive problems are common in people with Multiple Sclerosis (MS), and researchers and clinicians have used a vast array of measures to assess cognition. Our aim was to systematically identify cognitive measures routinely used in MS research, and outline their different uses. Previous recommendations of cognitive measures to use in MS have relied on expert consensus approaches. We believe this systematic review is a starting point for an evidence-based approach to recommend cognitive tests for use with people with MS. We systematically searched electronic databases using relevant search terms for studies that assessed cognitive functioning in MS (last search in February 2020). From 11,854 abstracts retrieved, based on title and abstract review, 2563 remained. Data were extracted from 1526 studies. Studies used 5665 measures of cognition, with 316,053 people with MS. Substitutional style tests, serial addition tests, and word list learning tests were the most commonly used individual tests, and the Brief Repeatable Battery of Neuropsychological Tests was the most commonly used battery. Some of the most frequently used measures were potentially inappropriate due to measuring irrelevant domains of cognition, and issues with sensitivity. Further research is needed to ascertain the psychometric properties, and acceptability of measures for people with MS.

Cognitive assessment in multiple sclerosis clinical care: A qualitative evaluation of stakeholder perceptions and preferences.

There is a growing consensus that cognitive assessments should form part of routine clinical care in Multiple Sclerosis (MS). However, what remains unclear is which assessments are preferred by "stakeholders" (including people with MS, family members, charity volunteers, clinicians, and healthcare commissioners), in which contexts, and in which formats. Therefore, the aim of this study was to collect and synthesize stakeholders' perceptions of the assessments that are acceptable and feasible for routine administration in the UK healthcare system.We interviewed 44 stakeholders and held one focus group (n = 5). We asked stakeholders about their experience with cognitive impairment and assessment and their views on how cognitive assessment could be implemented within routine clinical care.Using framework analysis, we summarized three themes: the current cognitive screening situation; the suitability of commonly used assessments; and feasibility aspects, including modality and location of testing. All participants acknowledged that cognitive impairment could have a significant impact on the quality of life, but that assessment and monitoring are not routinely performed in clinics. Barriers and enablers were described, and most participants reported that brief, routine screening with tests such as symbol substitution was acceptable. Electronic, self-administration of cognitive screening would be beneficial in minimizing clinic attendance and staff time.

The Effect of Hearing Loss and Hearing Device Fitting on Fatigue in Adults: A Systematic Review.

OBJECTIVES: To conduct a systematic review to address two research questions: (Q1) Does hearing loss have an effect on fatigue? (Q2) Does hearing device fitting have an effect on fatigue? It was hypothesized that hearing loss would increase fatigue (H1), and hearing device fitting would reduce fatigue (H2). DESIGN: Systematic searches were undertaken of five bibliographic databases: Embase, MedLine, Web of Science, Psychinfo, and the Cochrane Library. English language peer-reviewed research articles were included from inception until present. Inclusion and exclusion criteria were formulated using the Population, Intervention, Comparison, Outcomes and Study design strategy. RESULTS: Initial searches for both research questions produced 1,227 unique articles, after removal of duplicates. After screening, the full text of 61 studies was checked, resulting in 12 articles with content relevant to the research questions. The reference lists of these studies were examined, and a final updated search was conducted on October 16, 2019. This resulted in a final total of 20 studies being selected for the review. For each study, the information relating to the Population, Intervention, Comparison, Outcomes and Study design criteria and the statistical outcomes relating to both questions (Q1 and Q2) were extracted. Evidence relating to Q1 was provided by 15 studies, reporting 24 findings. Evidence relating to Q2 was provided by six studies, reporting eight findings. One study provided evidence for both. Using the Grading of Recommendations Assessment, Development and Evaluation guidelines, the quality of evidence on both research questions was deemed to be "very low." It was impossible to perform a meta-analysis of the results due to a lack of homogeneity. CONCLUSIONS: As the studies were too heterogeneous to support a meta-analysis, it was not possible to provide statistically significant evidence to support the hypotheses that hearing loss results in increased fatigue (H1) or that hearing device fitting results in decreased fatigue (H2). Despite this, the comparative volume of positive results and the lack of any negative findings are promising for future research (particularly in respect of Q1). There was a very small number of studies deemed eligible for the review, and there was large variability between studies in terms of population, and quantification of hearing loss and fatigue. The review highlights the need for consistency when measuring fatigue, particularly when using self-report questionnaires, where the majority of the current evidence was generated.

Cognitive rehabilitation for attention and memory in people with multiple sclerosis: a randomized controlled trial (CRAMMS).

OBJECTIVE: To assess the clinical and cost-effectiveness of cognitive rehabilitation for attention and memory problems in people with multiple sclerosis. DESIGN: Multicentre, pragmatic, randomized controlled trial. SETTING: Community. PARTICIPANTS: People with multiple sclerosis aged 18-69 years, who reported cognitive problems in daily life and had cognitive problems on standardized assessment. INTERVENTIONS: A group cognitive rehabilitation programme delivered in 10 weekly sessions in comparison with usual care. MAIN MEASURES: The primary outcome was the Multiple Sclerosis Impact Scale Psychological subscale at 12 months after randomization. Secondary outcomes included measures of everyday memory problems, mood, fatigue, cognitive abilities and employment at 6 and 12 months after randomization. RESULTS: In all, 245 participants were allocated to cognitive rehabilitation and 204 to usual care. Mean Multiple Sclerosis Impact Scale Psychological at 12 months was 22.2 (SD = 6.1) for cognitive rehabilitation and 23.4 (SD = 6.0) for usual care group; adjusted difference -0.6, 95% confidence interval (CI) = -1.5 to 0.3, P = 0.20. No differences were observed in cognitive abilities, fatigue or employment. There were small differences in favour of cognitive rehabilitation for the Multiple Sclerosis Impact Scale Psychological at 6 months and everyday memory and mood at 6 and 12 months. There was no evidence of an effect on costs (-£808; 95% CI = -£2248 to £632) or on quality-adjusted life year gain (0.00; 95% CI = -0.01 to 0.02). CONCLUSION: This rehabilitation programme had no long-term benefits on the impact of multiple sclerosis on quality of life, but there was some evidence of an effect on everyday memory problems and mood.

Using intervention mapping to develop an occupational advice intervention to aid return to work following hip and knee replacement in the United Kingdom.

BACKGROUND: There are increasing numbers of total hip replacements (THR) and total knee replacements (TKR) being performed in patients of working age. Providing patients undergoing TKR and THR with return to work advice might facilitate return to work. The aim of this paper is to report on the process used to systematically develop an occupational advice intervention to be delivered in hospital for those undergoing arthroplasty. METHODS: The six-step Intervention Mapping (IM) approach to development, implementation and evaluation of a theory and evidence-based interventions was followed. This paper reports on the development of the intervention covered by steps 1 to 4 of the IM process. Steps 1-3 gathered data on current practice and barriers to change using a mixed methods approach (cohort study of patients undergoing THR or TKR, stakeholder interviews, survey of practice, evidence synthesis) and provided a theoretical framework for intervention development. Step 4 used information from steps 1-3 in combination with a Delphi consensus process to develop the intervention and the associated tools and materials to facilitate its delivery. RESULTS: The final intervention identified included a number of core principles including: early patient identification; delivery of key information to patients and their employers; assessment and support by a member of the orthopaedic team; procedures for escalation based on patient need; mechanisms to support communication; and training and support for the clinical teams delivering care. A total of 13 patient and 20 staff performance objectives as delivery requirements, were supported by a range of tools, roles and training resources. The intervention addressed outcomes based at the individual and interpersonal levels of the ecological model. CONCLUSIONS: Following the IM approach resulted in a structured and justified occupational intervention for delivery in secondary care for patients undergoing total hip and knee replacement. The feasibility of the intervention will subsequently be tested alongside further investigation to establish its effectiveness and cost-effectiveness.

Using occupational therapists in vocational clinics in primary care: a feasibility study.

BACKGROUND: GPs are under considerable pressure providing routine care. However, they may not be the most appropriate professionals to manage getting patients back to work, and keeping them there. OBJECTIVE: To test the feasibility of delivering occupational therapy-led vocational clinics (OTVoc) to provide return to work advice and support for people with musculoskeletal conditions and mental health problems, in primary care. METHODS: Prospective mixed methods study in two primary care centres (eight GP surgeries). We collected anonymised service level data on all patients receiving OTVoc. Next, patient participants who met inclusion criteria and consented, undertook baseline and 3-month follow-up assessments. Interviews were also conducted to explore stakeholders' views- GPs, Nurse Practitioners, Front Desk Staff, Occupational Therapists, patients and their employers about OTVoc- and included study eligibility, referral, experiences and attitudes to return to work. Data were analysed using descriptive statistics and thematic analysis. RESULTS: The majority of standardized measures showed some improvement over the study period: the sickness absence rate dropped from 71 to 15% and use of GP 'fit' notes reduced from 76 to 6%. Interview data indicated positive attitudes to OTVoc, the use of the fit note and the Allied Health Professions Health and Work Reports (AHP H&WRs). GPs felt that OTVoc reduced their workload. CONCLUSION: Further research is feasible and warranted. OTVoc was positively received and stakeholders believed it was effective in getting patients back to work or preparing for their return. There was enthusiasm for extending service eligibility criteria, suggesting potential for further development and evaluation.

Evaluation of an Extended Stroke Rehabilitation Service (EXTRAS): A Randomized Controlled Trial and Economic Analysis.

Background and Purpose- There is limited evidence to guide rehabilitation to meet the longer term needs of stroke survivors. The clinical effectiveness and cost-effectiveness of an extended stroke rehabilitation service (EXTRAS) provided following early supported discharge were determined. Methods- EXTRAS was a pragmatic parallel-group observer-blind randomized controlled trial involving 19 UK centers. Patients with stroke were individually randomized to receive EXTRAS or usual care at discharge from early supported discharge. Five EXTRAS reviews were provided by an early supported discharge team member between one and 18 months, usually by telephone. Reviews consisted of a semi-structured interview assessing progress, rehabilitation needs, and service provision, with goal setting and action planning. The primary outcome was performance in extended activities of daily living (Nottingham EADL Scale) at 24 months post-randomization. The Nottingham EADL Scale is scored 0 to 66, with higher scores indicating better performance in these activities. Cost-effectiveness was estimated using resource utilization costs and Quality Adjusted Life Years. Analyses were intention to treat. Results- Between January 9, 2013 and October 26, 2015, 573 participants were randomized (EXTRAS, n=285; usual care, n=288). Mean 24 month Nottingham EADL Scale scores were EXTRAS (n=219) 40.0 (SD 18.1) and usual care (n=231) 37.2 (SD 18.5) giving an adjusted mean difference of 1.8 (95% CI, -0.7 to 4.2). 1155/1338 (86%) of expected EXTRAS reviews were undertaken. Over 24 months, the mean cost of resource utilization was lower in the intervention group: -£311 (-$450 [95% CI, -£3292 to £2787; -$4764 to $4033]). EXTRAS provided more Quality Adjusted Life Years (0.07 [95% CI, 0.01 to 0.12]). At current conventional thresholds of willingness to pay (£20 000 [$28 940] per Quality Adjusted Life Years), there was a 90% chance that EXTRAS could be considered cost-effective. Conclusions- EXTRAS did not significantly improve stroke survivors' performance in extended activities of daily living. However, given the impact on costs and Quality Adjusted Life Years, EXTRAS may be an affordable addition to improve stroke care. Clinical Trial Registration- URL: www.isrctn.com. Unique identifier: ISRCTN45203373.

Clinical and cost effectiveness of memory rehabilitation following traumatic brain injury: a pragmatic cluster randomized controlled trial.

OBJECTIVE: To evaluate the clinical and cost effectiveness of a group-based memory rehabilitation programme for people with traumatic brain injury. DESIGN: Multicentre, pragmatic, observer-blinded, randomized controlled trial in England. SETTING: Community. PARTICIPANTS: People with memory problems following traumatic brain injury, aged 18-69 years, able to travel to group sessions, communicate in English, and give consent. INTERVENTIONS: A total of 10 weekly group sessions of manualized memory rehabilitation plus usual care (intervention) vs. usual care alone (control). MAIN MEASURES: The primary outcome was the patient-reported Everyday Memory Questionnaire (EMQ-p) at six months post randomization. Secondary outcomes were assessed at 6 and 12 months post randomization. RESULTS: We randomized 328 participants. There were no clinically important differences in the primary outcome between arms at six-month follow-up (mean EMQ-p score: 38.8 (SD 26.1) in intervention and 44.1 (SD 24.6) in control arms, adjusted difference in means: -2.1, 95% confidence interval (CI): -6.7 to 2.5, p = 0.37) or 12-month follow-up. Objectively assessed memory ability favoured the memory rehabilitation arm at the 6-month, but not at the 12-month outcome. There were no between-arm differences in mood, experience of brain injury, or relative/friend assessment of patient's everyday memory outcomes, but goal attainment scores favoured the memory rehabilitation arm at both outcome time points. Health economic analyses suggested that the intervention was unlikely to be cost effective. No safety concerns were raised. CONCLUSION: This memory rehabilitation programme did not lead to reduced forgetting in daily life for a heterogeneous sample of people with traumatic brain injury. Further research will need to examine who benefits most from such interventions.

Hearing impairment and daily-life fatigue: a qualitative study.

Objective: Hearing impairment is linked to increased fatigue, yet little is known about the real-world impact of this fatigue. This qualitative study investigated the experience of daily-life fatigue in people with a hearing impairment. Design: Individual face-to-face semi-structured interviews were conducted. Thematic analysis was then used to analyse the data. Study sample: Fourteen hearing impaired participants (aged 44-70 years) who varied in terms of hearing loss, hearing aid status, age and gender. Results: The themes and sub-themes that emerged from the transcripts were: Fatigue (effort-driven fatigue, emotion-driven fatigue, breaks and recovery, the perceived relationship between hearing impairment and fatigue, and sleep), Effort (cognitive effort and physical effort), Coping Strategies (withdrawal, avoidance and planning), Relationships and Emotions, Hearing Aid Impact. Conclusions: The study highlights that hearing impairment-related fatigue is experienced by many but not all, and to different extents. Hearing aids were weakly linked to a beneficial effect on fatigue. In addition to the more widely researched effort-driven fatigue, participants described fatigue linked to the negative emotions related to having a hearing impairment. These findings, in conjunction with the widespread utilisation of different coping strategies, demonstrate that the experience of fatigue is varied and likely dependent on personal factors and lifestyle.

Effectiveness of cognitive rehabilitation for people with multiple sclerosis: a meta-synthesis of patient perspectives.

While previous randomised controlled trials and meta-analyses offer only limited evidence for the effectiveness of cognitive rehabilitation, qualitative studies examining patient perspectives report more positive outcomes. This meta-synthesis of qualitative studies examined patient perspectives of cognitive rehabilitation for memory, attention, and executive function problems in people with multiple sclerosis. Using set eligibility criteria, we screened electronic databases, reference lists, and academic networks for relevant papers. Seven papers (195 participants) were selected. Two independent researchers conducted quality appraisals of papers. Data analysis, guided by the thematic synthesis approach, yielded six main themes. These suggested that patients benefitted from the group environment in rehabilitation. Cognitive rehabilitation facilitated the participants' reflection and awareness of their cognitive deficits, and was associated with increased knowledge and understanding of their illness. Increased strategy use was reported and associated with improvements in cognitive functioning and greater confidence and perseverance. Participants reported emotional and social improvements, and felt more optimistic. Overall, these changes had a positive impact on participants' quality of life. This synthesis of qualitative studies indicates that people with multiple sclerosis who experience cognitive deficits benefit from cognitive rehabilitation programmes. This finding must, however, be viewed in light of the limitations of this meta-synthesis. The meta-synthesis was registered in the PROSPERO database under CRD42017040148.

Managing Employees Undergoing Total Hip and Knee Replacement: Experiences of Workplace Representatives.

Introduction There is little research on return to work (RTW) from a workplace perspective following hip and knee replacement (THR/TKR) despite employers and other workplace personnel having a key role. Our aim was to explore the experiences of individuals in the workplace in managing employees undergoing THR/TKR. Methods Employers and other workplace representatives from a cross-section of employment sectors and sizes, with experience of managing employees undergoing THR/TKR in the previous 12 months, were recruited. Interviewees included small business owners, line managers, colleagues, human resources managers and occupational health advisers. Semi-structured, qualitative interviews were conducted and data were analysed thematically. Results Twenty-five individuals were interviewed. The main themes identified were accommodating the employee, and barriers and facilitators to RTW. Accommodations included changes to the work environment, amended duties, altered hours, changed roles and colleague support. Perceived barriers and facilitators to RTW included the role of GPs and occupational health, surgical issues, characteristics of the work environment and of employees. Conclusions Employers are motivated to effect supported RTW for employees undergoing THR/TKR but have insufficient guidance. Strategies are required to signpost employers to existing RTW advice, and to develop recommendations specific to lower limb arthroplasty. Communication between medical practitioners and employers should be facilitated in order to enhance the RTW experience of individuals undergoing THR/TKR.

Assessment and management of cognitive problems in people with multiple sclerosis: A National Survey of Clinical Practice.

BACKGROUND: People diagnosed with multiple sclerosis often have cognitive problems. However, it is unclear how cognitive impairment is currently assessed and managed in the UK. AIM: The aim of this study was to understand the current clinical practice of assessment and management of cognitive impairment in people with MS and to highlight any national variation. METHODS: A survey was posted to 150 MS centres and large hospitals and an online version was shared via email and on social media. RESULTS: Responses were analysed from 109 healthcare professionals. Approximately 59% (n = 64) reported that they used cognitive assessment tools: the Montreal Cognitive Assessment (MoCA) was the most widely used. Assessments were usually done by occupational therapists (55%; n = 60) or clinical neuropsychologist and psychologists (38%; n = 41); 49% (n = 53) of respondents developed and implemented a cognitive rehabilitation plan when the assessment indicated that patients had cognitive problems; 16% (n = 17) indicated that they would refer patients to specialist cognitive rehabilitation for symptom management; 3% (n = 3) followed a manual when providing a cognitive rehabilitation programme. CONCLUSIONS: Clinical pathways for assessing and managing cognitive problems vary and are dependent on the individual expertise of health professionals, available resources, and access to specialist services. Although healthcare professionals highlight the importance of assessment and management, cognitive rehabilitation programmes are not routinely offered in the UK.

Reporting interventions in trials evaluating cognitive rehabilitation in people with multiple sclerosis: a systematic review.

OBJECTIVE: To determine the quantity and quality of description of cognitive rehabilitation for cognitive deficits in people with multiple sclerosis, using a variety of published checklists, and suggest ways of improving the reporting of these interventions. DATA SOURCES: A total of 10 electronic databases were searched, including MEDLINE, EMBASE, CINAHL and PsycINFO, from inception to May 2017. Grey literature databases, trial registers, reference lists and author citations were also searched. REVIEW METHODS: Papers were included if participants were people with multiple sclerosis aged 18 years and over and if the effectiveness of cognitive rehabilitation in improving functional ability for memory, attention or executive dysfunction, with or without a control group, was being evaluated. RESULTS: A total of 54 studies were included in this review. The reporting of a number of key aspects of cognitive rehabilitation was poor. This was particularly in relation to content of interventions (reported completely in 26 of the 54 studies), intervention procedures (reported completely in 16 of the 54 studies), delivery mode (reported completely in 24 of the 54 studies) and intervention mechanism of action (reported completely in 21 of the 54 studies). CONCLUSION: The quality of reporting of cognitive rehabilitation for memory, attention and executive function for multiple sclerosis, across a range of study designs, is poor. Existing reporting checklists do not adequately cover aspects relevant to cognitive rehabilitation, such as the approaches used to address cognitive deficits. Future checklists could consider these aspects we have identified in this review.

Why do stroke survivors not receive recommended amounts of active therapy? Findings from the ReAcT study, a mixed-methods case-study evaluation in eight stroke units.

OBJECTIVE: To identify why the National Clinical Guideline recommendation of 45 minutes of each appropriate therapy daily is not met in many English stroke units. DESIGN: Mixed-methods case-study evaluation, including modified process mapping, non-participant observations of service organisation and therapy delivery, documentary analysis and semi-structured interviews. SETTING: Eight stroke units in four English regions. SUBJECTS: Seventy-seven patients with stroke, 53 carers and 197 stroke unit staff were observed; 49 patients, 50 carers and 131 staff participants were interviewed. RESULTS: Over 1000 hours of non-participant observations and 433 patient-specific therapy observations were undertaken. The most significant factor influencing amount and frequency of therapy provided was the time therapists routinely spent, individually and collectively, in information exchange. Patient factors, including fatigue and tolerance influenced therapists' decisions about frequency and intensity, typically resulting in adaptation of therapy rather than no provision. Limited use of individual patient therapy timetables was evident. Therapist staffing levels were associated with differences in therapy provision but were not the main determinant of intensity and frequency. Few therapists demonstrated understanding of the evidence underpinning recommendations for increased therapy frequency and intensity. Units delivering more therapy had undertaken patient-focused reorganisation of therapists' working practices, enabling them to provide therapy consistent with guideline recommendations. CONCLUSION: Time spent in information exchange impacted on therapy provision in stroke units. Reorganisation of therapists' work improved alignment with guidelines.

Development of an occupational advice intervention for patients undergoing lower limb arthroplasty (the OPAL study).

BACKGROUND: There are an increasing number of patients of working age undergoing hip and knee replacements. Currently there is variation in the advice and support given about sickness absence, recovery to usual activities and return to work after these procedures. Earlier, sustainable, return to work improves the health of patients and benefits their employers and society. An intervention that encourages and supports early recovery to usual activities, including work, has the potential to reduce the health and socioeconomic burden of hip and knee replacements. METHODS/DESIGN: A two-phase research programme delivered over 27 months will be used to develop and subsequently test the feasibility of an occupational advice intervention to facilitate return to work and usual activities in patients undergoing lower limb arthroplasty. The 2 phases will incorporate a six-stage intervention mapping process: Phase 1: Intervention mapping stages 1-3: 1 Needs assessment (including rapid evidence synthesis, prospective cohort analysis and structured stakeholder interviews) 2 Identification of intended outcomes and performance objectives 3 Selection of theory-based methods and practical strategies Phase 2: Intervention mapping stages 4-6: 4 Development of components and materials for the occupational advice intervention using a modified Delphi process 5 Adoption and implementation of the intervention 6 Evaluation and feasibility testing The study will be undertaken in four National Health Service (NHS) hospitals in the United Kingdom and two Higher Education Institutions. DISCUSSION: OPAL (Occupational advice for Patients undergoing Arthroplasty of the Lower limb) aims to develop an occupational advice intervention to support early recovery to usual activities including work, which is tailored to the requirements of patients undergoing hip and knee replacements. The developed intervention will then be assessed with a specific focus on evaluating its feasibility as a potential trial intervention to improve speed of recovery to usual activities including work. TRIAL REGISTRATION: The study was registered retrospectively with the International Standard Randomised Controlled Trials Number (ISRCTN): 27426982 (Date 20/12/2016) and the International prospective register of systematic reviews (PROSPERO): CRD42016045235 (Date 04/08/2016).

Occupational therapy for adults with problems in activities of daily living after stroke.

BACKGROUND: A stroke occurs when the blood supply to part of the brain is cut off. Activities of daily living (ADL) are daily home-based activities that people carry out to maintain health and well-being. ADLs include the ability to: eat and drink unassisted, move, go to the toilet, carry out personal hygiene tasks, dress unassisted, and groom. Stroke causes impairment-related functional limitations that may result in difficulties participating in ADLs independent of supervision, direction, or physical assistance.For adults with stroke, the goal of occupational therapy is to improve their ability to carry out activities of daily living. Strategies used by occupational therapists include assessment, treatment, adaptive techniques, assistive technology, and environmental adaptations. This is an update of the Cochrane review first published in 2006. OBJECTIVES: To assess the effects of occupational therapy interventions on the functional ability of adults with stroke in the domain of activities of daily living, compared with no intervention or standard care/practice. SEARCH METHODS: For this update, we searched the Cochrane Stroke Group Trials Register (last searched 30 January 2017), the Cochrane Controlled Trials Register (The Cochrane Library, January 2017), MEDLINE (1946 to 5 January 2017), Embase (1974 to 5 January 2017), CINAHL (1937 to January 2017), PsycINFO (1806 to 2 November 2016), AMED (1985 to 1 November 2016), and Web of Science (1900 to 6 January 2017). We also searched grey literature and clinical trials registers. SELECTION CRITERIA: We identified randomised controlled trials of an occupational therapy intervention (compared with no intervention or standard care/practice) where people with stroke practiced activities of daily living, or where performance in activities of daily living was the focus of the occupational therapy intervention. DATA COLLECTION AND ANALYSIS: Two review authors independently selected trials, assessed risk of bias, and extracted data for prespecified outcomes. The primary outcomes were the proportion of participants who had deteriorated or were dependent in personal activities of daily living and performance in activities of daily living at the end of follow-up. MAIN RESULTS: We included nine studies with 994 participants in this update. Occupational therapy targeted towards activities of daily living after stroke increased performance scores (standardised mean difference (SMD) 0.17, 95% confidence interval (CI) 0.03 to 0.31, P = 0.02; 7 studies; 749 participants; low-quality evidence) and reduced the risk of poor outcome (death, deterioration or dependency in personal activities of daily living) (odds ratio (OR) 0.71, 95% CI 0.52 to 0.96; P = 0.03; 5 studies; 771 participants; low-quality evidence). We also found that those who received occupational therapy were more independent in extended activities of daily living (OR 0.22 (95% CI 0.07 to 0.37); P = 0.005; 5 studies; 665 participants; low-quality evidence). Occupational therapy did not influence mortality (OR: 1.02 (95% CI 0.65 to 1.61); P = 0.93; 8 studies; 950 participants), or reduce the combined odds of death and institutionalisation (OR 0.89 (95% CI 0.60 to 1.32); P = 0.55; 4 studies; 671 participants), or death and dependency (OR 0.89 (95% CI 0.64 to 1.23); P = 0.47; 4 trials; 659 participants). Occupational therapy did not improve mood or distress scores (OR 0.08 (95% CI -0.09 to 0.26); P = 0.35; 4 studies; 519 participants; low-quality evidence). There were insufficient data to determine the effects of occupational therapy on health-related quality of life. We found no studies of consenting carers prior to study participation and therefore there were no carer-related outcomes in our review. There were insufficient data to determine participants' and carers' satisfaction with services.Using GRADE, the quality of evidence was low. The major limitation was the number of studies at unclear risk of selection bias and an inevitable high risk of performance and detection bias, as both participants and occupational therapists could not be blinded to the intervention. In addition, there was a sparseness of data for our outcomes of interest and we downgraded the quality of our evidence for these reasons. AUTHORS' CONCLUSIONS: We found low-quality evidence that occupational therapy targeted towards activities of daily living after stroke can improve performance in activities of daily living and reduce the risk of deterioration in these abilities. Because the included studies had methodological flaws, this research does not provide a reliable indication of the likely effect of occupational therapy for adults with stroke.