Examining the effectiveness of the Gateway conditional caution on health and well-being of young adults committing low-level offences: a randomised controlled trial.

BACKGROUND: Young adults who commit low-level offences commonly have a range of health and social needs and are significantly over-represented in the criminal justice system. These young adults may need to attend court and potentially receive penalties including imprisonment. Alternative routes exist, which can help address the underlying causes of offending. Some feel more should be done to help young adults entering the criminal justice system. The Gateway programme was a type of out-of-court disposal developed by Hampshire Constabulary, which aimed to address the complex needs of young adults who commit low-level crimes. This study aimed to evaluate the effectiveness and cost-effectiveness of the Gateway programme, issued as a conditional caution, compared with usual process. METHODS: The Gateway study was a pragmatic, parallel-group, superiority randomised controlled trial that recruited young adults who had committed a low-level offence from four sites covering Hampshire and Isle of Wight. The primary outcome was mental health and well-being measured using the Warwick-Edinburgh Mental Well-being Scale. Secondary outcomes were quality of life, alcohol and drug use, and recidivism. Outcomes were measured at 4, 16 and 52 weeks postrandomisation. RESULTS: Due to issues with retention of participants and low data collection rates, recruitment ended early, with 191 eligible participants randomised (Gateway 109; usual process 82). The primary outcome was obtained for 93 (48.7%) participants at 4 weeks, 93 (48.7%) at 16 weeks and 43 (22.5%) at 1 year. The high attrition rates meant that effectiveness could not be assessed as planned. CONCLUSIONS: Gateway is the first trial in a UK police setting to have a health-related primary outcome requiring individual data collection, rather than focusing solely on recidivism. We demonstrated that it is possible to recruit and randomise from the study population, however follow-up rates were low. Further work is needed to identify ways to facilitate engagement between researchers and vulnerable populations to collect data. TRIAL REGISTRATION NUMBER: ISRCTN11888938.

Student-resourced service delivery of occupational therapy rehabilitation groups: patient, clinician and student perspectives about the ingredients for success.

BACKGROUND: A number of innovative models of student practice placements are emerging due to pressures on universities to provide quality practice placements and on health services to deliver rehabilitation efficiently, safely and cost-effectively. The student-resourced service delivery (SRSD) group program is one such model in occupational therapy. There is a paucity of research evidence to guide services in planning, implementing and evaluating the SRSD model. OBJECTIVE: The study aimed to explore and identify the factors that key stakeholders perceived as contributing to the successful development and implementation of the occupational therapy student-resourced service delivery group programs. METHODS: Participants in this multi-site study were rehabilitation inpatients, clinicians, Clinical Education Liaison Managers and students completing practice placement in the student-resourced service delivery group program. Data were collected using face-to-face semi-structured interviews and focus groups. RESULTS: A total of 83 participants consented to the study. Four themes emerged from the data. Planning needs to be an iterative process that commences before and continues during the program. Support processes need to be established for students and clinicians during and across placements. The creation of an engaging, client-relevant and graded group dynamic is critical for success. Establishing a culture whereby groups are valued by the clients, therapy and multidisciplinary teams is important. CONCLUSIONS: The above-mentioned factors were perceived as contributing to successful operationalisation of a student-resourced service delivery group program, and may be helpful when developing student-resourced service delivery professional practice placements in other settings.IMPLICATIONS FOR REHABILITATIONStudent-resourced service delivery of groups are one way to achieve additional professional practice placements for students and delivery of therapy services for patients.Ongoing investment for planning and preparation, provision of continual support for students, a culture of valuing groups and students, and creating a group dynamic that engages group participants were perceived by stakeholders as key ingredients for successful implementation of the student-resourced service delivery group model.Clinicians and educators are encouraged to use the perceived success factors identified in this study as a resource for future student-resourced service delivery program development.

Comparison of online awareness and error behaviour during occupational performance by two individuals with traumatic brain injury and matched controls.

BACKGROUND: Online awareness and error behaviour has largely been studied using computer-based tests or prescribed functional tasks in participants with traumatic brain injury (TBI). OBJECTIVES: This study aimed to compare online awareness and error behaviour of two participants with TBI with two matched controls during tasks of meaning and importance to the participants with TBI, using an occupation-based online awareness assessment. METHODS: Participants were two males with TBI (aged 22 and 23) and two controls (aged 23 and 27). The participants with TBI identified personally meaningful occupations and performed each task on two consecutive occasions. Performances were video-recorded and assessed by two occupational therapists to measure the frequency of errors, the percent of errors that were self-corrected, and the types of error behaviours observed. RESULTS: The participants with TBI demonstrated more frequent errors and poorer self-correction of errors compared to controls. Control participants made greater improvements in error frequency and self-correction with practice, and demonstrated a narrower range of error behaviours. CONCLUSIONS: This study builds upon previous research, by utilising an individualised, occupation-based approach to assess error behaviour and online awareness.

An occupation-based, metacognitive approach to assessing error performance and online awareness.

BACKGROUND/AIM: Online awareness is the ability to self-monitor, identify and self-correct errors while engaged in an activity. Current assessments of online awareness involve observing and classifying error behaviour during structured, uniform tasks. However, during rehabilitation, practitioners typically work towards improving performance in individually meaningful tasks unique to the client. This article presents a metacognitive, task analytic approach to assessing online awareness involving observation and classification of errors during meaningful occupations determined after client-centred goal setting with two male clients with severe traumatic brain injury (aged 22 and 23). Study aims were to describe the approach, evaluate its feasibility and determine inter-rater agreement for error detection and error categorisation by two experienced occupational therapists. Furthermore, the error profiles and cognitive impairments of the participants on standardised neuropsychological assessment were examined to explore the validity of the assessment. METHODS: Individualised assessment tasks included snack preparation, budgeting, timetabling, hot-drink preparation and use of a computer program, which were administered repeatedly over two to three months and audio-visual recordings taken. Independent ratings of two trained occupational therapists were compared using exact percent agreement. RESULTS: Overall agreement about errors was 76%, for which there was 65% agreement about error categorisation and 100% agreement about error correction. CONCLUSIONS: There was fair inter-rater agreement between two trained occupational therapists of error behaviour and error correction when using the described occupation-based approach to assessing online awareness. This approach has promise, particularly when combined with standardised, neuropsychological assessments, for providing an in-depth understanding of error behaviour and awareness of errors during meaningful occupations.

Individualised resting hand splints for adults with acquired brain injury: a randomized, single blinded, single case design.

AIM: To evaluate the effect of individualized resting mitt splints on hypertonicity (spasticity and tissue stiffness) and passive range of motion (PROM). METHODS: A randomized, single blinded, single case design. Ten adults with acquired brain injury were randomized to control (no-splint) and experimental (splint) groups. The experimental group received an individualized (wrist position, wearing schedule) thermoplastic resting mitt splint. Measures included wrist and finger PROM, muscle stiffness (Modified Ashworth Scale), and spasticity (Modified Tardieu Scale) which were taken at five time points. RESULTS: Between-group analyses indicated a statistically significant effect on PROM at the wrist (d = 2.14, CI95 = 0.57, 3.72, p < 0.05) and clinically important effects on finger PROM, and wrist and finger spasticity and stiffness. Within-group analyses indicated that splint-wear resulted in positive clinical effects ranging from zero effect (maintenance of pre-splinting status) to a large positive treatment effect. Non splint-wear resulted in negative clinical effects ranging from zero effect to a large negative treatment effect. CONCLUSION: Individualized resting splints for adults with moderate hypertonicity and no soft tissue contracture resulted in positive clinical effects to PROM, muscle stiffness and spasticity. Long-term splint-wear may be more beneficial than short-term wear, and may prevent the negative changes evident with no splint-wear. Resting hand splints should be considered for a select group where reduction in muscle stiffness and spasticity, or maintenance of PROM, is desired.

Randomized controlled trial of daily total end range time (TERT) for Capener splinting of the stiff proximal interphalangeal joint.

OBJECTIVE: Capener splinting is a common treatment for extension deficit of the proximal interphalangeal (PIP) joint. This study compared the effect of daily splint total end range time (TERT) of 6-12 hr versus 12-16 hr. METHOD: Twenty-two participants with extension deficits of the PIP joint were randomly allocated to a daily TERT of 6-12 hr or 12-16 hr. Progress after 8 wk of splinting was evaluated. RESULTS: No significant difference was found in change in extension range of motion (ROM) between groups (active ROM, F[4, 17] = 2.19, p = .13; passive ROM, F[4, 17] = 0.95, p = .46; torque ROM, F[4, 17] = 1.49, p = .26). Considerable crossover between groups resulted in a similar average daily TERT (9.5 hr for the 6-12 hr group vs. 11.5 hr for the 12-16 hr group). CONCLUSION: Further research with a larger sample is needed to determine whether longer daily TERT is beneficial. Our results suggest, however, that most patients find it difficult to wear splints >12 hr/day.

The Long-term relationship between duration of treatment and contracture resolution using dynamic orthotic devices for the stiff proximal interphalangeal joint: a prospective cohort study.

STUDY DESIGN: Descriptive design with a prospective cohort. INTRODUCTION: Little is known about the long-term relationship between the duration of treatment using dynamic orthoses (splints), and contracture resolution in the stiff proximal interphalangeal (PIP) joint. PURPOSE OF THE STUDY: To examine the long-term relationship between weeks of treatment using dynamic orthoses and contracture resolution, in both flexion and extension deficits of the PIP joint. METHODS: Forty-one participants were treated with a dynamic orthotic device (splint) for either a flexion or extension deficit of the PIP joint (n=48 joints). The relationship between contracture resolution and weeks of treatment was examined controlling for baseline range of motion (ROM), weekly total end range time, pretreatment joint stiffness, time since injury, and diagnosis. Outcome was measured via change in torque and active ROM. RESULTS: Outcome with orthotic use was significantly associated with the weeks of treatment (p<0.001). ROM increased in a linear fashion although faster progress was observed when treatment was aimed at improving flexion rather than extension. Flexion deficits appeared to maximize gains with orthotic treatment after 12 weeks. However, extension deficits continued to demonstrate slow and continuous improvement beyond the 17 weeks of recorded data. Less treatment duration (in weeks) was needed to restore flexion than extension. CONCLUSIONS: The duration of orthotic use (weeks of treatment) is significantly associated with the extent of contracture resolution. Slower recovery of ROM and a longer duration of orthotic use may be expected when the treatment goal is to improve extension rather than flexion. LEVEL OF EVIDENCE: 2b.

Dynamic splinting for the stiff hand after trauma: predictors of contracture resolution.

STUDY DESIGN: Prospective cohort. INTRODUCTION: Many variables are believed to influence the success of dynamic splinting, yet their relationship with contracture resolution is unclear. PURPOSE OF THE STUDY: To identify the predictors of outcome with dynamic splinting of the stiff hand after trauma. METHODS: Forty-six participants (56 joints) completed eight weeks of dynamic splinting, and the relationship between 13 clinical variables and outcome was explored. RESULTS: Improvement in passive range of motion, active range of motion (AROM), and torque range of motion averaged 21.8°, 20.0°, and 13.0°, respectively (average daily total end range time, 7.96 hours). Significant predictors included joint stiffness (modified Weeks Test), time since injury, diagnosis, and deficit (flexion/extension). For every degree change in ROM on the modified Weeks Test, AROM improved 1.09° (standard error, 0.2). Test-retest reliability of the modified Weeks Test was high (intraclass correlation coefficient [2, 1]=0.78). CONCLUSIONS: Better progress with dynamic splinting may be expected in joints with less pretreatment stiffness, shorter time since injury (<12 weeks), and in flexion rather than extension deficits. Further research is needed to determine the accuracy with which the modified Weeks Test may predict contracture resolution. LEVEL OF EVIDENCE: 2b.

Mobilizing the stiff hand: combining theory and evidence to improve clinical outcomes.

UNLABELLED: The purpose of this narrative review is to provide a clinically reasonable guide to intervention choices, by combining a sound understanding of theory with available research evidence. The pathology of contracture formation is presented within the context of tissue repair. The soft tissue response to stress is explained and the optimal "dose" of treatment is discussed. The evidence behind the use of exercise, joint mobilization, continuous passive motion, casting motion to mobilize stiffness, and mobilizing splinting is examined. Recommendations regarding treatment implementation and future research needs are highlighted. The importance of mobilizing splinting and exercise as treatment modalities in the management of joint contracture is demonstrated. LEVEL OF EVIDENCE: 5.

"Latte rural": the tangible and intangible factors important in the choice of a rural practice by recent GP graduates.

INTRODUCTION: A large of amount of literature exists on the factors that influence the recruitment and retention of rural general practitioners (GPs) in Australia and other countries. The selection of a rural practice location is known to be influenced by professional, personal and family, community and economic factors. Most of this research has been undertaken on the either the baby boomer generation or their predecessors, and this is likely to have influenced the responses gained. Generation X and Y doctors are known to have a different perception regarding workload, lifestyle and the support required to practise. The aim of this study was to explore, from a Generation X perspective, factors deemed important by general practice graduates in selecting a rural practice at completion of their training. The study also aimed to identify the process general practice graduates use to identify a potential rural practice, and when they commence this process. METHODS: Semi-structured interviews were held with 15 rural pathway general practice registrars in their final year of training with 2 regional training providers in South Australia. The interview topics included source of information on potential practices, their ideal rural practice and community, the process used to select a practice, and when they commenced this process. Phenomenological hermeneutic thematic analysis of interview transcripts was undertaken to identify themes and sub-themes. RESULTS: For an ideal rural practice, registrars wished to work in a practice with a friendly atmosphere, good business structure, support from senior GPs and in close proximity to a hospital. They also wanted reasonable on-call arrangements, the chance to develop further skills (such as anaesthetics or obstetrics) and the freedom to practise according to their interests. They also emphasised the importance of a good team and an ethical practice. In terms of community, registrars wanted a positive living place, access to amenities such as childcare, good schools and the opportunity of work for their spouses. They also appreciated attractions such as the beach, or green farmland. Word of mouth, referrals by colleagues and experience of a practice were the most common approaches to finding a suitable rural practice. The majority of the registrars commenced selection of a rural practice in their last 6 months of training. CONCLUSIONS: Many of the factors identified by the Generation X registrars were similar to those identified by the previous generation. However, they also identified factors such as a positive team environment and practice with good ethics as important. The results can be used to tailor the marketing of rural practices to Generation X general practice registrars.

Patient centered goal-setting in a subacute rehabilitation setting.

PURPOSE: The purpose of this research is to describe current practices in goal-setting within a subacute rehabilitation setting from the perspective of therapists representing the disciplines of occupational therapy, speech pathology and physiotherapy. METHOD: Qualitative semi-structured email interviews were conducted with therapists from the Geriatric Assessment and Rehabilitation Unit of an Australian hospital. Therapists were required to respond to questioning with reference to identified rehabilitation patients with stroke. RESULTS: Three approaches to goal-setting were identified: therapist controlled, therapist led and patient centred. Goals aimed at the ICF levels of impairment and activity limitations were predominant. Barriers to a patient centered goal-setting approach largely outweighed facilitators. Potential successful resolutions were offered to overcome these barriers. CONCLUSIONS: The inability of patients to participate fully in the goal-setting process largely determines the approach taken by therapists. This influences the level of patient centeredness incorporated into the goal-setting process. Goals expressed at the level of impairment, by therapists, may be stepping stones to perceived patient goals at the levels of activity and participation. Barriers to a patient centered approach can be overcome through education of the patient and family regarding the nature of the injury and modification of communication between therapist and patient.

Awareness typologies, long-term emotional adjustment and psychosocial outcomes following acquired brain injury.

Previous research suggests considerable heterogeneity within groups of individuals identified as having low self-awareness or good self-awareness following acquired brain injury (ABI). The present study aimed to identify typologies of individuals according to neuropsychological and psychological factors related to awareness deficits and compare emotional adjustment and psychosocial outcomes at the initial assessment and 12-month follow-up. Eighty-four participants with ABI (mean time since injury = 3.9 years) were assessed on the Self-Awareness of Deficits Interview, Awareness Questionnaire, Symptom Expectancy Checklist, Marlowe-Crowne Social Desirability Scale, Hospital Anxiety Depression Scale, Sydney Psychosocial Reintegration Scale, and an error self-regulation index. A 12-month follow-up assessment of emotional adjustment and psychosocial outcomes was conducted. A hierarchical cluster analysis distinguished four awareness typologies, namely, "poor self-awareness" (n = 12), "high defensiveness" (n = 13), "high symptom reporting" (n = 15), and "good self-awareness" (n = 44). An overall comparison of outcomes indicated that the poor self-awareness and high symptom reporting typologies experienced poorer outcomes than the high defensiveness and good self-awareness typologies. The findings confirm that there are different awareness typologies and highlight the need to tailor interventions according to the nature of awareness deficits.

Australian issues in the provision of after-hours primary medical care services in rural communities.

OBJECTIVE: In 2003 the Rural Doctors Workforce Agency in South Australia (SA) facilitated the 'SA Rural Hospital After Hours Triage Education and Training Program'. It was designed to improve communication between rural general practitioners (GPs) and nurses undertaking after-hours triage, provide training in triage for rural nurses and develop local collaborative after-hours primary medical care models that can be applied in other settings. DESIGN: The program consisted of a series of three workshops. The first workshop provided an opportunity for GPs and nurses to discuss local issues relating to after-hours primary medical care service delivery. This was followed by a one-day workshop on triage for nurses. A follow-up refresher workshop was conducted approximately six months later. SETTING: Twenty-three rural communities in SA. PARTICIPANTS: Rural GPs and nurses working in rural communities. RESULTS: This paper reports on the issues highlighted by clinicians in providing after-hours primary medical care in rural and remote communities. These included community expectations, systems of care, scope of practice, private practice/public hospital interface, and medico legal issues. CONCLUSION: The issues facing after-hours health services in rural communities are not new. There are many opportunities for improvement of systems. A formal program including workshops and training has provided a useful forum to commence service improvements.

A metacognitive contextual intervention to enhance error awareness and functional outcome following traumatic brain injury: a single-case experimental design.

Very few empirically validated interventions for improving metacognitive skills (i.e., self-awareness and self-regulation) and functional outcomes have been reported. This single-case experimental study presents JM, a 36-year-old man with a very severe traumatic brain injury (TBI) who demonstrated long-term awareness deficits. Treatment at four years post-injury involved a metacognitive contextual intervention based on a conceptualization of neuro-cognitive, psychological, and socio-environmental factors contributing to his awareness deficits. The 16-week intervention targeted error awareness and self-correction in two real life settings: (a) cooking at home; and (b) volunteer work. Outcome measures included behavioral observation of error behavior and standardized awareness measures. Relative to baseline performance in the cooking setting, JM demonstrated a 44% reduction in error frequency and increased self-correction. Although no spontaneous generalization was evident in the volunteer work setting, specific training in this environment led to a 39% decrease in errors. JM later gained paid employment and received brief metacognitive training in his work environment. JM's global self-knowledge of deficits assessed by self-report was unchanged after the program. Overall, the study provides preliminary support for a metacognitive contextual approach to improve error awareness and functional outcome in real life settings.