First Contact Physiotherapy: An evaluation of clinical effectiveness and costs.

BACKGROUND: First Contact Physiotherapy Practitioners (FCPPs) are embedded within general practice, providing expert assessment, diagnosis and management plans for patients with musculoskeletal disorders (MSKDs), without the prior need for GP consultation. AIM: To determine the clinical effectiveness and costs of FCPP-led compared to GP-led models of care. DESIGN AND SETTING: Multiple site case study design. UK GP practices. METHOD: General Practice sites were recruited representing three models: 1. GP-led care; 2. FCPPs who could not prescribe/inject (Standard (St)); 3. FCPPs who could prescribe/inject (Additional Qualifications (AQ)). Patient participants from each site completed clinical outcome data at baseline, 3 and 6 months. The primary outcome was the SF-36v.2 Physical Component Score (PCS). Healthcare usage was collected for 6 months. RESULTS: N=426 adults were recruited from 46 practices across the UK. Non-inferiority analysis showed no significant difference in physical function (SF36-PCS) across all three arms at 6 months (p=0.999). At 3 months a significant difference in numbers improving was seen between arms: 54.7% GP consultees; 72.4% FCPP-St, 66.4% FCPP-AQ; (p=0.037). No safety issues were identified. Following initial consultation, a greater proportion of patients received medication (including opioids) in the GP-led arm (44.7%) compared with FCPP-St (17.5%) and FCPP-AQ (22.8%); (p<0.001). NHS costs (initial consultation and over 6 months follow up) were significantly higher in the GP-led model (median £105.50) vs FCPP-St (£41) and FCPP-AQ (£44); (p<0.001). CONCLUSION: FCPP led models provide safe, clinically effective and cost-beneficial management for patients with MSKDs in general practice and reduced opioid use in this cohort.

Randomised pragmatic waitlist trial with process evaluation investigating the effectiveness of peer support after brain injury: protocol.

INTRODUCTION: Traumatic brain injury (TBI) is an important global health problem. Formal service provision fails to address the ongoing needs of people with TBI and their family in the context of a social and relational process of learning to live with and adapt to life after TBI. Our feasibility study reported peer support after TBI is acceptable to both mentors and mentees with reported benefits indicating a high potential for effectiveness and likelihood of improving outcomes for both mentees and their mentors. OBJECTIVES: To (a) test the effectiveness of a peer support intervention for improving participation, health and well-being outcomes after TBI and (b) determine key process variables relating to intervention, context and implementation to underpin an evidence-based framework for ongoing service provision. METHODS AND ANALYSIS: A randomised pragmatic waitlist trial with process evaluation. Mentee participants (n=46) will be included if they have moderate or severe TBI and are no more than 18 months post-injury. Mentor participants (n=18) will be people with TBI up to 6 years after injury, who were discharged from inpatient rehabilitation at least 1 year prior. The primary outcome will be mentee participation, measured using the Impact on Participation and Autonomy questionnaire after 22 weeks. Primary analysis of the continuous variables will be analysis of covariance with baseline measurement as a covariate and randomised treatment as the main explanatory predictor variable at 22 weeks. Process evaluation will include analysis of intervention-related data and qualitative data collected from mentors and service coordinators. Data synthesis will inform the development of a service framework for future implementation. ETHICS AND DISSEMINATION: Ethics approval has been obtained from the New Zealand Health and Disability Ethics Committee (19/NTB/82) and Auckland University of Technology Ethics Committee (19/345). Dissemination of findings will be via traditional academic routes including publication in internationally recognised peer-reviewed journals. TRIAL REGISTRATION NUMBER: ACTRN12619001002178.

Benefits of realist evaluation for rapidly changing health service delivery.

Realist evaluation is a methodology that addresses the questions: 'what works, for whom, in which circumstances, and how?'. In this approach, programme theories are developed and tested against available evidence. However, when complex interventions are implemented in rapidly changing environments, there are many unpredictable forces that determine the programme's scope and architecture, as well as resultant outcome. These forces can be theorised, in real time, and included in realist evaluation outputs for current and future optimisation of programmes. Reflecting on a realist evaluation of first-contact physiotherapy in primary care (the FRONTIER Study), five important considerations are described for improving the quality of realist evaluation outputs when studying rapidly changing health service delivery. These are: (1) ensuring that initial programme theories are developed through creative thinking sessions, empirical and non-empirical literature, and stakeholder consultation; (2) testing the causal impact of formal and informal (eg, emergent) components of service delivery models; (3) contrasting initial programme theories with rival theory statements; (4) envisioning broad system impacts beyond the immediate implementation setting; and (5) incorporating rapidly evolving service developments and context changes into the theory testing process in real-time (eg, Additional Role Reimbursement Scheme, COVID-19). Through the reflections presented, the aim is to clarify the benefit of realist evaluation to assess emerging models of care and rapidly changing health service delivery.

Design considerations for a multiple sclerosis fatigue mobile app MS Energize: A pragmatic iterative approach using usability testing and resonance checks.

Multiple sclerosis (MS) is a chronic neurological condition affecting around 2.2 million people worldwide. The illness includes a range of symptoms, with fatigue considered to be one of the most disabling. This paper describes how a pragmatic and iterative approach, supported by usability and resonance testing, was used to build a minimum viable product of MS Energize-or MS Energise in UK English regions. MS Energise is a mobile application focused on self-management of fatigue for people with MS. The iterative approach included various stages of testing, during which user feedback including comments about interface, navigation and content, was sought to inform incremental app development and continual improvement. Usability testing was conducted with 11 people with longstanding multiple sclerosis in New Zealand and the United Kingdom, and focused on particular sections of the app as well as the accessibility of the app to users with MS. Two participants contributed to further resonance testing post-release to ensure the app was perceived as relevant and useful to the user. The usability testing and resonance testing phases suggested that user experience of MS Energise was mostly positive. Participants provided a number of suggestions for improvements to aspects of content and design; some of which we implemented during our app development process. Findings will also contribute to future planning and design iteration to enhance the user experience. The next step is further improvement of MS Energise prior to a trial of its clinical and cost effectiveness.

Collegial surface acting emotional labour, burnout and intention to leave in novice and pre-retirement nurses in the United Kingdom: A cross-sectional study.

Aim: To investigate the relationship between surface and deep acting in nurses' patient-focused and collegial emotional labour, with emotional exhaustion, depersonalization and personal accomplishment and intention to leave. Design: A cross-sectional descriptive study using the Emotional Labour Scale, the Maslach Burnout Inventory and intention to leave Yes/No questions with 118 Registered Nurses to measure patient-focused and collegial emotional labour, burnout and intention to leave. Results: Surface acting in patient-focused and collegial emotional labour was found to have positive associations with burnout and intention to leave their current job. Only surface acting in patient-focused emotional labour was positively associated with intention to leave the organization and/or the profession. The novice nurses carried out more deep acting collegial emotional labour than the pre-retirement nurses. Conclusions: Collegial emotional labour is significant to nurses' intention to leave their current job but not their intention to leave the organization and/or the profession.

Developing clinical expertise in musculoskeletal physiotherapy; Using observed practice to create a valued practice-based collaborative learning cycle.

BACKGROUND: Observed clinical practice is a commonly used approach to develop clinical expertise in the musculoskeletal (MSK) physiotherapy workforce. The value of this approach is not known. OBJECTIVES: To understand how regular observed clinical practice is considered to support the development of MSK physiotherapy clinical expertise in one UK organisation who adopts this approach to practice-based education. DESIGN: A qualitative, constructivist grounded theory study. METHOD: Eight initial individual interviews were undertaken with MSK physiotherapists engaged in this approach to practice-based education. Secondary interviews were completed with two participants. A focus group concluded data generation. Data were analysed using a three-stage constant comparative process. FINDINGS: Regular observed clinical practice was found to facilitate the development of clinical expertise by enabling a valued practice-based collaborative learning cycle. Three essential elements were identified: PRECURSORY REQUIREMENTS: Mentors are required to reflect on their own successful experiences of clinical development and consider their professional moral responsibility to develop the future workforce. LEARNING ACTIVITY: Observed clinical practice situated in the workplace can successfully facilitate clinical expertise development. Whole-team involvement adds further value. SUBSEQUENT REQUIREMENTS: Successful learning outcomes are achieved when mentor and learner engage in collaborative reflection and analysis soon after the observed practice. Developing an 'educational alliance', sharing fallibilities, adopting a developmental approach and placing the learner as the 'judge' of the learning experience are important considerations to achieve successful learning outcomes. CONCLUSION: These findings offer a framework to consider when using observed clinical practice to develop the clinical expertise of a MSK physiotherapy workforce.

Predicting Recurrent Instability of the Shoulder (PRIS): A Valid Tool to Predict Which Patients Will Not Have Repeat Shoulder Instability After First-Time Traumatic Anterior Dislocation.

OBJECTIVE: To assess the sensitivity, specificity, and validity of the Predicting Recurrent Instability of the Shoulder (PRIS) tool in people with a first-time traumatic anterior shoulder dislocation. DESIGN: Prospective cohort study. METHODS: People with first-time traumatic anterior shoulder dislocation (n = 85), aged 16 to 40 years, were recruited within 12 weeks of their shoulder dislocation and followed prospectively for 1 year post injury. We calculated the sensitivity, specificity, negative predictive value, and positive predictive value of the PRIS tool. RESULTS: Of the 75 participants available for 1-year follow-up, 57 (76%) did not have recurrent shoulder instability. With the PRIS tool cut point set at 0.895, the tool's sensitivity was 39% (95% confidence interval [CI]: 17.3%, 64.3%) and its specificity was 95% (95% CI: 85.4%, 98.9%). The area under the curve was 0.69 (95% CI: 0.55, 0.84; P = .01). The PRIS tool correctly identified 54 of the 57 (95%) who did not have recurrent instability (accuracy, 81%; 95% CI: 70.7%, 89.4%). Negative and positive predictive values were 83% (95% CI: 77.2%, 87.7%) and 70% (95% CI: 40.2%, 89.0%), respectively. CONCLUSION: The PRIS tool can predict those who will not have further shoulder instability in the year following first-time traumatic anterior shoulder dislocation. The PRIS tool cannot accurately predict those who will have recurrent shoulder instability. J Orthop Sports Phys Ther 2020;50(8):431-437. doi:10.2519/jospt.2020.9284.

Provision of first contact physiotherapy in primary care across the UK: a survey of the service.

BACKGROUND: First Contact Physiotherapy (FCP) is an emerging model of care whereby a specialist physiotherapist located within general practice undertakes the first patient assessment, diagnosis and management without a prior GP consultation. Despite institutional and professional body support for this model and NHS commitment to its implementation, data regarding current FCP provision are limited. OBJECTIVES: To identify current FCP service provision across the UK, including models of provision and key professional capabilities. DESIGN: Cross-sectional online survey, targeting physiotherapists and service managers involved in FCP. METHODS: Recruitment involved non-probability sampling targeting those involved in FCP service provision through emails to members of known clinical networks, snowballing and social media. The survey gathered data about respondents, FCP services and the role and scope of physiotherapists providing FCP. RESULTS: The authors received 102 responses; 32 from service managers and 70 working in FCP practice from England (n=60), Scotland (n=22), Wales (n=14), and Northern Ireland (n=2). Most practitioners were NHS band 7 or 8a (91%, n=63), with additional skills (e.g. requesting investigations, prescribing). 17% (12/70) worked 37.5hours/week; 37% (26/70) ≤10hours; most (71%, 50/70) used 20-minute appointments (range 10-30minutes); varying arrangements were reported for administration and follow-up. Services covered populations of 1200 to 600,000 (75% <100,000); access mostly involved combinations of self-booking and reception triage. Commissioning and funding arrangements varied widely; NHS sources provided 90% of services. CONCLUSIONS: This survey provides new evidence regarding variation in FCP practice across the UK, indicating that evidence-informed, context specific guidance on optimal models of provision is required.

Incidence and outcomes of major trauma in New Zealand: findings from a feasibility study of New Zealand's first national trauma registry.

AIMS: The aim of the study was to pilot the feasibility of long-term outcomes data collection from adult major trauma survivors in New Zealand. This initial paper aims to characterise the New Zealand major trauma population in terms of long-term disability and functional outcomes after major trauma. METHODS: A prospective cohort study of adults who had survived major trauma was conducted between June 2015 and December 2016 at two major trauma centres in Auckland. RESULTS: Of 256 trauma referrals, 112 (44%) were confirmed eligible and consented. One hundred completed the survey at six months and 83 at 12 months. A majority of the study sample were male (72%), under 65 years (84%), with a disproportionally higher number of Maori in the sample (23%). At six months post-injury, the majority of participants were categorised as experiencing either moderate disability (37%) or good recovery (42%). Half of the participants experienced moderate pain at both 6 and 12 months post-injury (50% and 52% respectively), and problems with their usual activities at six months post-injury (51%). CONCLUSIONS: Most study participants made a good recovery, but there was still a large group of people experiencing disability, pain and not in paid employment at 12 months post-injury.

Digitizing a Face-to-Face Group Fatigue Management Program: Exploring the Views of People With Multiple Sclerosis and Health Care Professionals Via Consultation Groups and Interviews.

BACKGROUND: Fatigue is one of the most common and debilitating symptoms of multiple sclerosis (MS) and is the main reason why people with MS stop working early. The MS Society in the United Kingdom funded a randomized controlled trial of FACETS-a face-to-face group-based fatigue management program for people with multiple sclerosis (pwMS)-developed by members of the research team. Given the favorable trial results and to help with implementation, the MS Society supported the design and printing of the FACETS manual and materials and the national delivery of FACETS training courses (designed by the research team) for health care professionals (HCPs). By 2015 more than 1500 pwMS had received the FACETS program, but it is not available in all areas and a face-to-face format may not be suitable for, or appeal to, everyone. For these reasons, the MS Society funded a consultation to explore an alternative Web-based model of service delivery. OBJECTIVE: The aim of this study was to gather views about a Web-based model of service delivery from HCPs who had delivered FACETS and from pwMS who had attended FACETS. METHODS: Telephone consultations were undertaken with FACETS-trained HCPs who had experience of delivering FACETS (n=8). Three face-to-face consultation groups were held with pwMS who had attended the FACETS program: London (n=4), Liverpool (n=4), and Bristol (n=7). The interviews and consultation groups were digitally recorded and transcribed. A thematic analysis was undertaken to identify key themes. Toward the end of the study, a roundtable meeting was held to discuss outcomes from the consultation with representatives from the MS Society, HCPs, and pwMS. RESULTS: Key challenges and opportunities of designing and delivering an integrated Web-based version of FACETS and maintaining user engagement were identified across 7 themes (delivery, online delivery, design, group, engagement, interactivity, and HCP relationships). Particularly of interest were themes related to replicating the group dynamics and the lack of high-quality solutions that would support the FACETS' weekly homework tasks and symptom monitoring and management. CONCLUSIONS: A minimum viable Web-based version of FACETS was suggested as the best starting point for a phased implementation, enabling a solution that could then be added to over time. It was also proposed that a separate study should look to create a free stand-alone digital toolkit focusing on the homework elements of FACETS. This study has commenced with a first version of the toolkit in development involving pwMS throughout the design and build stages to ensure a user-centered solution.

Optimizing the real-world impact of rehabilitation reviews: increasing the relevance and usability of systematic reviews in rehabilitation.

BACKGROUND: Despite a growing portfolio of rehabilitation reviews, uptake of review findings into practice remains slow, with review findings perceived to be lacking in relevance and usability for stakeholders. Key aspects of review design, production and dissemination have been identified to contribute to this knowledge translation (KT) gap. AIM: The aim of this study is to identify strategies relevant to rehabilitation review design, production and dissemination which have the potential to optimize uptake of review findings into practice. RESULTS: Two strategies are discussed, drawing on case examples of existing rehabilitation reviews, including: 1) involving stakeholders in review design, production and dissemination; and 2) moving towards theory-based, mixed methods review design. The merits of these strategies are discussed with reference to the unique and specific characteristics of the rehabilitation context, where there is complexity inherent in the multiple interacting components across population, intervention, context and implementation processes. CONCLUSIONS: Moving towards theory-based, mixed methods reviews which involve stakeholders may be a critical first step in supporting uptake of review findings into rehabilitation practice. Doing so also has the potential to support advances in knowledge and practice in rehabilitation through theory development, as well as creating the context for evidence-based practice.

Who will redislocate his/her shoulder? Predicting recurrent instability following a first traumatic anterior shoulder dislocation.

OBJECTIVE: To develop a multivariate tool that would predict recurrent instability after a first-time traumatic anterior shoulder dislocation. METHODS: Participants (aged 16-40 years) were recruited across New Zealand into a prospective cohort study. Baseline data were collected during a telephone interview and through examination of radiology records. Variables associated with recurrent instability were selected for the multivariate logistic regression model using backwards selection (p<0.10). Coefficients for those variables retained in the model were used to develop the predictive tool. RESULTS: Among the 128 participants, 36% had redislocated at least once in the first 12 months. Univariate analysis showed an increased likelihood of recurrent dislocation with bony Bankart lesions (OR=3.65, 95% CI 1.05 to 12.70, p=0.04) and participants who had: not been immobilised in a sling (OR = 0.38, 95% CI 0.15 to 0.98, p=0.05), higher levels of shoulder activity (OR=1.13, 95% CI 1.01 to 1.27, p=0.03), higher levels of pain and disability (OR=1.03, 95% CI 1.01 to 1.06, p=0.02), higher levels of fear of reinjury (OR=1.12, 95% CI 1.01 to 1.26, p=0.04) and decreased quality of life (OR=1.01, 95% CI 1.00 to 1.02, p=0.05). There was no significant difference in those with non-dominant compared with dominant shoulder dislocations (p=0.10) or in those aged 16-25 years compared with 26-40 years (p=0.07). CONCLUSION: Six of seven physical and psychosocial factors can be used to predict recurrent shoulder instability following a first-time traumatic anterior shoulder dislocation.

Developing a comprehensive framework of community integration for people with acquired brain injury: a conceptual analysis.

PURPOSE: Despite increasing emphasis on the importance of community integration as an outcome for acquired brain injury (ABI), there is still no consensus on the definition of community integration. The aim of this study was to complete a concept analysis of community integration in people with ABI. MATERIALS AND METHODS: The method of concept clarification was used to guide concept analysis of community integration based on a literature review. Articles were included if they explored community integration in people with ABI. Data extraction was performed by the initial coding of (1) the definition of community integration used in the articles, (2) attributes of community integration recognized in the articles' findings, and (3) the process of community integration. This information was synthesized to develop a model of community integration. RESULTS: Thirty-three articles were identified that met the inclusion criteria. The construct of community integration was found to be a non-linear process reflecting recovery over time, sequential goals, and transitions. Community integration was found to encompass six components including: independence, sense of belonging, adjustment, having a place to live, involved in a meaningful occupational activity, and being socially connected into the community. Antecedents to community integration included individual, injury-related, environmental, and societal factors. CONCLUSION: The findings of this concept analysis suggest that the concept of community integration is more diverse than previously recognized. New measures and rehabilitation plans capturing all attributes of community integration are needed in clinical practice. Implications for rehabilitation Understanding of perceptions and lived experiences of people with acquired brain injury through this analysis provides basis to ensure rehabilitation meets patients' needs. This model highlights the need for clinicians to be aware and assess the role of antecedents as well as the attributes of community integration itself to ensure all aspects are addressed in in a manner that will enhance the recovery and improve the level of integration into the community. The finding that community integration is a non-linear process also highlights the need for rehabilitation professionals to review and revise plans over time in response to a person's changing circumstances and recovery journey. This analysis provides the groundwork for an operational model of community integration for the development of a measure of community integration that assesses all six attributes revealed in this review not recognized in previous frameworks.

MS Energize: Field trial of an app for self-management of fatigue for people with multiple sclerosis.

Multiple sclerosis (MS) is a lifelong neurological condition affecting around 2.2 million people worldwide. There are a wide range of symptoms, with fatigue reported as one of the most troublesome. MS Energize-or MS Energise in UK English regions-is an iPhone app focused on self-management of fatigue for people with MS. Based on cognitive-behavioral therapy principles, the app covers MS fatigue, how to use energy effectively, how behavior, thoughts and emotions interact and impact on MS fatigue, as well as the potential effects of bodily and environmental factors. MS Energize provides education, interactive tasks, and supports application of the principles into a user's day-to-day life. We field tested the usability and perceived usefulness of MS Energize with 11 people with longstanding multiple sclerosis in New Zealand and the United Kingdom. Participants used the app over a period of five to six weeks after which they rated the usability of the app and participated in an in-depth qualitative interview. We developed four main themes through our thematic analysis. 1. Validation of participants' own experiences of living with MS fatigue. 2. The personal cost in engaging with such an intervention. 3. Reframing experiences and adding to knowledge. 4. That the app was generally a good idea. Field testers' feedback also identified usability issues that could be addressed. In particular, the amount of text-based content in the app contributed to the app itself being fatiguing. This field-testing process has highlighted the value of the app while also guiding our roadmap for further developments to enhance usability and usefulness. The next step is further refinement of components of MS Energize in preparation for a trial of its clinical and cost effectiveness.

Making sense of recovery after traumatic brain injury through a peer mentoring intervention: a qualitative exploration.

OBJECTIVE: To explore the acceptability of peer mentoring for people with a traumatic brain injury (TBI) in New Zealand. DESIGN: This is a qualitative descriptive study exploring the experiences reported by mentees and mentors taking part in a feasibility study of peer mentoring. Interviews with five mentees and six mentors were carried out. Data were analysed using conventional content analysis. SETTING: The first mentoring session took place predischarge from the rehabilitation unit. The remaining five sessions took place in mentees' homes or community as preferred. PARTICIPANTS: Twelve people with TBI took part: six mentees (with moderate to severe TBI; aged 18-46) paired with six mentors (moderate to severe TBI >12 months previously; aged 21-59). Pairing occurred before mentee discharge from postacute inpatient brain injury rehabilitation. Mentors had been discharged from rehabilitation following a TBI between 1 and 5 years previously. INTERVENTION: The peer mentoring programme consisted of up to six face-to-face sessions between a mentee and a mentor over a 6-month period. The sessions focused on building rapport, exploring hopes for and supporting participation after discharge through further meetings and supported community activities. RESULTS: Data were synthesised into one overarching theme: making sense of recovery. This occurred through the sharing of experiences and stories; was pivotal to the mentoring relationship; and appeared to benefit both mentees and mentors. Mentors were perceived as valued experts because of their personal experience of injury and recovery, and could provide support in ways that were different from that provided by clinicians or family members. Mentors required support to manage the uncertainties inherent in the role. CONCLUSIONS: The insight mentors developed through their own lived experience established them as a trusted and credible source of hope and support for people re-engaging in the community post-TBI. These findings indicate the potential for mentoring to result in positive outcomes.

Development of a toolkit to enhance care processes for people with a long-term neurological condition: a qualitative descriptive study.

OBJECTIVE: To (A) explore perspectives of people with a long-term neurological condition, and of their family, clinicians and other stakeholders on three key processes: two-way communication, self-management and coordination of long-term care; and (B) use these data to develop a 'Living Well Toolkit', a structural support aiming to enhance the quality of these care processes. DESIGN: This qualitative descriptive study drew on the principles of participatory research. Data from interviews and focus groups with participants (n=25) recruited from five hospital, rehabilitation and community settings in New Zealand were analysed using conventional content analysis. Consultation with a knowledge-user group (n=4) and an implementation champion group (n=4) provided additional operational knowledge important to toolkit development and its integration into clinical practice. RESULTS: Four main, and one overarching, themes were constructed: (1) tailoring care:referring to getting to know the person and their individual circumstances; (2) involving others: representing the importance of negotiating the involvement of others in the person's long-term management process; (3) exchanging knowledge: referring to acknowledging patient expertise; and (4) enabling: highlighting the importance of empowering relationships and processes. The overarching theme was: assume nothing. These themes informed the development of a toolkit comprising of two parts: one to support the person with the long-term neurological condition, and one targeted at clinicians to guide interaction and support their engagement with patients. CONCLUSION: Perspectives of healthcare users, clinicians and other stakeholders were fundamental to the development of the Living Well Toolkit. The findings were used to frame toolkit specifications and highlighted potential operational issues that could prove key to its success. Further research to evaluate its use is now underway.

Strengths and Difficulties Questionnaire: internal validity and reliability for New Zealand preschoolers.

OBJECTIVES: This observational study examines the internal construct validity, internal consistency and cross-informant reliability of the Strengths and Difficulties Questionnaire (SDQ) in a New Zealand preschool population across four ethnicity strata (New Zealand European, Maori, Pasifika, Asian). DESIGN: Rasch analysis was employed to examine internal validity on a subsample of 1000 children. Internal consistency (n=29 075) and cross-informant reliability (n=17 006) were examined using correlations, intraclass correlation coefficients and Cronbach's alpha on the sample available for such analyses. SETTING AND PARTICIPANTS: Data were used from a national SDQ database provided by the funder, pertaining to New Zealand domiciled children aged 4 and 5 and scored by their parents and teachers. RESULTS: The five subscales do not fit the Rasch model (as indicated by the overall fit statistics), contain items that are biased (differential item functioning (DIF)) by key variables, suffer from a floor and ceiling effect and have unacceptable internal consistency. After dealing with DIF, the Total Difficulty scale does fit the Rasch model and has good internal consistency. Parent/teacher inter-rater reliability was unacceptably low for all subscales. CONCLUSION: The five SDQ subscales are not valid and not suitable for use in their own right in New Zealand. We have provided a conversion table for the Total Difficulty scale, which takes account of bias by ethnic group. Clinicians should use this conversion table in order to reconcile DIF by culture in final scores. It is advisable to use both parents and teachers' feedback when considering children's needs for referral of further assessment. Future work should examine whether validity is impacted by different language versions used in the same country.

Cluster-randomised controlled trial of an occupational therapy intervention for children aged 11-13 years, designed to increase participation to prevent symptoms of mental illness.

BACKGROUND: The impact of occupational therapy on mental health outcomes for children is largely unexplored. The aim of this study was to investigate an evidence-based occupational therapy intervention designed to increase participation in daily occupations to prevent symptoms of mental illness for children and run in schools. METHODS: The study used a pragmatic, cluster-randomised controlled trial design with two arms. Fourteen clusters (schools), equating to 151 child participants, were stratified by school decile-rank category and block randomised. Blinding of participants post-randomisation was not feasible; however, outcomes assessors were blinded. Outcomes were measured at baseline, after the parallel and crossover phases, and at follow-up; and were anxiety symptoms (primary), depression symptoms, self-esteem, participation and wellbeing. Intention-to-treat analysis was applied and mixed linear modelling was used to account for clusters and repeated measures, and to adjust for covariates identified. RESULTS: This trial found significant positive effects of the intervention on child-rated satisfaction with their occupational performance and teacher-rated child anxiety. No evidence was found to support the effect of the intervention on anxiety and depression symptoms, self-esteem and wellbeing. CONCLUSIONS: This was the first known cluster-randomised controlled trial to investigate an occupational therapy intervention promoting emotional wellbeing in a non-clinical sample of children. No compelling evidence was found to support the use of the intervention in schools in its current format, however, results were promising that the focus on occupations influenced participation. Recommendations are made to redesign the intervention as an embedded intervention in the classroom, cotaught by teachers and including parental involvement.

Mobile Technology Use by People Experiencing Multiple Sclerosis Fatigue: Survey Methodology.

BACKGROUND: Fatigue is one of the most commonly reported symptoms of multiple sclerosis (MS). It has a profound impact on all spheres of life, for people with MS and their relatives. It is one of the key precipitants of early retirement. Individual, group, and Internet cognitive behavioral therapy-based approaches to supporting people with MS to manage their fatigue have been shown to be effective. OBJECTIVE: The aim of this project was to (1) survey the types of mobile devices and level of Internet access people with MS use or would consider using for a health intervention and (2) characterize the levels of fatigue severity and their impact experienced by the people in our sample to provide an estimate of fatigue severity of people with MS in New Zealand. The ultimate goal of this work was to support the future development of a mobile intervention for the management of fatigue for people with MS. METHODS: Survey methodology using an online questionnaire was used to assess people with MS. A total of 51 people with MS participated. The average age was 48.5 years, and the large majority of the sample (77%) was female. RESULTS: Participants reported significant levels of fatigue as measured with the summary score of the Neurological Fatigue Index (mean 31.4 [SD 5.3]). Most (84%) respondents scored on average more than 3 on the fatigue severity questions, reflecting significant fatigue. Mobile phone usage was high with 86% of respondents reporting having a mobile phone; apps were used by 75% of respondents. Most participants (92%) accessed the Internet from home. CONCLUSIONS: New Zealand respondents with MS experienced high levels of both fatigue severity and fatigue impact. The majority of participants have a mobile device and access to the Internet. These findings, along with limited access to face-to-face cognitive behavioral therapy-based interventions, create an opportunity to develop a mobile technology platform for delivering a cognitive behavioral therapy-based intervention to decrease the severity and impact of fatigue in people with MS.

What influences the implementation of the New Zealand stroke guidelines for physiotherapists and occupational therapists?

Purpose To explore perceived barriers and facilitators to the use of the New Zealand (NZ) stroke guidelines by occupational therapists and physiotherapists. Methods A qualitative descriptive methodology was used. Eligible physiotherapists and occupational therapists (NZ registered, working in one of two hospitals, treating at least 10 patients with stroke in the previous year) were invited to participate in semi-structured interviews to elicit their perceptions of the utility and feasibility of the NZ stroke guidelines and identify barriers and facilitators to their implementation. All interviews were audio-recorded and transcribed. Conventional content analysis with constant comparative methods was used for coding and analysis. Results The main themes influencing guideline implementation were resources and characteristics of the guidelines, the organization, the patient and family and the therapist. Insufficient resources were a major barrier that crossed many of the themes. Participants suggested a range of strategies relating to the organization to improve therapists' alignment to the guidelines. Conclusion Alignment to the guidelines in NZ is influenced both positively and negatively by a range of interacting factors, consistent with other studies. Alignment might be improved by the introduction of some relatively simple strategies, such as ring-fencing time for access to resources and training in the use of the guidelines. Many of the barriers and related interventions are likely to be more complex. Implications for rehabilitation Alignment with stroke guidelines has been shown to improve patient outcomes. Therapist alignment with the implementation of the New Zealand stroke guidelines is influenced by guideline characteristics, organizational characteristics, resources, patient and family characteristics and therapist characteristics. Frequently encountered barriers related to limited resources, particularly time. Ring-fencing regular time for access to resources and training in the use of guidelines are examples of simple strategies that may reduce barriers.