Self-management programs within rehabilitation yield positive health outcomes at a small increased cost compared to usual care: A systematic review and meta-analysis.

OBJECTIVE: To determine if self-management programs, supported by a health professional, in rehabilitation are cost-effective. DATA SOURCES: Six databases were searched to December 2023. STUDY SELECTION: Randomised controlled trials with adults completing a supported self-management program while participating in rehabilitation, or receiving health professional input, in the hospital or community settings, were included. Self-management programs were completed outside of structured, supervised therapy and health professional sessions. Included trials had a cost measure and an effectiveness outcome reported, such as health-related quality of life or function. Grading of Recommendations, Assessment, Development and Evaluations (GRADE) was used to determine the certainty of evidence across trials included in each meta-analysis. Incremental cost effectiveness ratios (ICERS) were calculated based on the mean difference from the meta-analyses of contributing healthcare costs and quality of life. DATA EXTRACTION: Following application of the search strategy, two independent reviewers determined eligibility of identified literature, initially by reviewing the title and/or abstract prior to full text review. Using a customised form, data was extracted by one reviewer and checked by a second reviewer. DATA SYNTHESIS: Forty-three trials were included and 27 had data included in meta-analyses. Where self-management was a primary intervention there was moderate certainty of a meaningful positive difference in quality of life utility index, of 0.03 units (95% CI 0.01 to 0.06). The cost difference between self-management as the primary intervention and usual care (comprising usual intervention/therapy, minimal intervention (including education only), or no intervention), potentially favoured the comparison group (MD $AUD90, 95% CI -$AUD130 to $AUD310). The cost per quality adjusted life year (QALY) gained for self-management programs as a stand-alone intervention was $AUD3,000, below the acceptable willingness-to-pay threshold in Australia per QALY gained ($50,000/QALY gained). CONCLUSIONS: Self-management as an intervention is low cost and could improve health-related quality of life. PROSPERO REGISTRATION: CRD42021275472.

Older people's views and usage of recreational spaces in parks with age-friendly outdoor exercise equipment.

Recreational spaces are important public spaces for people of all ages to engage in leisure and physical activities, however older people remain one of the lowest users of park. This study investigated older people's perceptions and reasons for visiting parks that have undergone refurbishment with the installation of age-friendly outdoor exercise equipment, the Seniors Exercise Park. On-site intercept surveys took place in six parks in Victoria, Australia. Seniors Exercise Park equipment usage was audited over 12 months using on-site Quick Response (QR). A total of 139 older people were surveyed, 55.4% reported visiting to exercise, 25.9% for walking and 21.5% for fresh air/nature. Proximity to home/family (37.4%) and the availability of the Seniors Exercise Park equipment (36.7%) were the main reasons for visiting these parks. The availability of age-suitable exercise equipment in recreational spaces can support and encourage older people to access local parks and engage in physical activity.

Associations between physical activity, sedentary behaviour and cognitive domain performance of people living with mild cognitive impairment in the community.

INTRODUCTION: Physical activity is known to positively influence cognitive performance. For adults with mild cognitive impairment (MCI), the relationship between physical activity levels and cognitive performance is unknown. This cross-sectional study aimed to determine if cognitive performance [as measured by the Montreal Cognitive Assessment (MoCA)] of people living in the community with MCI is associated with their physical activity levels or sedentary behaviour. METHODS: ActivPAL™ accelerometers were used to objectively measure physical activity and sedentary behaviour for seven full days. Cognitive performance was measured using the MoCA. CONSUMER AND COMMUNITY INVOLVEMENT: No involvement other than as research participants RESULTS: Eighty-two participants from the Balance on the Brain randomised controlled trial were included. Most participants were retired (88%), with 33 (40%) reporting a fall in the last year. The median MoCA score was 24 (IQR 22-26). Participants achieved a mean of 6296 (±2420) steps per day and were sedentary for 10.6 (±2) hours per day. The only physical activity outcomes that had a fair, positive correlation were moderate- to vigorous-intensity physical activity measures of total stepping time and total number of steps (with a cadence of ≥100 steps/min) with the orientation MoCA domain score (r(82) = 0.36, p ≤ 0.001 and r(82) = 0.37, p ≤ 0.001, respectively). Higher total sedentary time had a weak, positive correlation with better visuospatial/executive performance (r(82) = 0.23, p = 0.041). The orientation outcomes remained significant when analysed in an adjusted logistic regression model. CONCLUSION: This study found that performance in the MoCA orientation domain had a fair-positive correlation with moderate-intensity physical activity (i.e., stepping time and step count with a cadence of ≥100 steps/min) as measured by a thigh-worn accelerometer for community-dwelling older adults with MCI. When considering the relationship between cognitive domains and sedentary behaviour, consideration may be needed regarding whether cognitive enhancing activities (such as crosswords and other brain games) are being performed, which may confound this relationship. Further investigation is required to confirm these results.

A self-management program increases the dosage of inpatient rehabilitation by 26 minutes per day: a process evaluation.

PURPOSE: To evaluate the implementation of a self-management program, My Therapy, designed to increase inpatient rehabilitation therapy dosage via independent practice. MATERIALS AND METHODS: A process evaluation of My Therapy for adult patients admitted for rehabilitation for any condition supervised by physiotherapists and occupational therapists across eight rehabilitation wards compared usual care. Outcomes included reach, dosage, fidelity and adaptation. RESULTS: The mean (SD) age of the process evaluation sample (n = 123) was 73 (11) years with a mean (SD) length of stay of 14.0 (6.6) days. The My Therapy program reached 68% of participants (n = 632/928), and resulted in an average increase in therapy dosage of 26 (95% CI 12 to 40) minutes/day of independent practice. All My Therapy audited programs (n = 28) included body function/structure impairment-based exercises, and half (n = 13/28) included activity/participation-based exercises. On average, participants completed programs 1.8 (SD 1.2) times/day, which were prescribed in accordance with the My Therapy criteria, demonstrating fidelity. There were no between-group differences in daily steps or standing time, however, My Therapy participants spent more time sitting (p ≤ 0.05). Implementation adaptations were minimal. CONCLUSION: A self-management rehabilitation program was implemented with fidelity for two in three rehabilitation patients, resulting in increased therapy dosage with minimal adaptations.

The My Therapy self-management program was implemented with good reach (68% of participants received My Therapy) across four public and private inpatient rehabilitation services.Under My Therapy conditions, the dosage of inpatient rehabilitation therapy participation increased by an average of 26 minutes per day, which will help close the evidence-practice gap between the current rehabilitation dosage of about 1-hour per day, and the recommended rehabilitation dosage of 3-hours per day.My Therapy programs most frequently included impairment-based exercises that were completed in sitting, and did not increase time spent standing and walking.Consideration should be given to prescribing My Therapy (content and dosage) at an optimal level to promote patient functional independence, while maintaining safety.

Physical Activity Levels and Sedentary Behavior of People Living With Mild Cognitive Impairment: A Cross-Sectional Study Using Thigh-Worn Accelerometers.

Community-dwelling people with Mild Cognitive Impairment self-reporting not to be meeting recommended physical activity levels participated in this study to (a) determine compliance of wearing (thigh-worn) accelerometers, (b) describe physical activity levels and sedentary behavior, and (c) determine the validity of the Physical Activity Scale for the Elderly (PASE) compared with activPAL accelerometers. A total of 79 people had valid accelerometer data (median [interquartile range]: age, 71 [54-75] years). Compliance was 86.81%. Participants were sedentary for 10.6 hr per day and engaged in a median of 9 min per day of moderate-intensity physical activity. Fair correlations were found between the PASE and total stepping time per day (r = .35, p < .01), total number of steps per day (r = .36, p < .01), and number of steps in stepping activities completed for ≤1 min (r = .42, p < .01). The PASE and Standing time (r = .04, p = .724) and PASE and Sitting time (r = .04, p = .699) had little to no relationship. The use of thigh-worn accelerometers for this population is achievable. People with Mild Cognitive Impairment have high levels of sedentary behavior and minimal engagement in moderate-intensity physical activity. The PASE has fair, positive criterion validity with activity-based outcomes measured by activPAL accelerometers but not with sedentary behavior, which is high for this population.

The ENJOY Seniors Exercise Park IMP-ACT project: IMProving older people's health through physical ACTivity: a hybrid II implementation design study protocol.

INTRODUCTION: The health benefits of physical activity are well established; however, most older people are not sufficiently physically active. Despite the availability of various physical activity interventions and programs, implementation of effective prevention strategies to reduce older people's physical inactivity are lacking. The ENJOY IMP-ACT project is an implementation research project, based on a previous evidence-based physical and social activity program utilising specialised outdoor exercise equipment (the Seniors Exercise Park) for older people. The ENJOY IMP-ACT aims to increase participation in physical activity to improve health outcomes for older people in Victoria, Australia. METHOD: The ENJOY IMP-ACT is a hybrid II implementation-effectiveness pre-post mixed method study design. Five local governments (6 public sites/parks) will undergo a 3-month control period followed by 9-months implementation intervention (TERM framework intervention: Training, Engagement, Resources development, Marketing and promotion), and a maintenance phase (3 months). Various methodologies will be employed throughout the project at each site and will include direct observations of park users, intercept surveys with park users, online access monitor platform (using an online app), interviews with stakeholders and exercise program leaders, a process evaluation of physical activity programs, a social return-on-investment analysis, and other related activities. DISCUSSION: Through the implementation framework design, the ENJOY IMP-ACT is uniquely placed to translate an evidenced-based physical and social activity program into real world settings and increase physical activity among older people. If successful, this program will inform scale up across Australia with the goal of improving the health and wellbeing of older people. TRIAL REGISTRATION: This registration trial is prospectively registered with the Australian New Zealand Clinical Trials Registry. Trial number ACTRN12622001256763 . Date registered 20/09/2022.

Experiences of Indonesian people with dementia and carers undertaking an online-delivered exercise program.

Participating in physical activity is beneficial for older people with dementia. Little is known however about the perceptions of people living with dementia undertaking an online-delivered exercise program. This study aimed to explore the experiences and perceptions of older people with dementia and their carers in Indonesia participating in an online-delivered exercise program, and factors that may influence acceptability to the program. An exploratory qualitative study design using semi-structured interviews was used. Data were recorded, transcribed verbatim, translated into English, and analyzed thematically. Twelve participants with dementia (mean age = 63.3 years) and 30 carers (26 family carers and 4 paid carers) (mean age = 37.9 years) were interviewed separately. Seven themes were identified: (i) Motivating factors to participate; (ii) Benefits for people with dementia; (iii) Impacts on carers; (iv) Challenges and enablers to exercising; (v) Carers' strategies for exercise engagement; (vi) Roles, relationships and supports; and (vii) Participants' receptiveness to online delivery of the exercise program. This study illustrated that an online-delivered exercise program was acceptable for people with dementia and their carers in Indonesia and reinforced the importance of carers' support for the exercise program. These findings can help physiotherapists and other exercise practitioners in considering the aspects of delivery that people with dementia and their carers value in participating in online-delivered exercise programs.

Age and Type of Task-Based Impact of Mental Fatigue on Balance: Systematic Review and Meta-Analysis.

The role of cognition in balance control suggests that mental fatigue may negatively affect balance. However, cognitive involvement in balance control varies with the type or difficulty of the balance task and age. Steady-state balance tasks, such as quiet standing, are well-learned tasks executed automatically through reflex activities controlled by the brainstem and spinal cord. In contrast, novel, and challenging balance tasks, such as proactively controlling balance while walking over rugged terrain or reacting to unexpected external perturbations, may require cognitive processing. Furthermore, individuals with preexisting balance impairments due to aging or pathology may rely on cognitive processes to control balance in most circumstances. This systematic review and meta-analysis investigated the effect of mental fatigue on different types of balance control tasks in young and older adults. A literature search was conducted in seven electronic databases and 12 studies met eligibility criteria. The results indicated that mental fatigue had a negative impact on both proactive (under increased cognitive load) and reactive balance in young adults. In older adults, mental fatigue affected steady-state and proactive balance. Therefore, mentally fatigued older individuals may be at increased risk of a loss of balance during steady-state balance task compared to their younger counterparts.

Program Evaluation and Refinement of the "Safe Functional Home Exercise" Program for Improving Physical Activity in Older People with Dementia Who Receive Home Care.

INTRODUCTION: People with dementia who receive home care have low levels of physical activity participation. OBJECTIVES: To evaluate and refine a co-designed exercise program for home care clients with dementia, led by trained care support workers. METHODS: An action research cycle whereby support workers, clients and carers (each n = 26) from the "Safe Functional Home Exercise" feasibility study were invited to complete an evaluation survey. Participants rated statements using Likert-style scales on (1) staff training, (2) staff confidence, (3) program support and (4) satisfaction. The participants could provide comments for situations that affected exercise performance, suggested improvements for staff training, program support and exercises. The co-design panel (original program designers) was reconvened to refine the exercise program. RESULTS: Support workers (n = 19), clients (n = 15) and carers (n = 13) returned their surveys. Support workers (74-90%), carers (77-92%) and clients (100%) rated program support positively and were overall satisfied. Support workers (>80%) agreed that the training course was relevant and were confident in delivering the exercises to clients. Situations included "Covid isolation", the client's "poor medical condition" and "mood fluctuations" that made exercising difficult. Improvements included "making a client video" and "providing tips to motivate clients". The co-design panel modified the exercise program. CONCLUSIONS: The "Safe Functional Home Exercise" program is the first exercise program co-designed for people with dementia. It is well accepted by support workers, people with dementia and carers. Utilising support workers to facilitate physical activity participation is potentially low-cost and scalable in home care. Future studies are needed to evaluate the refined program in home care.

Effects of physical activity on depressive symptoms in older caregivers: The IMPACCT randomized controlled trial.

OBJECTIVES: Physical activity (PA) can reduce depressive symptoms but has not been tested amongst depressed older caregivers and their care-recipients. The aim of this single-blind randomized controlled trial was to investigate the effect of a 6-month tailored PA program on depressive symptoms in older caregivers. METHOD: Caregivers were included if they had scores of ≥5 on the 15-item geriatric depression scale (GDS-15). Care-recipients could have any type of physical, mental or cognitive condition requiring support. The PA intervention group completed an individualized program based on the Otago-Plus Exercise Program. The primary outcome was improvement in depressive symptoms in caregivers measured at six and 12 months. RESULTS: Two hundred and twelve participants (91 dyads and 30 caregivers only) were randomized using a 3:3:1 ratio to PA intervention, social-control, and usual-care control groups. There were no significant differences in depressive symptoms of the caregivers between the three groups at 6 months or 12 months. However, more than 50% of caregivers in all three groups no longer had a GDS-15 score ≥5 at 6 months. Further analysis revealed that caregivers in the PA group caring for someone with a standardised mini-mental state examination (SMMSE) score ≥24 had significantly less depressive symptoms than those caring for someone with a SMMSE score <24 compared with social-control (p < 0.02) and usual-care groups (p < 0.02). CONCLUSIONS: A PA intervention may be beneficial for some caregivers in reducing symptoms of depression but may not be as beneficial to caregivers of people living with cognitive impairment.

Reforming allied health service provision in residential aged care to improve the rehabilitation reach: a feasibility study.

Objective My Therapy is an allied health guided, co-designed rehabilitation self-management program for residents of aged care facilities. This study aimed to determine the feasibility of implementing My Therapy in a residential aged care setting. Methods This observational study was conducted on a 30-bed wing, within a 90-bed metropolitan residential aged care facility, attached to a public health service, in Victoria, Australia. Staff and resident data were collected prospectively over 6 weeks (staff focus groups, patient surveys, and audits) to evaluate the feasibility domains of acceptability , reach and demand , practicality , integration , limited efficacy testing and adaptations . Results Twenty-six residents and five allied health staff (physiotherapy and occupational therapy) participated. My Therapy was acceptable to residents (survey) and staff (focus groups). Via initial My Therapy discussions between the resident and the therapists, to determine goals and resident preferences, My Therapy reached 26 residents (n = 26/26, 100% program reach ), with 15 residents subsequently receiving a rehabilitation program (n = 15/26, 58% program demand ). The remaining 11 residents did not participate due to resident preference or safety issues (n = 11/26, 42%). Collecting physical function outcome measures for limited efficacy testing was practical , and the cost of My Therapy was AUD$6 per resident per day, suggesting financial integration may be possible. Several adaptations were required, due to limited allied health staff, complex resident goal setting and program co-design. Conclusion My Therapy has the potential to improve the rehabilitation reach of allied health services in residential aged care. While introducing this low-cost intervention is feasible, adaptations were required for successful implementation.

'Nih Waangkiny Kaadatjiny': 'Listening, learning and knowing': Stakeholders' perspectives about barriers and enablers to delivering a successful physical activity program for older Aboriginal people.

There is limited evidence about how physical activity (PA) programs should be provided for older Aboriginal and Torres Strait Islander peoples. Recently two groups of Aboriginal Elders on Noongar Boodja (Country) in Western Australia participated in the Ironbark PA program. ISSUE ADDRESSED: The objective of this study was to explore the views of key stakeholders about the barriers and enablers to delivering a successful PA program and provide feedback for future program delivery. METHODS: The research took a 'Nih (listening), Waangkiny (learning), Kaadatjiny (knowing)' approach. The lead researcher, a Noongar Wadjuk woman, conducted semi-structured interviews (n = 17) with key stakeholders: Aboriginal and non-Aboriginal workers who assisted to deliver the program, and family and local members of the communities. Data were also collected through weekly program notes and researcher diary entries. Data were analysed thematically. RESULTS: The overarching theme highlighted that stakeholders felt a sense of building a PA program that was culturally appropriate. They reflected that the program attracted older Aboriginal people because it was designed to make them feel welcomed with a sense of belonging. Five major themes were identified: Relationships, Belonging, Program structure, Benefits of the program and Future planning. Positive changes observed in Elders' health and well-being were a source of inspiration for team workers. CONCLUSIONS: Key enablers to delivering a PA program for older Aboriginal people are building a culturally strong program that creates a sense of belonging for the participants. SO WHAT?: Practitioners who are planning PA programs for older Aboriginal people should prioritise the development of cultural safety and security.

Parks Visitation, Physical Activity Engagement, and Older People's Motivation for Visiting Local Parks.

Despite the health benefits of parks and outdoor recreational spaces, small numbers of older people visit parks. This study identified older park visitors' perceptions of their local parks, visit motivation, health, and physical activity level in six parks in Victoria, Australia. Characteristics of general community park visitors and their physical activity engagement were also recorded. Fifty-five older people were surveyed onsite; 92.7% lived within a 5-km distance from the park. Walking was the most common reason for visiting (36.4%), followed by walking the dog (36.4%) and exercise (23.6%). Most older visitors (77.8%) were determined as being sufficiently active. Observation of parks visitors over 1 week recorded 3,770 park visitors, with <5% being older people. Half of all park visitors were inactive, and half of older people visitors (50.5%) engaged in walking. This study supports the importance of parks, park features, and their potential in helping older people to achieve levels of physical activity required for good health.

Exercise for falls prevention in aged care: systematic review and trial endpoint meta-analyses.

BACKGROUND: There is strong evidence that exercise reduces falls in older people living in the community, but its effectiveness in residential aged care is less clear. This systematic review examines the effectiveness of exercise for falls prevention in residential aged care, meta-analysing outcomes measured immediately after exercise or after post-intervention follow-up. METHODS: Systematic review and meta-analysis, including randomised controlled trials from a Cochrane review and additional trials, published to December 2022. Trials of exercise as a single intervention compared to usual care, reporting data suitable for meta-analysis of rate or risk of falls, were included. Meta-analyses were conducted according to Cochrane Collaboration methods and quality of evidence rated using the Grading of Recommendations Assessment, Development and Evaluation approach. RESULTS: 12 trials from the Cochrane review plus 7 new trials were included. At the end of the intervention period, exercise probably reduces the number of falls (13 trials, rate ratio [RaR] = 0.68, 95% confidence interval [CI] = 0.49-0.95), but after post-intervention follow-up exercise had little or no effect (8 trials, RaR = 1.01, 95% CI = 0.80-1.28). The effect on the risk of falling was similar (end of intervention risk ratio (RR) = 0.84, 95% CI = 0.72-0.98, 12 trials; post-intervention follow-up RR = 1.05, 95% CI = 0.92-1.20, 8 trials). There were no significant subgroup differences according to cognitive impairment. CONCLUSIONS: Exercise is recommended as a fall prevention strategy for older people living in aged care who are willing and able to participate (moderate certainty evidence), but exercise has little or no lasting effect on falls after the end of a programme (high certainty evidence).

Risk Factors for the Impairment of Ambulation in Older People Hospitalized with COVID-19: A Retrospective Cohort Study.

(1) Background: Some older people hospitalized with COVID-19 have experienced reduced ambulation capacity. However, the prevalence of the impairment of ambulation capacity still needs to be established. Objective: To estimate the prevalence of, and identify the risk factors associated with, the impairment of ambulation capacity at the point of hospital discharge for older people with COVID-19. (2) Methods: A retrospective cohort study. Included are those with an age > 60 years, of either sex, hospitalized due to COVID-19. Clinical data was collected from patients' medical records. Ambulation capacity prior to COVID-19 infection was assessed through the patients' reports from their relatives. Multiple logistic regressions were performed to identify the risk factors associated with the impairment of ambulation at hospital discharge. (3) Results: Data for 429 older people hospitalized with COVID-19 were randomly collected from the medical records. Among the 56.4% who were discharged, 57.9% had reduced ambulation capacity. Factors associated with reduced ambulation capacity at discharge were a hospital stay longer than 20 days (Odds Ratio (OR): 3.5) and dependent ambulation capacity prior to COVID-19 (Odds Ratio (OR): 11.3). (4) Conclusion: More than half of the older people who survived following hospitalization due to COVID-19 had reduced ambulation capacity at hospital discharge. Impaired ambulation prior to the infection and a longer hospital stay were risks factors for reduced ambulation capacity.

Who cares for the carer? Codesigning a carer health and wellbeing clinic for older care partners of older people in Australia.

INTRODUCTION: Older carers or 'care partners' of older people experiencing care needs often provide essential support, at times while neglecting their own health and well-being. This is an increasingly frequent scenario due to both demographic changes and policy shifts towards ageing in place. Multiple community stakeholders within the care and support ecosystem hold valuable expertise about the needs of older care partners, and the programme and policy responses that may better support their health and well-being. The aim of this study was to identify the perspectives of stakeholders obtained through the codesign phase of a multicomponent research project investigating new models of care and support for older care partners suitable for the Australian context. METHODS: Principles of codesign were used to engage a purposeful sample of older care partners, health professionals, researchers, policy makers and health service administrators. Participants took part in a series of three codesign workshops conducted remotely via video conferencing. The workshops were supported with briefing material and generated consensus-based summaries, arriving at a preferred service model. FINDINGS: This paper reports the research design and structure of the codesign panels, the range of findings identified as important to support the health and well-being of older carers of older people, and the resulting service model principles. The codesigned and preferred model of care is currently being prepared for implementation and evaluation in Australia. PUBLIC CONTRIBUTION: This study was conducted using codesign methodology, whereby stakeholders including older care partners and others involved in supporting older carers, were integrally involved with design, development, results and conclusions.

Perspectives of telehealth access and implementation in people recovering from serious transport injury, health care providers and compensation system staff during the COVID-19 pandemic in Australia.

INTRODUCTION: Before the COVID-19 pandemic, few injury compensation schemes supported access to service-delivery via telehealth. The aim of this qualitative study was to explore the perspectives of people recovering from serious transport injury, health care providers, and senior staff of a transport injury compensation scheme, in relation to the uptake and implementation of telehealth during the COVID-19 pandemic, and its ongoing use. METHODS: Semi-structured interviews were undertaken with 35 participants, including 15 seriously injured patients, 16 health care providers and 4 compensation scheme staff. A thematic analysis was performed using a framework approach. RESULTS: Themes identified included the need to provide continuity of care via telehealth during the pandemic for patients recovering from injury, and the associated organisational and technical support needs. It was noted that some types of services worked well via telehealth, including psychology, while others did not, including physical assessments. The convenience of telehealth was highlighted, in relation to reduced travel. However, there were often safety fears relating to falls, and communication issues with injured people. CONCLUSIONS: This research found that the majority of injured patients and health care providers had benefitted from the introduction of service delivery via telehealth during the pandemic for some types of services. Participants saw opportunities for continued benefit post-pandemic, particularly for improving equity of access to health care for people with barriers to mobility and travel.

Physiotherapists' decision-making about transition to independent walking in hospital after stroke: a qualitative study.

PURPOSE: Physiotherapists working in hospitals have a key role in decisions about when a person with stroke is safe to walk independently. The aim of this study was to explore the factors influencing decision-making of physiotherapists in this situation. METHODS: A qualitative design with semi-structured interviews and reflexive thematic analysis was used. Fifteen physiotherapists with recent experience working in inpatient stroke rehabilitation participated. RESULTS: Multiple factors influence decision-making about walking independence after stroke in hospitals. Four themes were identified: (1) Assessment of walking safety involves observation of walking function and consideration of complex individual factors; (2) Perspectives on risk vary, and influence whether a person is considered safe to walk; (3) Institutional culture involves background pressures that may influence decision-making; and (4) Physiotherapists adopt a structured, individualised mobility progression to manage risk. Physiotherapists consistently use observation of walking and understanding of attention and perception in this decision-making. There can sometimes be a conflict between goals of independence and of risk avoidance, and decisions are made by personal judgements. CONCLUSIONS: Decision-making about independent walking for people in a hospital after a stroke is complex. Improved guidance about clinical assessment of capacity and determining acceptable risk may enable physiotherapists to engage more in shared decision-making.IMPLICATIONS FOR REHABILITATIONRegaining independence in walking after a stroke comes with the potential risk of falls.Assessment of walking safety should be specific to the complexity of the situation and consider perception and cognition.Benefits of activity and autonomy, and the risk of falls need to be considered in decisions about walking independence.Patients with the capacity to understand consequences and accept risk can be active participants in determining what is sufficiently safe.

Validity and reliability of a new clinician-rated tool for freezing of gait severity.

PURPOSE: The Freezing of Gait Severity Tool (FOG Tool) was developed because of limitations in existing assessments. This cross-sectional study investigated its validity and reliability. METHODS: People with Parkinson's disease (PD) were recruited consecutively from clinics. Those who could not walk eight-metres independently (with or without an assistive device), comprehend instructions, or with co-morbidities affecting walking were excluded. Participants completed a set of assessments including the FOG Tool, Timed Up and Go (TUG), and Freezing of Gait Questionnaire. The FOG Tool was repeated and those reporting no medication state change evaluated for test-retest reliability. Validity and reliability were investigated through Spearman's correlations and ICC (two-way, random). McNemar's test was applied to compare the FOG Tool and TUG on the proportion of people with freezing. RESULTS: Thirty-nine participants were recruited [79.5%(n = 31) male; Median(IQR): age-73.0(9.0) years; disease duration-4.0(5.8) years]. Fifteen (38.5%) contributed to test-retest reliability analyses. The FOG Tool demonstrated strongest associations with the Freezing of Gait Questionnaire (ρ = 0.67, 95%CI 0.43-0.83). Test-retest reliability was excellent (ICC = 0.96, 95%CI 0.88-0.99). The FOG Tool had 6.2 times the odds (95%CI 2.4-20.4, p < 0.001) of triggering freezing compared to the TUG. CONCLUSIONS: The FOG Tool appeared adequately valid and reliable in this small sample of people with PD. It was more successful in triggering freezing than the TUG.Implications for RehabilitationThe Freezing of Gait Severity Tool's assessment course is more effective than the commonly-used Timed Up and Go's assessment course for eliciting freezing of gait for clinical evaluation in people with Parkinson's disease.The Freezing of Gait Severity Tool can be considered for scoring freezing of gait severity in people with Parkinson's disease in the clinical setting.