Use of removable support boot versus cast for early mobilisation after ankle fracture surgery: cost-effectiveness analysis and qualitative findings of the Ankle Recovery Trial (ART).

OBJECTIVES: To estimate the cost-effectiveness of using a removable boot versus a cast following ankle fracture from the National Health Service and Personal Social Services (NHS+PSS) payer and societal perspectives and explore the impact of both treatments on participants' activities of daily living. DESIGN: Cost-effectiveness analyses and qualitative interviews performed alongside a pragmatic multicentre randomised controlled trial. SETTING: Eight UK NHS secondary care trusts. PARTICIPANTS: 243 participants (60.5% female, on average 48.2 years of age (SD 16.4)) with ankle fracture. Qualitative interviews with 16 participants. Interventions removable air boot versus plaster cast 2 weeks after surgery weight bearing as able with group-specific exercises. PRIMARY AND SECONDARY OUTCOME MEASURES: Quality-adjusted life years (QALYs) estimated from the EQ-5D-5L questionnaire, costs and incremental net monetary benefit statistics measured 12 weeks after surgery, for a society willing-to-pay £20 000 per QALY. RESULTS: Care in the boot group cost, on average, £88 (95% CI £22 to £155) per patient more than in the plaster group from the NHS+PSS perspective. When including all societal costs, the boot saved, on average, £676 per patient (95% CI -£337 to £1689). Although there was no evidence of a QALY difference between the groups (-0.0020 (95% CI -0.0067 to 0.0026)), the qualitative findings suggest participants felt the boot enhanced their quality of life. Patients in the boot felt more independent and empowered to take on family responsibilities and social activities. CONCLUSIONS: While the removable boot is slightly more expensive than plaster cast for the NHS+PSS payer at 12 weeks after surgery, it reduces productivity losses and the need for informal care while empowering patients. Given that differences in QALYs and costs to the NHS are small, the decision to use a boot or plaster following ankle surgery could be left to patients' and clinicians' preferences. TRIAL REGISTRATION NUMBER: ISRCTN15497399, South Central-Hampshire A Research Ethics Committee (reference 14/SC/1409).

CycLing and EducATion (CLEAT): protocol for a single centre randomised controlled trial of a cycling and education intervention versus standard physiotherapy care for the treatment of hip osteoarthritis.

BACKGROUND: Osteoarthritis (OA) is a chronic degenerative joint disorder for which there is no known cure. Non-surgical management for people with mild-to-moderate hip OA focuses mainly on alleviating pain and maximising function via the National Institute for Health and Care Excellence (NICE) recommended combination of education and advice, exercise, and, where appropriate, weight loss. The CHAIN (Cycling against Hip pAIN) intervention is a group cycling and education intervention conceived as a way of implementing the NICE guidance. METHODS: CycLing and EducATion (CLEAT) is a pragmatic, two parallel arm, randomised controlled trial comparing CHAIN with standard physiotherapy care for the treatment of mild-to-moderate hip OA. We will recruit 256 participants referred to the local NHS physiotherapy department over a 24-month recruitment period. Participants diagnosed with hip OA according to NICE guidance and meeting the criteria for GP exercise referral will be eligible to participate. Primary outcome is the difference in Hip Disability and Osteoarthritis Outcome Score (HOOS) function, daily living subscale between those receiving CHAIN and standard physiotherapy care. Secondary outcomes include performance-based functional measures (40 m walking, 30s chair stand and stair climb tests), ability for patient to self-care (patient activation measure) and self-reported health-related resource use including primary and secondary care contacts. The primary economic endpoint is the number of quality adjusted life years (QALYs) at 24 weeks follow-up. The study is funded by the National Institute for Health Research, Research for Patient Benefit PB-PG-0816-20033. DISCUSSION: The literature identifies a lack of high-quality trials which inform on the content and design of education and exercise in the treatment of patients with hip OA and explore cost-effectiveness. CLEAT is a pragmatic trial which seeks to build further evidence of the clinical benefits of the CHAIN intervention compared to standard physiotherapy care within a randomised, controlled trial setting, and examine its cost-effectiveness. TRIAL REGISTRATION NUMBER: ISRCTN19778222. Protocol v4.1, 24th October 2022.

Colorectal cancer and the blood loss paradox.

Background: Faecal occult blood (FOB) positivity and iron deficiency anaemia (IDA) are common manifestations of colorectal cancer (CRC) and both potentially facilitate diagnosis at an earlier, more treatable stage. It has been assumed that both are the consequence of low-grade blood loss from the tumour bed. Method: A retrospective analysis of 1121 cases of CRC diagnosed at a single centre between 2010 and 2016, comparing cases presenting via FOB-based Bowel Cancer Screening Programme (BCSP) and IDA pathways for a series of variables including age, sex, tumour location and prevalence of anaemia. Results: The BCSP and IDA pathways each accounted for about 15% of the total case load. There were significant differences between the BCSP and IDA sub-groups in median age (68 vs 78 years: p<0.001), median haemoglobin (138 vs 89 g/L: p<0.001) and proportion of lesions in right colon (31.1% vs 82.5%: p<0.001). The major disparity in the prevalence of anaemia (overall 20.0% vs 98.2%: p<0.001) persisted when controlled for tumour location. Conclusion: Paradoxically, CRC screening through the detection of FOB positivity and IDA identifies distinctly different sub-populations of cases. The theoretical implication is that an additional mechanism may be required to explain the development of IDA in CRC. The practical implication is that detection of IDA may have a complementary role to the BCSP in population screening for CRC.

Early Laser for Burn Scars (ELABS): protocol for a multi-centre randomised, controlled trial of both the effectiveness and cost-effectiveness of the treatment of hypertrophic burn scars with Pulsed Dye Laser and standard care compared to standard care alone [version 1; peer review: 2 approved].

This paper outlines the protocol for a study that is being carried out at multiple centres across the UK in the next three years. It is a Research for Patient Benefit (RfPB) study funded by the National Institute for Healthcare Research (NIHR). The aim is to assess the effectiveness of treating hypertrophic burns scars with pulsed dye laser (PDL) at an early stage of scar formation. The objective is to improve Quality of Life for the patient by improving both the appearance and quality of burn scarring, as well as reducing its psychological impact. This is a parallel-arm randomised, controlled trial to compare PDL and standard care against standard care alone. The difference is measured between baseline and six-month follow-up. Recruits are within three months of healing from a burn injury; with wounds showing a defined potential for hypertrophic scarring. A total of 120 patients are recruited in a multi-centre study; with randomisation in a 1:1 allocation to each arm. The treatment arm receives 3 PDL treatments at six-week intervals in addition to standard care, whereas the control arm receives standard care alone. The primary outcome is the patient-rated part of the Patient and Observer Scar Scale (POSAS). Psychological and psycho-social impact is evaluated using the CARe burn scale (UWE, Bristol) and Quality Adjusted Life Years (QALY) is determined using the Short-Form Health Survey (SF-12). The study evaluates both the cost-effectiveness through an economic analysis and the patient-reported experience of the treatment by phone interviews.

Broad external validation of a multivariable risk prediction model for gastrointestinal malignancy in iron deficiency anaemia.

BACKGROUND: Using two large datasets from Dorset, we previously reported an internally validated multivariable risk model for predicting the risk of GI malignancy in IDA-the IDIOM score. The aim of this retrospective observational study was to validate the IDIOM model using two independent external datasets. METHODS: The external validation datasets were collected, in a secondary care setting, by different investigators from cohorts in Oxford and Sheffield derived under different circumstances, comprising 1117 and 474 patients with confirmed IDA respectively. The data were anonymised prior to analysis. The predictive performance of the original model was evaluated by estimating measures of calibration, discrimination and clinical utility using the validation datasets. RESULTS: The discrimination of the original model using the external validation data was 70% (95% CI 65, 75) for the Oxford dataset and 70% (95% CI 61, 79) for the Sheffield dataset. The analysis of mean, weak, flexible and across the risk groups' calibration showed no tendency for under or over-estimated risks in the combined validation data. Decision curve analysis demonstrated the clinical value of the IDIOM model with a net benefit that is higher than 'investigate all' and 'investigate no-one' strategies up to a threshold of 18% in the combined validation data, using a risk cut-off of around 1.2% to categorise patients into the very low risk group showed that none of the patients stratified in this risk group proved to have GI cancer on investigation in the validation datasets. CONCLUSION: This external validation exercise has shown promising results for the IDIOM model in predicting the risk of underlying GI malignancy in independent IDA datasets collected in different clinical settings.

A public and patient consultation process as an aid to design a person-centred randomized clinical trial.

BACKGROUND: Involving patients and members of the public, together with researchers, in decisions about how studies are designed and conducted can create a study that is more person-centred. The aim of this consultation process was to explore ways of designing a study which takes the person into consideration for the randomized clinical study entitled 'Biomechanical Effects of Manual Therapy-A Feasibility Study' using the novel approach of usability testing. DESIGN: Patient and public volunteers were sought with experience of low back pain. Volunteers were invited to participate in usability testing (a physical walkthrough) of the proposed study method. This was followed by a discussion of areas where usability testing could not be used, such as recruitment strategies, continuity of participant care and dissemination of results. Resulting feedback was considered by the research team and alterations to the original study method were incorporated, provided the research questions could be answered and were practical within the resources available. RESULTS: Additional recruitment strategies were proposed. Alterations to the study included reduction in study time burden; completion of study paperwork in a quieter location; continuity of participant care after the study; and methods of dissemination of overall study results to participants. CONCLUSION: The consultation process used the unique method of usability testing, together with a post-usability discussion, and resulted in alterations to the future study which may facilitate making it more person-centred. PATIENT AND PUBLIC CONTRIBUTION: Patients and public developed the future study design but did not participate in manuscript preparation.

Evidence for improved prognosis of colorectal cancer diagnosed following the detection of iron deficiency anaemia.

Iron deficiency anaemia (IDA) is common in colorectal cancer (CRC), especially, in right-sided CRC which is known to have an overall worse prognosis. The associations between diagnostic pathway (Bowel Cancer Screening Programme (BCSP), IDA, symptomatic) and tumour side/stage was assessed using logistic regression models in 1138 CRC cases presenting during 2010-2016 at a single secondary-care centre in the UK. In the IDA sub-group, the relationship between CRC stage and the event of having a blood count prior to CRC diagnosis was examined using Bayesian parametric survival model. IDA was found as the only significant predictor of right-sided CRC (OR 10.61, 95% CI 7.02-16.52). Early-stage CRC was associated with both the IDA (OR 1.65, 95% CI 1.18-2.29) and BCSP pathway (OR 2.42, 95% CI 1.75-3.37). At any age, the risk of detecting CRC at late-stage was higher in those without a previous blood count check (hazard ratio 1.53, 95% credibility interval 1.08-2.14). The findings of this retrospective observational study suggest a benefit from diagnosing CRC through the detection of IDA, and warrant further research into the prognosis benefit of systematic approach to blood count monitoring of the at-risk population.

Stakeholder involvement in the development of trial material for a clinical trial.

BACKGROUND: Stakeholder involvement includes not just patients and public, but also those delivering treatment for example clinicians and students. Each stakeholder brings unique experiences to the process. The aim of this stakeholder exercise was to explore readability and understanding of the trial material for the future trial to be conducted by the authors: Biomechanical Effects of Manual Therapy-A Feasibility Study. DESIGN: Volunteers from identified stakeholder groups were provided with trial material which included the information sheet, consent form, questionnaires and home management booklet. They provided feedback on content (readability, understanding) and style (font, layout). An additional document was provided with genres of pictures to choose the most appropriate style to be used in the booklet. Readability formulas were used to calculate reading age before and after feedback to objectively measure ease of reading. RESULTS: The public group provided a layperson's perspective to clarify the information sheet for patients, whereas practitioner and intern groups indicated where information could be clarified. The reading age of all documentation decreased following feedback; however, templated sections of the documentation did not. The majority (87%) of volunteers chose coloured classic cartoons for the booklet. CONCLUSION: This process highlighted the importance of involving different stakeholder groups in the development of research materials as each group made a unique contribution. Readability and understanding of the trial material were improved, feeding back into the consent process contributing towards fully informed consent. PATIENT OR PUBLIC CONTRIBUTION: Public helped develop materials for a future trial but not with manuscript preparation.

Young and Older Adults Differ in Integration of Sensory Cues for Vertical Perception.

INTRODUCTION: The subjective visual vertical (SVV) measures the perception of a person's spatial orientation relative to gravity. Weighted central integration of vestibular, visual, and proprioceptive inputs is essential for SVV perception. Without any visual references and minimal proprioceptive contribution, the static SVV reflects balance of the otolith organs. Normal aging is associated with bilateral and progressive decline in otolith organ function, but age-dependent effects on SVV are inconclusive. Studies on sensory reweighting for visual vertical and multisensory integration strategies reveal age-dependent differences, but most studies have included elderly participants in comparison to younger adults. The aim of this study was to compare young adults with older adults, an age group younger than the elderly. METHODS: Thirty-three young and 28 older adults (50-65 years old) adjusted a tilted line accurately to their perceived vertical. The rod's final position from true vertical was recorded as tilt error in degrees. For otolithic balance, visual vertical was recorded in the dark without any visual references. The rod and frame task (RFT) with tilted disorienting visual frames was used for creating visuovestibular conflict. We adopted Nyborg's analysis method to derive the rod and frame effect (RFE) and trial-to-trial variability measures. Rod alignment times were also analyzed. RESULTS: There was no age difference in signed tilts of SVV without visual reference. There was an age effect on RFE and on overall trial-to-trial variability of rod tilt, with older adults displaying larger frame effects and greater variability in rod tilts. Alignment times were longer in the tilted-frame conditions for both groups and in the older adults compared to their younger counterparts. The association between tilt accuracy and tilt precision was significant for older adults only during visuovestibular conflict, revealing an increase in RFE with an increase in tilt variability. Correlation of σ SVV, which represents vestibular input precision, with RFE yielded exactly the same contribution of σ SVV to the variance in RFE for both age groups. CONCLUSIONS: Older adults have balanced otolithic input in an upright position. Increased reliance on visual cues may begin at ages younger than what is considered elderly. Increased alignment times for older adults may create a broader time window for integration of relevant and irrelevant sensory information, thus enhancing their multisensory integration. In parallel with the elderly, older adults may differ from young adults in their integration of sensory cues for visual vertical perception.

Chronic kidney disease referrals from general practitioners pre- and post National Institute for Health and Care Excellence guidance 2014.

INTRODUCTION: Mortality from chronic kidney disease (CKD) is increasing. Most patients die from cardiovascular disease and management of cardiovascular risks is key to prevent both mortality and progression to end-stage renal disease. In 2014, the National Institute of Health and Care Excellence (NICE) introduced guidance to help general practitioners (GPs) manage CKD patients. AIM: We aimed to determine the impact of the updated CKD guidance on CKD/cardiovascular risks optimisation and the timeliness of referral from the primary care. METHODS: All new GP referrals to the Regional Renal Service in 2012 and 2016 were analysed. Data were collected on patient age, estimated glomerular filtration rate (eGFR) at referral, blood pressure (BP), smoking, body mass index, glycated haemoglobin (HbA1c; in diabetic patients) and lipid assessment. RESULTS: A total of 486 new GP referrals were received in 2012, and 574 in 2016 (18% increase post NICE CKD guideline). Post NICE, fewer stage 4 and 5 CKD patients were being referred. But late referrals (eGFR <20 mL/min/1.73 m2) were not improved. BP control had improved. More patients had cholesterol-levels checked. The number of smokers and obese patients had not improved. CONCLUSION: Post NICE guidelines, GPs are better in optimising BP. Diabetes management and lifestyle modifications need further improvement.

High-normal blood glucose levels may be associated with decreased spatial perception in young healthy adults.

The negative effects of high normal glucose on cognitive function were previously reported in euglycemic individuals of middle age and the elderly population. This study aimed at examining the effect of baseline blood glucose levels on spatial ability, specifically verticality perception on the computerized rod and frame test (CRFT) in young healthy adults. 63 healthy male medical students (age range from 18-23 years), of whom 30 were non-fasting outside the month of Ramadan and 33 fasting during Ramadan of the year 2016, were recruited in order to create varying degrees of glycemia during which verticality perception was carried out. Baseline blood glucose reading was obtained prior to commencing the CRFT test. Blood glucose levels at the time of testing decreased as the duration between the last meal and testing increased. A blood glucose range of 62-117 mg/dl was achieved among participants for this study. Linear regression analysis showed that blood glucose level at testing correlated positively with all alignment spatial error parameters, indicating a probable reduction of spatial perception ability with higher blood glucose levels. These results are consistent with other cognitive studies in older healthy humans and emphasize the critical impact of early glucose dys-homeostasis on cognitive function. They also indicate that elevated blood glucose may affect cognitive functioning outside of the usual complications of diabetes.

Stories and Music for Adolescent/Young Adult Resilience During Transplant Partnerships: Strategies to Support Academic-Clinical Nurse Collaborations in Behavioral Intervention Studies.

Evidence-based nursing is in the forefront of healthcare delivery systems. Federal and state agencies, academic institutions, and healthcare delivery systems recognize the importance of nursing research. This article describes the mechanisms that facilitate nursing partnerships yielding high-level research outcomes in a clinical setting. A phase-II multicenter behavioral intervention study with pediatric stem cell transplant patients was the context of this academic/clinical research partnership. Strategies to develop and maintain this partnership involved a thorough understanding of each nurse's focus and barriers. A variety of communication plans and training events maximized preexisting professional networks. Academic/clinical nurses' discussions identified barriers to the research process, the most significant being role conflict. Communication and validation of benefits to each individual and institution facilitated the research process during challenging times. Establishing strong academic/clinical partnerships should lead to evidence-based research outcomes for the nursing profession, healthcare delivery systems, and patients and families.

Augmented asymmetrical visual field dependence in asymptomatic diabetics: evidence of subclinical asymmetrical bilateral vestibular dysfunction.

BACKGROUND: Diabetes negatively affects the vestibular system in many ways, with vestibular dysfunction (VD), a co-morbidity with a high prevalence in diabetics. PROCEDURES: The ability to perceive subjective visual vertical (SVV), as a sign of vestibular dysfunction, and visual field dependence was measured using a computerized rod and frame test (CRAF). Alignment errors recorded from 47 asymptomatic Type II diabetics (no vertigo or falls, without peripheral neuropathy or retinopathy) were compared to 29 healthy age matched (46-69years) controls. FINDINGS: Visual field dependence was significantly larger and more asymmetrical in the diabetics than controls. In the absence of any visual references, or when a vertical reference frame was provided, SVV perception was accurate in both groups, with no significant difference between the controls and diabetics. During tilted frame presentations, the proportion of subjects with either SVV deviations, or an asymmetry index, larger than an upper limit derived from the control data was significantly greater in diabetics than controls. CONCLUSION: These results suggest that the decreased ability to resolve visuo-vestibular conflict in asymptomatic diabetic patients (free of retinopathy and peripheral neuropathy) compared to controls may be related to diabetic complications affecting vestibular structures and thus causing a decompensation of subclinical vestibular asymmetries.

The "Rod and Fran Test": relationship priming influences cognitive-perceptual performance.

We theorized that interpersonal relationships can provide structures for experience. In particular, we tested whether primes of same-sex versus mixed-sex relationships could foster cognitive-perceptual processing styles known to be associated with independence versus interdependence respectively. Seventy-two participants visualized either a same-sex or other-sex relationship partner and then performed two measures of cognitive-perceptual style. On a computerized Rod and Frame Test, individuals were more field-dependent after visualizing a mixed-sex versus same-sex relationship partner. On a measure involving perceptions of group behavior, participants demonstrated more holistic/contextually based perception after being primed with a female versus male relationship partner. These findings support the hypothesis that activated cognitive structures representing interpersonal relationships can shape individuals' cognitive-perceptual performance.

Changes in rod and frame test scores recorded in schoolchildren during development--a longitudinal study.

The Rod and Frame Test has been used to assess the degree to which subjects rely on the visual frame of reference to perceive vertical (visual field dependence-independence perceptual style). Early investigations found children exhibited a wide range of alignment errors, which reduced as they matured. These studies used a mechanical Rod and Frame system, and presented only mean values of grouped data. The current study also considered changes in individual performance. Changes in rod alignment accuracy in 419 school children were measured using a computer-based Rod and Frame test. Each child was tested at school Grade 2 and retested in Grades 4 and 6. The results confirmed that children displayed a wide range of alignment errors, which decreased with age but did not reach the expected adult values. Although most children showed a decrease in frame dependency over the 4 years of the study, almost 20% had increased alignment errors suggesting that they were becoming more frame-dependent. Plots of individual variation (SD) against mean error allowed the sample to be divided into 4 groups; the majority with small errors and SDs; a group with small SDs, but alignments clustering around the frame angle of 18°; a group showing large errors in the opposite direction to the frame tilt; and a small number with large SDs whose alignment appeared to be random. The errors in the last 3 groups could largely be explained by alignment of the rod to different aspects of the frame. At corresponding ages females exhibited larger alignment errors than males although this did not reach statistical significance. This study confirms that children rely more heavily on the visual frame of reference for processing spatial orientation cues. Most become less frame-dependent as they mature, but there are considerable individual differences.

Perception of subjective visual vertical and horizontal in patients with chronic neck pain: a cross-sectional observational study.

Previous studies have shown that chronic neck pain (CNP) patients have a larger spread of perceptual errors for subjective visual vertical (SVV) than those exhibited by asymptomatic controls. The current study investigated whether this was also the case for perception of subjective visual horizontal (SVH) and whether there was a correlation between the two measurements. Fifty patients with CNP were compared with a group of 50 age- and gender-matched controls. All subjects were required to complete a test to measure SVH as well as SVV using the computerised rod and frame (CRAF) test. These tests were conducted under various frame conditions. No difference was found between the errors of the CNP and control groups in the absence of a surrounding frame. When a tilted frame was added to the CRAF test, the range of errors observed in the CNP group increased for both SVV and SVH. In particular, significantly more CNP patients fell outside the reference range of errors and a subgroup of patients, characterised by higher neck pain disability indices, was identified who demonstrated higher than expected errors for both SVV and SVH. However no conclusion could be drawn with regards to the direction of error asymmetry and laterality of pain as those patients with unilateral pain exhibited errors both towards and away from the affected area.

Subjective visual vertical perception and sense of smell in Parkinson disease.

This article describes an open cross-sectional observational study involving 47 participants with Parkinson disease (PD) and 47 (age- and sex-matched) nondisabled controls without PD. The aim was to determine the profiles of subjective visual vertical (SVV) perception and sense of smell perception in both groups. There was a statistically significant difference (p < 0.001) between patients and controls on their smell test performance. Controls were more likely to correctly identify odors, with a median score of 10 out of 12 compared with 6.5 out of 12 for patients with PD. The median SVV error for the PD group when the frame was untilted was 0.75 degrees compared with 0.50 degrees for controls. This difference was statistically significant (p = 0.02). When the frame was tilted, the median SVV error for the PD group was 2.31 degrees compared with 2.00 degrees for controls (not statistically significant), with both groups showing similar distribution pattern of errors. There was no statistical correlation between number of correctly identified odors and an individual's SVV error. However, a statistically significant negative correlation (r = -0.45, p = 0.01) was found between Mini-Mental State Examination score and mean time taken to complete each rod and frame test in patients with PD, suggesting that SVV errors might be more correlated with cognitive function than with loss of sense of smell.

Prevalence of low back pain (LBP) in rotary wing aviation pilots.

INTRODUCTION: The high prevalence of low back pain (LBP) in helicopter pilots has been well documented, although the reason behind it remains unclear. To date, little research exists comparing the Royal Air Force (RAF) to civilian pilots. METHODS: A questionnaire inquiring into participant demographics, flying experience, and back pain was distributed to RAF pilots based at units around the United Kingdom and civilian pilots working for groups such as Air Ambulance and Her Majesty's Coastguards. RESULTS: RAF pilots were significantly younger than civilian pilots (mean age 38.9 +/- 8.8 yr and 47.1 +/- 9.2 yr, respectively) and had been flying for a mode length of 6-10 yr compared with +26 yr in civilian pilots. Of civilian pilots, 40% had previously served as a pilot in the military. Neither RAF (83%) nor civilian (81%) pilots were significantly more likely to suffer from LBP and the nature of the pain experienced was similar. There were 33% of RAF and 55% of civilian pilots who used a back support. DISCUSSION: The high prevalence of back pain reported by civilian and RAF pilots may be due to several factors. To investigate this further would require responses from a greater number of civilian pilots, particularly those who do not have previous military experience. In the meantime, further use of lumbar support may go some of the way to alleviating the problem.

From line to dots: an improved computerised rod and frame system for testing subjective visual vertical and horizontal.

BACKGROUND: Perception of subjective visual vertical (SVV) and horizontal (SVH) has traditionally been measured by rotating a mechanical rod either with or without a frame present. The computerised rod and frame (CRAF) system has previously only been used to measure SVV. We have expanded the use of this system by testing its feasibility to measure SVH. This was done by comparing two groups of subjects (n = 103) randomly assigned to be tested for SVV or SVH. FINDINGS: Preliminary results showed a higher than expected percentage of individuals with SVH errors < 0.5 degrees . This was attributed to additional visual cues provided by the changing appearance of the rod as it approached the horizontal. A solution to this problem was sought by replacing the rod by two dots to mark its ends. In a second investigation 30 subjects were tested using both the "rod as line" and "rod as dots" presentation. Bland and Altman analysis showed no difference between the rod and dots presentations in the measurement of SVV, but confirmed a fixed error of -0.93 degrees between rods and dots for SVH. Changing the rod from a line to dots in the computer system resulted in errors for both SVV and SVH that were comparable to previous studies using manual systems. CONCLUSIONS: The computerized rod and frame system may be improved by replacement of the line with two dots. This reduces clues provided to the subject by the appearance of the rod on the screen.