Effects of dual-task interference on dexterity performance in people with mild to moderately severe Parkinson's disease: An observational analysis.

BACKGROUND: Debilitating problems with hand function experienced by people with Parkinson's disease (PD) can worsen during multitasking. PURPOSE: To investigate the effects of dual-task interference on a pegboard task in people with mild to moderately severe PD. STUDY DESIGN: Descriptive analysis. METHODS: A secondary analysis of baseline data from the ParkinsonNet physiotherapy study conducted in 2006 in the Netherlands. The 9-hole peg test was performed with the more affected hand under single- and dual-task conditions. In dual-task trials, a cognitive task was added. The patient specific index-Parkinson's disease identified two functional priority groups-those reporting arm and hand problems as a priority for allied health management ("upper extremity priority") and those prioritizing other issues ("other priority"). We investigated differences in single- and dual-task performance at different levels of disease severity (Hoehn and Yahr stage) and for the two priority groups, and calculated the dual-task effect. RESULTS: Participants were 566 people with PD (Hoehn and Yahr stages I-IV). Dual-task interference occurred at each disease stage. Significant interactions existed between the task condition and disease severity (F (3, 559) = 4.28, p = 0.005) and task condition and priority group (F (1, 561) = 4.44, p = 0.036). Dual-task interference was greater in participants with more advanced disease or those prioritizing upper extremity problems. CONCLUSION: We described the effects of dual-task interference on more affected hand performance of a standardized dexterity test in a broad sample of people with PD. Dual-task interference may impact the daily lives of people with PD, especially those with more severe disease or who report arm and hand problems. It is important for clinicians to consider dual-task interference during upper extremity assessment and treatment.

Effect of digital monitoring and counselling on self-management ability in patients with rheumatoid arthritis: a randomised controlled trial.

OBJECTIVES: To assess a remote physiotherapist (PT) counselling intervention using self-monitoring tools for improving self-management ability, physical activity participation, and health outcomes in people with rheumatoid arthritis (RA). METHODS: Eligible participants were randomly assigned to receive group education, a Fitbit®, a self-monitoring app, and PT counselling phone calls (Immediate Group). The Delayed Group received a monthly e-newsletter until week 26, and then the intervention. The primary outcome was Patient Activation Measure (PAM-13). Participants were assessed at baseline, 27 weeks (the primary end point) and 53 weeks. Secondary outcomes included disease activity, pain, fatigue, depression, sitting/walking habits, daily physical activity time, and daily awake sedentary time. Generalized Linear Mixed-effect Models (GLMMs) were used to assess the effect of the intervention on the change of each outcome measure from the initiation to 27 weeks after the intervention. RESULTS: Analysis included 131 participants (91.6% women; 80.2% completed during the COVID-19 pandemic). The mean change of PAM-13 at 27 weeks was 4.6 (SD = 14.7) in the Immediate Group vs -1.6 (SD = 12.5) in the Delayed Group. The mean change in Delayed Group at 53 weeks (after the 26-week intervention) was 3.6 (SD = 14.6). Overall, the intervention improved PAM-13 at 27 weeks post-intervention from the GLMM analysis (adjusted coefficient: 5.3; 95% CI: 2.0, 8.7; p = <0.001). Favourable intervention effects were also found in disease activity, fatigue, depression, and self-reported walking habit. CONCLUSION: Remote counselling paired with self-monitoring tools improved self-management ability in people with RA. Findings of secondary outcomes indicate that the intervention had a positive effect on symptom management.

Effects of Upper Limb Exercise or Training on Hand Dexterity and Function in People With Parkinson Disease: A Systematic Review and Meta-analysis.

OBJECTIVE: This systematic review investigated the effects of exercise and training on hand dexterity and function outcomes in people with Parkinson disease (PD). DATA SOURCES: We searched 5 databases (MEDLINE Ovid, CINAHL, PEDro, PubMed, Cochrane Database) from inception to October 2022. STUDY SELECTION: Included studies were randomized controlled trials delivering upper limb exercise or training interventions to people with PD and evaluating 1 or more upper limb activity outcomes. Two independent reviewers screened 668 articles for inclusion. DATA EXTRACTION: Two reviewers independently extracted data relating to study participants, intervention characteristics, and key outcomes. Cochrane Risk of Bias and GRADE tools assessed methodological quality of included studies, and strength of evidence for 3 outcomes: hand dexterity, self-reported hand function, and handwriting performance. Meta-analyses synthesized results for within-hand dexterity and self-reported function. RESULTS: Eighteen randomized controlled trials (n=704) with low to unclear risk of bias were identified. Experimental interventions varied considerably in their approach and treatment dose, and 3 studies focused on training handwriting. Meta-analysis showed moderate quality evidence of a small positive effect on within-hand dexterity (SMD=0.26; 95% CI 0.07, 0.44). Very low-quality evidence pointed toward a nonsignificant effect on self-reported hand function (SMD=0.67; 95% CI -0.40, 1.75). A narrative review of handwriting interventions showed low quality evidence for improved performance after training. CONCLUSIONS: There is moderate certainty of evidence supporting the use of exercise and training to address dexterity problems, but evidence remains unclear for self-reported hand function and handwriting. Our findings suggest that training could employ task-related approaches. Future research should interrogate aspects of clinical practice such as optimal dose and key ingredients for effective interventions.

Measuring Hand Dexterity in People With Parkinson's Disease: Reliability of Pegboard Tests.

IMPORTANCE: Knowledge regarding the reliability of pegboard tests when used to measure dexterity in people with Parkinson's disease (PD) is currently limited. OBJECTIVE: To examine the test-retest and interrater reliability of the 9-Hole Peg Test (9HPT) and Purdue Pegboard Test (PPT) in people with PD. DESIGN: Cross-sectional observational study. For test-retest reliability, tests were completed on 2 days, 1 wk apart, in the "on" phase and "end-of-dose" period of participants' medication cycle. For interrater reliability, occupational therapists and physical therapists rated prerecorded pegboard test performance of participants with PD. SETTING: Test-retest reliability was determined in participants' homes or in a university department. Interrater reliability was determined in a university department or a hospital setting. PARTICIPANTS: Test-retest reliability was determined with volunteers diagnosed with PD (N = 30). Interrater reliability was determined with a convenience sample of occupational and physical therapists (N = 11). OUTCOMES AND MEASURES: The 9HPT and PPT are commonly used measures of manual dexterity. RESULTS: PPT subtests showed higher test-retest reliability (intraclass correlation coefficients [ICCs] ≥ .90) in both phases of the medication cycle compared with the 9HPT (ICCs = .70-.81). Minimal detectable change scores indicated acceptable measurement error for both tools. Interrater reliability for recorded performance of each measure was very good (ICCs > .99), with no calculable measurement error. CONCLUSIONS AND RELEVANCE: Although both tools showed adequate test-retest and interrater reliability, results suggest that the PPT may be a more reliable measure of dexterity loss in people with PD. WHAT THIS ARTICLE ADDS: This study informs the clinical measurement of the loss of manual dexterity in people with PD, a frequent problem reported by people living with this disorder.

Do Performance Measures of Strength, Balance, and Mobility Predict Quality of Life and Community Reintegration After Stroke?

OBJECTIVE: To investigate the extent to which physical performance measures of strength, balance, and mobility taken at discharge from inpatient stroke rehabilitation can predict health-related quality of life (HRQoL) and community reintegration after 6 months. DESIGN: Longitudinal study. SETTING: University laboratory. PARTICIPANTS: Adults (N=75) recruited within 1 month of discharge home from inpatient stroke rehabilitation. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: 36-Item Short Form Health Survey (SF-36) for HRQoL and Subjective Index of Physical and Social Outcome (SIPSO) for community reintegration. Physical performance measures were the 6-minute walk test, timed Up and Go (TUG) test, Berg Balance Scale, Community Balance and Mobility Scale, and isokinetic torque and power of hip, knee, and ankle on the paretic and nonparetic sides. Other prognostic variables included age, sex, stroke type and location, comorbidities, and motor FIM score. RESULTS: Separate stepwise linear regressions were performed using the SF-36 and SIPSO as dependent variables. The total paretic lower limb torque and 6-minute walk test predicted the SF-36 Physical Component Summary (adjusted R2=.30). The total paretic lower limb torque and TUG test predicted the SIPSO physical component (adjusted R2=.47). The total paretic lower limb torque significantly predicted the SF-36 Mental Component Summary, but the adjusted R2 was low (.06). Similarly, the TUG test significantly predicted the SIPSO social component, but again the adjusted R2 was low (.09). CONCLUSIONS: Measures of physical performance including muscle strength and mobility at discharge can partially predict HRQoL and community reintegration 6 months later. Further research is necessary for more accurate predictions.

Motor Planning for Loading During Gait in Subacute Stroke.

OBJECTIVES: To determine the characteristics of motor planning surrounding initial contact during gait through examination of thigh muscle timing, amplitude, and co-contraction of the paretic and nonparetic limbs in people poststroke, and to investigate whether muscle timing, amplitude, and clinical performance measures of balance and mobility differ based on the level of co-contraction. DESIGN: Observational study. SETTING: University-based research laboratory. PARTICIPANTS: Individuals (n=27) in the subacute phase after stroke and healthy controls (n=8) (N=35). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Timing (onset and offset) and normalized amplitude (percent electromyography maximum) of the biceps femoris (BF) and rectus femoris (RF) muscles were measured during terminal swing and early stance. A co-contraction index (CCI) was calculated for the BF and RF muscle activity. Individuals with CCI values equal to or below the mean of the healthy group were in the low CCI group, whereas those with values above the mean were in the high CCI group. Functional balance and mobility evaluation used the Community Balance and Mobility Scale (CB&M). RESULTS: For the paretic and nonparetic limbs, measures of timing, amplitude, and co-contraction were similar for both limbs. Compared with the healthy group, the high CCI group had lower CB&M scores, longer durations, and higher levels of RF and BF muscle activity, whereas the low CCI group had electromyographic measures statistically similar to healthy controls. CONCLUSIONS: The motor control of gait after subacute stroke is characterized by symmetry of timing and amplitude of muscle recruitment at the knee. High co-contraction levels surrounding the knee were associated with lower functional balance and mobility. These findings suggest a compensatory strategy of increased co-contraction in those with more impairment while maintaining symmetry of lower-limb biomechanics between limbs.

Evaluation of measures of upper limb functioning and disability in people with Parkinson disease: a systematic review.

OBJECTIVES: To identify measurement tools used for upper limb evaluation in people with Parkinson disease (PD), to summarize the content of each tool using the International Classification of Functioning, Disability and Health, and to examine the reliability, validity, clinical utility, and responsiveness of the measurement tools specific to this clinical group. DATA SOURCES: Two systematic searches of online databases included articles published from inception to November 2013. STUDY SELECTION: Search 1 identified upper limb measures. Search 2 retrieved studies investigating the measurement properties of these tools in people with PD. DATA EXTRACTION: Independent reviewers screened articles and extracted data, classified measurement tool content on the basis of the International Classification of Functioning, Disability and Health content domains, and applied both the COnsensus-based Standards for the selection of health status Measurement INstruments checklist to evaluate the study's methodological quality and a second checklist by Terwee et al to assess the measurement tool's quality. A third reviewer adjudicated differences between reviewers. Information on clinical utility was also compiled. DATA SYNTHESIS: The 18 identified measures included PD-specific scales, generic measures, and tools developed for other clinical populations; most measures evaluated impairments and/or activity limitations. Measurement properties of 10 of the 18 identified measures were evaluated in people with PD. No high-quality studies investigated validity or responsiveness. High-quality evidence supported the interrater reliability of some Unified Parkinson's Disease Rating Scale subtests, and lower quality studies provided limited evidence for the test-retest reliability of measures evaluating fine hand function and bradykinesia. CONCLUSIONS: There are relatively few high-quality studies to support the measurement properties, particularly the validity and responsiveness, of tools currently used to evaluate upper limb disability and function in people with PD. Further research is needed to inform measurement tool selection and treatment evaluation in this clinical group.

Instrumenting gait assessment using the Kinect in people living with stroke: reliability and association with balance tests.

BACKGROUND: The Microsoft Kinect has been used previously to assess spatiotemporal aspects of gait; however the reliability of this system for the assessment of people following stroke has not been established. This study examined the reliability and additional information that the Kinect provides when instrumenting a gait assessment in people living with stroke. METHODS: The spatiotemporal variables of step length, step length asymmetry, foot swing velocity, foot swing velocity asymmetry, peak and mean gait speed and the percentage difference between the peak and mean gait speed were assessed during gait trials in 30 outpatients more than three months post-stroke and able to stand unsupported. Additional clinical assessments of functional reach (FR), step test (ST), 10 m walk test (10MWT) and the timed up and go (TUG) were performed, along with force platform instrumented assessments of center of pressure path length velocity during double-legged standing balance with eyes closed (DLEC), weight bearing asymmetry (WBA) and dynamic medial-lateral weight-shifting ability (MLWS). These tests were performed on two separate occasions, seven days apart for reliability assessment. Separate adjusted multiple regressions models for predicting scores on the clinical and force platform assessments were created using 1) the easily assessed clinically-derived gait variables 10MWT time and total number of steps; and 2) the Kinect-derived variables which were found to be reliable (ICC > 0.75) and not strongly correlated (Spearman's ρ < 0.80) with each other (i.e. non-redundant). RESULTS: Kinect-derived variables were found to be highly reliable (all ICCs > 0.80), but many were redundant. The final regression model using Kinect-derived variables consisted of the asymmetry scores, mean gait velocity, affected limb foot swing velocity and the difference between peak and mean gait velocity. In comparison with the clinically-derived regression model, the Kinect-derived model accounted for >15% more variance on the MLWS, ST and FR tests and scored similarly on all other measures. CONCLUSIONS: In conclusion, instrumenting gait using the Kinect is reliable and provides insight into the dynamic balance capacity of people living with stroke. This system provides a minimally intrusive method of examining potentially important gait characteristics in people living with stroke.

Protocol for a randomized controlled clinical trial investigating the effectiveness of Fast muscle Activation and Stepping Training (FAST) for improving balance and mobility in sub-acute stroke.

BACKGROUND: Following stroke, many people have difficulty activating their paretic muscles quickly and with sufficient power to regain their balance by taking quick and effective steps. Reduced dynamic balance and mobility following stroke, or 'walking balance', is associated with reduced self-efficacy and restrictions in daily living activities, community integration, and quality of life. Targeted training of movement speeds required to effectively regain balance has been largely overlooked in post-stroke rehabilitation. The Fast muscle Activation and Stepping Training (FAST) program incorporates fast functional movements known to produce bursts of muscle activation essential for stepping and regaining standing balance effectively. The purpose of this study is to: 1) compare the effectiveness of an outpatient FAST program to an active control outpatient physiotherapy intervention in improving walking balance following stroke, and 2) explore potential mechanisms associated with improvements in walking balance. METHODS/DESIGN: This will be an assessor-blinded, parallel group randomized controlled trial design. Sixty participants (30 per group) who have sustained a stroke within the previous six months will be randomly assigned with stratification for lower limb motor recovery to receive twelve 45-minute 1:1 physiotherapy intervention sessions over 6 - 10 weeks in an outpatient setting of either: 1) FAST intervention - systematic and progressive practice of fast squatting and stepping exercises, or 2) active control - conventional physiotherapy directed at improving balance and mobility that includes no targeted fast movement training. The same blinded research physiotherapist will assess outcomes at three time points: 1) baseline (prior to intervention), 2) follow up (within one week post-intervention); and 3) retention (one month post-intervention). The primary outcome is dynamic balance assessed using the Community Balance and Mobility Scale. We will also assess fast and self-selected walking speed, balance self-efficacy, and the ability to respond to internal and external perturbations to balance and associated changes in postural muscle activation. DISCUSSION: The targeted training of fast functional movements in the FAST program is expected to improve walking balance following stroke compared to the active control intervention. Unique to this study is the investigation of potential mechanisms associated with improvements in walking balance. TRIAL REGISTRATION: NCT01573585.

Effectiveness and feasibility of virtual reality and gaming system use at home by older adults for enabling physical activity to improve health-related domains: a systematic review.

BACKGROUND: use of virtual reality and commercial gaming systems (VR/gaming) at home by older adults is receiving attention as a means of enabling physical activity. OBJECTIVE: to summarise evidence for the effectiveness and feasibility of VR/gaming system utilisation by older adults at home for enabling physical activity to improve impairments, activity limitations or participation. METHODS: a systematic review searching 12 electronic databases from 1 January 2000-10 July 2012 using key search terms. Two independent reviewers screened yield articles using pre-determined selection criteria, extracted data using customised forms and applied the Cochrane Collaboration Risk of Bias Tool and the Downs and Black Checklist to rate study quality. RESULTS: fourteen studies investigating the effects of VR/gaming system use by healthy older adults and people with neurological conditions on activity limitations, body functions and physical impairments and cognitive and emotional well-being met the selection criteria. Study quality ratings were low and, therefore, evidence was not strong enough to conclude that interventions were effective. Feasibility was inconsistently reported in studies. Where feasibility was discussed, strong retention (≥70%) and adherence (≥64%) was reported. Initial assistance to use the technologies, and the need for monitoring exertion, aggravation of musculoskeletal symptoms and falls risk were reported. CONCLUSIONS: existing evidence to support the feasibility and effectiveness VR/gaming systems use by older adults at home to enable physical activity to address impairments, activity limitations and participation is weak with a high risk of bias. The findings of this review may inform future, more rigorous research.

Clinical feasibility of the Nintendo Wii™ for balance training post-stroke: a phase II randomized controlled trial in an inpatient setting.

OBJECTIVE: To investigate the feasibility and potential efficacy of the Nintendo Wii™ for balance rehabilitation after stroke. DESIGN: Phase II, single-blind, randomized controlled trial. SETTING: Inpatient rehabilitation facility. SUBJECTS: Thirty adults (mean age 63.6 (14.7) years) undergoing inpatient rehabilitation who were less than three months post-stroke and able to stand unsupported. INTERVENTIONS: Participants were allocated to a Balance Group, using the 'Wii Fit Plus' in standing, or Upper Limb Group, using the 'Wii Sports/Sports Resort' in sitting. Both groups undertook three 45 minute sessions per week over two to four weeks in addition to standard care. MAIN MEASURES: The primary focus was feasibility, addressed by recruitment, retention, adherence, acceptability and safety. Efficacy was evaluated by balance, mobility and upper limb outcomes. RESULTS: Twenty-one percent of individuals screened were recruited and 86% (n = 30) of eligible people agreed to participate. Study retention and session adherence was 90% and > 99%, respectively, at two weeks; dropping to 70% and 87% at four weeks due to early discharge. All participants reported enjoying the sessions and most felt they were beneficial. No major adverse events occurred. Wii use by the Balance Group was associated with trends for improved balance, with significantly greater improvement in outcomes including the Step Test and Wii Balance Board-derived centre of pressure scores. The Upper Limb Group had larger, non-significant changes in arm function. CONCLUSIONS: A Wii-based approach appears feasible and promising for post-stroke balance rehabilitation. A larger randomized controlled trial is recommended to further investigate efficacy.

Postural control and fear of falling assessment in people with chronic obstructive pulmonary disease: a systematic review of instruments, international classification of functioning, disability and health linkage, and measurement properties.

OBJECTIVES: To systematically review the instruments used to assess postural control and fear of falling in people with chronic obstructive pulmonary disease (COPD), and to synthesize and evaluate their breadth of content and measurement properties. DATA SOURCES: MEDLINE, EMBASE, Web of Science, CINAHL, CENTRAL, PsycINFO, PEDro, and OTSeeker databases searched in September 2012. STUDY SELECTION: Two independent reviewers performed the selection of articles, the ICF linking process and quality assessment. Only quantitative studies were included, irrespective of language or publication date. DATA EXTRACTION: This systematic review comprised two phases. Phase 1 aimed to identify the commonly used instruments to assess postural control and fear of falling in the COPD literature. The breadth of content of each instrument was examined based on the International Classification of Functioning, Disability and Health (ICF). In phase 2, a measurement property search filter was adopted and used in four electronic databases to retrieve properties reported in the COPD population. The COSMIN checklist was used to assess the methodological quality of each measurement property reported. DATA SYNTHESIS: Seventeen out of 401 publications were eligible in phase 1. Seventeen instruments were identified including 15 for postural control and 2 for fear of falling assessment. The Berg Balance Scale, the Short Physical Performance Battery, and the Activities-specific Balance Confidence (ABC) scale were the most frequently used instruments to assess postural control and fear of falling respectively. The ICF categories covered varied considerably among instruments. The Balance Evaluation Systems test and ABC presented the greatest breadth of content. Measurement properties reported included criterion predictive validity (4 instruments), construct validity (11 instruments) and responsiveness (1 instrument), with inconsistent findings based on 'fair' and 'poor' quality studies. CONCLUSIONS: Different instruments with heterogeneous content have been used to assess postural control and fear of falling outcomes. Standardized assessment methods and best evidence on measurement properties is required in the COPD literature.

Pilot of a Training Format for Clinicians' Continuing Professional Development: Open House With Rotating Short Segments.

INTRODUCTION: Access to continuing professional development offered at lunchtime is limited by hospital scheduling that has staff members taking their lunch breaks at different times. To overcome this barrier, we developed a three-part training format with (1) a focus group segment soliciting participants' opinions on the training's target behavior, (2) a didactic segment introducing tools to support the behavior, and (3) a question-and-answer segment about the session topic. We rotated through these segments, each 15 minutes long, over 3 hours. Participants could join at any segment and experience the full curriculum after 45 minutes. METHODS: We piloted this training format five times at three hospitals. Our training aimed to encourage clinicians to consistently inform involuntary patients about their Mental Health Act rights. We gauged the effect of the training and participants' opinions of the session using the Continuing Professional Development Reaction questionnaire and a session evaluation, respectively. RESULTS: Continuing Professional Development-Reaction results (n = 80) showed a detectable increase in clinicians' intent to consistently give involuntary patients rights advice. Participants reported finding the training organized, informative, and valuable. DISCUSSION: The open house with rotating short segments is a feasible and adaptable training format to engage clinicians in voluntary continuing professional development.

Organizational supports for knowledge translation in paediatric health centres and research institutes: insights from a Canadian environmental scan.

BACKGROUND: Organizational supports are thought to help address wide-ranging barriers to evidence-informed health care (EIHC) and knowledge translation (KT). However, little is known about the nature of the resources and services that exist within paediatric health care and research settings across Canada to facilitate evidence use in health care delivery. This survey examined existing supports for EIHC/KT within these organizations to inform the design of similar EIHC/KT support programmes. METHODS: A national environmental scan was conducted using a bilingual online survey distributed to leaders at Canadian paediatric academic health science centres and their affiliated research institutes. Participants were invited through email, social media and webinar invitations and snowball sampling. Supports of interest included personnel, resources, services, organizational structures or processes, and partnerships or collaborations; barriers and successes were also probed. Data were compiled by site, reported using descriptive statistics, or grouped thematically. Supports were described using the AIMD (Aims, Ingredients, Mechanism, Delivery) framework. RESULTS: Thirty-one respondents from 17 sites across seven provinces represented a 49% site response rate. Eleven (65%) sites reported an on-site library with variable staffing and services. Ten (59%) sites reported a dedicated KT support unit or staff person. Supports ranged from education, resource development and consultation to protocol development, funded initiatives and collaborations. Organizations leveraged internal and external supports, with the majority also employing supports for clinical research integration. Supports perceived as most effective included personnel, targeted initiatives, leadership, interdepartmental expertise, external drivers and logistical support. Barriers included operational constraints, individual-level factors and lack of infrastructure. CONCLUSIONS: This first survey of organizational supports for EIHC/KT identified the range of supports in place in paediatric research and health care organizations across Canada. The diversity of supports reported across sites may reflect differences in resource capacity and objectives. Similarities in EIHC/KT and research integration supports suggest common infrastructure may be feasible. Moreover, stakeholder engagement in research was common, but not pervasive. Tailored support programmes can target multi-faceted barriers. Findings can inform the development, refinement and evaluation of EIHC/KT support programmes and guide the study of the effectiveness and sustainability of these strategies.

A qualitative study of clinicians' perspectives on independent rights advice for involuntary psychiatric patients in British Columbia, Canada.

BACKGROUND: In British Columbia (BC), Canada, clinicians are responsible for giving involuntary psychiatric patients rights information upon admission. Yet an investigation by the BC Office of the Ombudsperson found that clinicians are not always fulfilling this responsibility. The Ombudsperson recommended that the provincial government fund an independent body to give rights advice to patients. METHODS: To understand how clinicians feel about this recommendation, focus groups of clinicians who may give psychiatric patients rights information (n = 81) were conducted in Vancouver, BC, to probe their attitudes toward independent rights advisors. The focus group transcripts were thematically analyzed. RESULTS: Most clinicians believe that giving rights information is within their scope of practice, although some acknowledge that it poses a conflict of interest when the patient wishes to challenge the treatment team's decisions. Participants' chief concerns about an independent rights-advice service were that (a) patients may experience a delay in receiving their rights information, (b) integrating rights advisors into the workflow would complicate an already chaotic admission process, and (c) more patients would be counselled to challenge their hospitalization, leading to an increased administrative workload for clinical staff. However, many participants believed that independent rights advisors would be a positive addition to the admission process, both allowing clinicians to focus on treatment and serving as a source of rights-related information. CONCLUSIONS: Participants were generally amenable to an independent rights-advice service, suggesting that the introduction of rights advisors need not result in an adversarial relationship between treatment team and patient, as opponents of the proposal fear. Clearly distinguishing between basic rights information and in-depth rights advice could address several of the clinicians' concerns about the role that independent rights advisors would play in the involuntary admission process. Clinicians' and other stakeholders' concerns should be considered as the province develops its rights-advice service.

Hand dexterity assessment in Parkinson's disease: construct validity of the 9-Hole peg test for the more affected hand.

PURPOSE: There is limited understanding of the characteristics and evaluation of more affected hand dexterity loss in Parkinson's disease. We described 9-Hole Peg Test performance for the more affected hand and examined the construct validity of these pegboard scores in mild to severe Parkinson's disease. Methods: This observational study analysed baseline data from a cluster-randomised controlled trial.Participants (n = 582) completed the pegboard with their more affected hand, the Patient-Specific Index-Parkinson's Disease and Self-assessment Parkinson's Disease Disability Scale. Mean pegboard performance was summarised at each disease stage. To investigate known groups validity, we explored differences in pegboard scores between participants identifying upper limb problems in their 'top three' functional limitations, and those prioritising other limitations. Convergent validity investigated correlations between pegboard performance and self-reported hand function. RESULTS: Pegboard performance was reduced compared with normative values, and problems with hand activities were reported at each disease stage. Significant differences in pegboard performance between the two functional limitation priority groups (p < 0.05), and moderate correlations between pegboard dexterity and hand function (Self-assessment Parkinson's Disease Disability Scale) provided evidence for construct validity. CONCLUSIONS: People with mild to severely disabling Parkinson's disease have reduced dexterity and problems with hand function. Evidence supported the construct validity of 9-Hole Peg Test more affected hand performance.IMPLICATIONS FOR REHABILITATIONPeople with mild to severely disabling PD experience dexterity loss and problems with hand function.It is important for clinicians to assess dexterity and hand function in people with this movement disorder.Evidence supports the construct validity of 9-Hole Peg Test for measuring more affected hand performance in Parkinson's disease.

Construct validity of the 9-Hole Peg Test and Purdue Pegboard Test in people with mild to moderately severe Parkinson's disease.

OBJECTIVES: To evaluate the construct validity of two dexterity measures, the 9-Hole Peg Test (9HPT) and Purdue Pegboard Test (PPT) in people with Parkinson's disease (PD). DESIGN: Cross-sectional observational study. SETTING: Testing was conducted at the university or in participants' homes. PARTICIPANTS: Thirty community dwelling people with mild to moderately severe PD and no major upper limb comorbidities or cognitive impairments. INTERVENTIONS: Pegboard tests were administered in the 'on' and 'end-of-dose' phases of participants' PD medication cycles. Participants rated hand function with two self-report questionnaires - the Manual Ability Measure-36 (MAM-36) and a subset of upper limb items from the MDS-UPDRS. To explore construct validity, we compared 'on' phase pegboard scores with normative values for unimpaired men and women and investigated relationships between pegboard scores and hand function questionnaires. RESULTS: In the 'on' phase, pegboard scores were poorer than normative values. Differences in individual subtest scores ranged between 10 and 41%. Correlations between self-reported hand function and pegboard scores were weak to moderately strong in the 'on' phase (r=0.21-0.51), and weak at 'end-of-dose' (r=0.13-0.22). Higher correlation coefficients were observed between hand function and PPT subtest scores than with hand function and 9HPT scores. Most participants reported difficulty with daily hand tasks. CONCLUSIONS: We found evidence for construct validity supporting the use of the 9HPT and PPT to evaluate people with mild to moderately severe PD when 'on', but not at the 'end-of-dose'. Results also suggest that the PPT may be more sensitive to PD-related changes in dexterity than the 9HPT.

Examining Coronary Revascularization Practice Patterns for Diabetics: Perceived Barriers, Facilitators, and Implications for Knowledge Translation.

BACKGROUND: The FREEDOM trial provided robust evidence that coronary artery bypass grafting (CABG) was superior to percutaneous coronary intervention (PCI) for coronary revascularization in patients with diabetes mellitus (DM) and multivessel coronary artery disease (MV-CAD). The present study examined practice pattern changes and perceived barriers and facilitators to implementing FREEDOM trial evidence in British Columbia (BC). METHODS: Using a population-based database of cardiac procedures in BC, PCI:CABG ratios from 2007-2014 were compared before and after publication of the FREEDOM trial in the 4 tertiary cardiac centres that provided both CABG and PCI. Surveys of barriers and facilitators to implementation of evidence in practice were completed by 57 health care providers (HCPs) attending educational outreach sessions conducted in 2016-17 at 5 tertiary cardiac centres in BC. RESULTS: The overall PCI:CABG ratio declined from 1.59 (95% confidence interval [CI] 1.48-1.70, range 1.16-1.86) before publication to 0.88 (95% CI 0.75-1.01, range 0.56-0.82) after publication (P < 0.01). This decline from before to after publication was significant in 3 centres, but not in the fourth centre (from 1.62 to 1.49; P = 0.61). Barriers were identified at the levels of evidence (applicability, credibility), HCP (awareness/knowledge, practice behaviours), patient (knowledge/misconceptions, preferences), and systems (siloing of care, financial disincentives, resource limitations, geography). Facilitators were additional studies/guidelines, education/dissemination, shared decision making, a heart team approach, changes to remuneration models, and increased resources. CONCLUSIONS: Following publication of the FREEDOM trial, the proportion of patients with DM and MV-CAD undergoing CABG increased in BC; however, practice patterns varied across cardiac centres. HCPs attributed these practice variations to multilevel barriers and facilitators. Future knowledge translation strategies should be multifaceted and tailored to identified determinants.