Developing an international competency and capability framework for advanced practice physiotherapy: a scoping review with narrative synthesis

INTRODUCTION

The need to address increasing numbers of people seeking care, insufficient numbers of physicians, and providing high-value and sustainable care has contributed to changing physiotherapy practice across the world, often referred to as advanced practice physiotherapy. Currently, there is no internationally standardized competency and capability framework to support advanced practice physiotherapy.

OBJECTIVES

This scoping review has two aims; 1) To identify and map out the competencies of advanced practice physiotherapy available in the literature. 2) To develop a competency and capability framework by mapping the competencies identified from the review.

DESIGN

The Arksey and O'Malley framework and the PRISMA Scoping review methodology were used. Databases searched included CINAHL Plus, MEDLINE Ovid, PubMed, and Scopus. The competency and capability framework was developed through a narrative synthesis approach.

RESULTS

Nineteen documents were included in the final review, with 13 grey literature (government reports, policy documents, thesis) and six research papers. Included publications came from the United Kingdom, Ireland, Australia, New Zealand, and Canada. The included documents covered predominantly musculoskeletal practice (n = 17). The others focused on cardiorespiratory care, incontinence and pelvic health. Through narrative synthesis, 27 competencies and capabilities were identified and grouped under seven domains.

CONCLUSION

The synthesis of this scoping review provides the first competency and capability framework for advanced practice physiotherapy that integrates competencies and capabilities from five different countries. With the expansion of advanced practice physiotherapy, the framework developed from this review is the first step towards international recognition, standardization and consistency of education and training of practitioners. CONTRIBUTION OF THE PAPER.

Developing a core competency and capability framework for advanced practice physiotherapy: A qualitative study

INTRODUCTION

There is an urgent need to develop an international competency and capability framework to support standardization of education and roles in advanced practice physiotherapy (APP). This need arose due to the rapid growth of the APP model of care, implemented out of necessity in the absence of agreement as to the competencies and capabilities or formal education required for the roles. This study explores the views and perceptions of practitioners and key stakeholders on a draft competency and capability framework for advanced practice physiotherapists.

OBJECTIVES

The purpose of this study was to: 1) gather feedback from key stakeholders (advanced practice physiotherapists, researchers, and leaders) on a draft competency and capability framework and 2) use that feedback to revise and improve the draft framework.

DESIGN

Qualitative study using a series of four multi-national online focus groups. Thematic analysis was conducted according to Braun and Clarke.

RESULTS

Sixteen participants from the United Kingdom, Ireland, Canada, Australia, and New Zealand participated in the study. Five themes were generated after data analysis: clinical expert, experienced communicator, strong leader, collaborator, and knowledge creator). A modified competency and capability framework was developed based on feedback from the focus groups and input from subject matter experts (SMEs).

CONCLUSION

This study provides a modified core competency and capability framework comprising 24 competencies grouped under six domains. This study is a step toward international standardization of advanced practice physiotherapy based on a commonly agreed framework for the education and training of advanced practice physiotherapists.

Advanced practice in physiotherapy: a global survey

INTRODUCTION

Advanced practice in physiotherapy represents a development in the practice of physiotherapy and has developed in different ways around the world. There is growing evidence to support advanced physiotherapy practice. In May 2019, the member organisations adopted the first World Physiotherapy policy on advanced practice in physiotherapy. However, to date, there is no evidence on the nature and extent of this practice globally.

OBJECTIVES

To investigate the extent to which advanced practice is present within the global physiotherapy community, to document the titles used, to describe the pathway to become an advanced physiotherapy practitioner and to investigate the barriers and facilitators to the development of the roles.

DESIGN

An online cross-sectional survey was sent to the various national associations of the World Physiotherapy.

PARTICIPANTS

Participants were the member organisations of World Physiotherapy.

INSTRUMENT

The survey comprised 14 questions. The questions were developed based on a review of the evidence around advanced practice and in-depth discussions with the expert group set up by World Physiotherapy.

RESULTS

A total of 82/112 MOs responded to the survey representing a 73% response rate. Fourteen respondents (14/82, 17%) indicated that they had formal roles in their country/territory. The terms specialist and advanced physiotherapy practitioner were often used interchangeably and were a source of confusion. Seventy-nine (11/14, 79%) percent stated that most advanced physiotherapy practitioners have a combination of clinical practice and a Master's or Doctoral degree. The major facilitators to the development and sustainability of the role were the research evidence, advocacy by the professional organisation, the need to reduce cost and the support received by the advanced physiotherapy practitioners from their employers.

CONCLUSION

The outcomes of this study provide a clearer understanding of how member organisations of World Physiotherapy defined advanced practice in physiotherapy and what titles are used. It provides insights into the barriers and facilitators to the development of advanced practice in physiotherapy.

536 Use of A Cost-Efficient Colonoscopy Simulation Model to Improve Endoscopy Skills During the COVID Pandemic

Introduction

The use of endoscopic simulators as a learning aid in surgical training has been well established. This has been emphasised during the challenging times of COVID-19. However, their utility for training is countered by the high cost of the equipment, with the most basic simulators costing upwards of £50,000.

Method

A simple polypectomy simulator model was created using a drain-pipe and surgical gloves. n = 9 junior doctors were timed in their ability to remove the 3 polyps from the simulator. The exercise was repeated over 6 sessions over the course of 3 weeks. Means were compared using ANOVA.

Results

There was a mean relative reduction of 75% in overall time taken to complete the task(p < 0.0001). This improvement was seen for both surgical trainees(p = 0.005) and FY1 novices(p < 0.0001) and junior doctors reported feeling more confident with basic Colonoscopic skills.

Conclusions

We have demonstrated an improvement in performance times across both surgical trainees and novices. In today’s era of COVID-19, when direct training opportunities may become more scarce, simple alternatives may become vital in ensuring progression of basic surgical skills such as endoscopy. This cheap polypectomy simulator can be easily re-created across surgical units and can be used as an adjunct to traditional endoscopic training

Core competencies for physiotherapists working with refugees: a scoping review

OBJECTIVE

To summarise the existing knowledge base that can inform the development of a core competency profile for physiotherapists to support and deliver rehabilitation services to refugees.

METHOD

In this scoping review, a comprehensive search of peer-reviewed and grey literature was conducted. The search parameters included studies relevant to the physiotherapy profession and published between 2000 and 2019. MEDLINE, EMBASE, CINAHL, PEDro, and Ovid PsycINFO databases were searched. Grey literature was accessed through website searches, Google Scholar, and direct requests.

FINDINGS

Three themes were identified in the literature. The first theme encompassed the physical and mental health of refugees. The second theme explored the cultural competence physiotherapists need to work with refugees. This theme included the cultural influences on health and healthcare and communication strategies that could be used to optimise healthcare for refugees. The last theme described refugees and the healthcare system which encompassed the challenges that refugees face in accessing healthcare and navigating the healthcare system. The main physiotherapy competencies detected in the literature were an understanding of refugee health, the administration of culturally competent care and knowledge of healthcare systems as they relate to refugees.

CONCLUSION

This comprehensive search identified three themes that can be used to inform the development of a competency profile for physiotherapists working with refugees. These themes are, however, rather vague and non-specific and signal the need for research to further examine the physiotherapy competencies necessary to provide the highest quality of care for this growing population.

Perioperative intravenous contrast administration and the incidence of acute kidney injury after major gastrointestinal surgery: prospective, multicentre cohort study

BACKGROUND

This study aimed to determine the impact of preoperative exposure to intravenous contrast for CT and the risk of developing postoperative acute kidney injury (AKI) in patients undergoing major gastrointestinal surgery.

METHODS

This prospective, multicentre cohort study included adults undergoing gastrointestinal resection, stoma reversal or liver resection. Both elective and emergency procedures were included. Preoperative exposure to intravenous contrast was defined as exposure to contrast administered for the purposes of CT up to 7 days before surgery. The primary endpoint was the rate of AKI within 7 days. Propensity score-matched models were adjusted for patient, disease and operative variables. In a sensitivity analysis, a propensity score-matched model explored the association between preoperative exposure to contrast and AKI in the first 48 h after surgery.

RESULTS

A total of 5378 patients were included across 173 centres. Overall, 1249 patients (23·2 per cent) received intravenous contrast. The overall rate of AKI within 7 days of surgery was 13·4 per cent (718 of 5378). In the propensity score-matched model, preoperative exposure to contrast was not associated with AKI within 7 days (odds ratio (OR) 0·95, 95 per cent c.i. 0·73 to 1·21; P = 0·669). The sensitivity analysis showed no association between preoperative contrast administration and AKI within 48 h after operation (OR 1·09, 0·84 to 1·41; P = 0·498).

CONCLUSION

There was no association between preoperative intravenous contrast administered for CT up to 7 days before surgery and postoperative AKI. Risk of contrast-induced nephropathy should not be used as a reason to avoid contrast-enhanced CT.

Leadership development of health and social care professionals: a systematic review

The need to develop leaders across all levels of the health system including clinical staff has been recognised. Investments are made by healthcare organisations each year to develop leadership within their workforce hence there is a need to evaluate these development programmes to investigate whether the stated objectives have been achieved. The aim of this review was to systematically review published literature on the effect of leadership development for health and social care professionals (HSCPs). The databases, CINAHL, EMBASE, ERIC, Medline, PsychInfo, Scopus and Web of Science, were systematically searched. After screening and quality analysis, nine full-text articles were included in the review. The included studies demonstrated a range of methodological quality and there was high variability in the leadership development programmes in terms of programme length, content, structure, participants and evaluation methods. Transformational leadership was the leadership model most frequently employed. The reported results suggest that these educational interventions have positive effects on participants such as improved leadership behaviours, increased confidence and workplace engagement. However, the mixed methodological quality of the studies and high variability between the courses mean that definitive recommendations for leadership development programmes for HSCPs cannot be made. High-quality, longitudinal studies using rigorous evaluation methods are needed to provide the necessary evidence to inform the development of future programmes.

Leadership in physiotherapy: experiences of leaders of physiotherapy professional organisations

Background

The changing demands of healthcare and ongoing advances in practice and technology require corresponding change and development of the physiotherapy profession. Physiotherapy professional organisations perform many important functions in ensuring the ongoing growth and success of the profession. The leaders of these organisations therefore have key roles in progressing the physiotherapy profession in their country. To date, however, there has been very little written about these physiotherapy leaders and their work for the profession.

Purpose

To explore the professional leadership journeys of international physiotherapy leaders and their experiences of leading physiotherapy professional organisations.

Methods

Semistructured interviews were conducted with a purposive sample of 16 physiotherapy leaders from a range of physiotherapy professional organisations from around the world. The interviews were analysed using inductive thematic analysis.

Results

Three main themes were found in the analysis of the data: ‘Leadership roles, behaviours and challenges’, ‘Perceptions of the profession of physiotherapy’ and ‘Leadership development’.

Conclusions

The physiotherapy leaders describe interesting and varied roles that can also be challenging and demanding. They recognise the many challenges facing the physiotherapy profession internationally and the need for physiotherapists to more effectively advocate for the profession and demonstrate leadership. Leadership development opportunities and mentoring may be potential strategies to enable the development of future leaders of the physiotherapy profession.

Leadership capabilities of physiotherapy leaders in Ireland: Part 2. Clinical specialists and advanced physiotherapy practitioners

Background: Investigation of the leadership capabilities of physiotherapy managers found that they report predominantly demonstrating capabilities associated with the human resource and structural frames. However, little is known about the leadership capabilities of clinical specialists and advanced physiotherapy practitioners (APPs) who also are identified as having responsibility for leadership. Objective: To explore clinical specialists´ and APPs' perceptions of their leadership capabilities and compare them with the reported leadership capabilities of physiotherapy managers. Methods: Semi-structured interviews were conducted with a purposive sample of 17 physiotherapy clinical specialists and APPs from a range of practice settings across Ireland. The interviews were analyzed using template analysis and the coding template was based on the Bolman and Deal Leadership framework. Results: The participants described demonstrating leadership capabilities associated with each of the four leadership frames. However, the language used by the clinical specialists/APPs suggested that they work predominantly through the human resource frame. Structural frame capabilities were reported by the clinical specialists/APPs and there were some differences to those reported by the managers. In keeping with the reported leadership capabilities of the physiotherapy managers, the employment of capabilities associated with the political frame varied between participants and symbolic frame capabilities were underused. Conclusion: There are many similarities in the self-reported leadership capabilities of managers and clinical specialists/APPs. However, differences were also noted. Both cohorts of physiotherapy leaders may benefit from specific development programs to develop leadership capabilities associated with the political and symbolic frames.

Leadership capabilities of physiotherapy leaders in Ireland: Part 1 physiotherapy managers

Background: Investigation of the leadership capabilities of physiotherapists is needed to allow understanding of current leadership practice and to enable appropriate training programs to be developed. Purpose: To explore physiotherapy managers´ perceptions of their leadership capabilities. Methods: Semi-structured interviews were conducted with a purposive sample of 18 physiotherapy managers from a range of public services and private practices in Ireland. The interviews were analyzed using template analysis and the coding template was based on the Bolman and Deal Leadership framework which details four leadership frames: structural, human resource, political, and symbolic. Results: The physiotherapy managers described demonstrating leadership capabilities associated with each of the four leadership frames. However, the language used by the physiotherapy managers suggested that they work predominantly through the structural and human resource frames. The employment of capabilities associated with the political frame varied between participants; some participants described working through this frame while others reported difficulties. The symbolic frame was underused; there were fewer examples given of capabilities such as communicating their vision, demonstrating passion and facilitating a positive workplace culture. Conclusions: Physiotherapy managers work predominantly through the structural and human resource frames. To successfully meet the leadership requirements of their roles physiotherapy managers may benefit from specific leadership development training to develop leadership capabilities in the political and symbolic frames.

Clinical physiotherapists’ experiences of leadership in physiotherapy in Ireland

Background

Previous studies indicated that physiotherapy managers and clinical specialists perceive themselves to be most effective at demonstrating leadership capabilities associated with the human resource and structural frames.

Aim

To investigate physiotherapists’ perceptions of the leadership capabilities of physiotherapy management in their workplace.

Methods

A quantitative study was performed using a paper-based survey with a purposive sample of physiotherapists. The survey asked participants to rate 24 leadership capabilities on two questions: ‘How important are these capabilities for physiotherapy management to demonstrate?’ and ‘How effective is physiotherapy management in your workplace at demonstrating these capabilities?’ The leadership capabilities were derived from the leadership framework of Bolman and Deal.

Results

The response rate was 55% (n=303). The Friedman test indicated that there was a significant difference in the ratings of importance of the leadership capabilities across the frames (X2(3)=9.362, P=0.025). Post-hoc analysis demonstrated that the symbolic leadership capabilities were rated more highly for importance than the structural leadership capabilities (Z=−2.640, P=0.008). There was also a significant difference in the ratings of effectiveness on the leadership capabilities across the frames (X2(3)=78.022, P<0.001). Physiotherapy management were rated as most effective at demonstrating structural and political frame capabilities and least effective on symbolic frame capabilities.

Conclusions

There is a discrepancy between the leadership capabilities that physiotherapists perceive physiotherapy management to be most effective at demonstrating and the leadership capabilities they perceive to be most important. Physiotherapy management may benefit from specific leadership programmes to develop their leadership capabilities in the symbolic frame.

Physiotherapy managers' perceptions of their leadership effectiveness: a multi-frame analysis

OBJECTIVES

The purpose of this study was to investigate the leadership frames of physiotherapy managers in Ireland. To be effective leaders in today's challenging healthcare environment physiotherapy managers must employ a comprehensive, adaptable and balanced leadership style.

DESIGN

This was a purposive, cross-sectional study.

PARTICIPANTS

Physiotherapy managers were surveyed using the Bolman and Deal Leadership Orientations Instrument.

SETTING

The survey was administered to members of the Chartered Physiotherapists in Management employment group (n=73) of the Irish Society of Chartered Physiotherapists via email.

RESULTS

Forty-five physiotherapy managers responded to the survey to give a response rate of 62%. The human resource frame was the most frequently used (61%) and the political frame was the least (9%). The majority of respondents reported using only one or no frames at all (65%). When asked about their effectiveness as a manager 33% of respondents (n=14) gave themselves the top rating of 5, whereas 19% of respondents (n=8) gave themselves the top rating for their leadership effectiveness. There was a statistically significant trend between the number of leadership frames a physiotherapy manager used and their perceived effectiveness as a manager (T_JT=380, z=1.975, p=0.048) and as a leader (T_JT=431, z=3.245, p=0.001).

CONCLUSIONS

The physiotherapy managers' use of the human resource frame demonstrates that they see the building of relationships as key to effective leadership. Development of physiotherapy managers' underused skills through appropriate leadership development training may enhance their leadership skill set and make them more confident as leaders.

Perceptions of Leadership: Comparing Canadian and Irish Physiotherapists' Views

Purpose: To contribute to the growing body of research on leadership in physiotherapy by comparing leadership-related perceptions of physiotherapists in Ireland and in Canada. Methods: This article compares the results of a survey of Canadian physiotherapists with those of the same survey administered to Irish physiotherapists. The results of both studies have previously been reported and are used here to allow a cultural comparison of the perceptions of physiotherapists. The present study used two-portion Z-tests to compare the percentage of physiotherapists in Ireland who self-declared as a leader with the percentage of physiotherapists in Canada who did so. Results: Physiotherapists in both Ireland and Canada most often rated communication and professionalism as extremely important characteristics. Physiotherapists in Canada were more likely than those in Ireland to perceive themselves as leaders (Z=2.67, p < 0.05; 95% CI: 1.33, 9.87). Factors associated with self-declaration as a leader differed between the two countries. Conclusion: Physiotherapists in Canada and Ireland showed both similarities and differences in their perceptions of leadership characteristics. Results from this study may aid the development of future leadership training programmes specifically targeted at physiotherapists.

Leadership and leadership development within the profession of physiotherapy in Ireland

BACKGROUND

Health service reform, physiotherapy graduate unemployment, and the impending introduction of state regulation mean that physiotherapists in Ireland today are facing many challenges. Leadership is needed to ensure that the profession will be able to adapt to the demands and inevitable changes ahead.

OBJECTIVE

To investigate the perceptions of physiotherapists in Ireland of leadership and leadership characteristics, and to explore their participation in leadership development training.

METHODS

In this cross-sectional nationwide study, an Internet-based survey was administered via e-mail to members of the Irish Society of Chartered Physiotherapists (n = 2,787).

RESULTS

There were 615 responses to the survey. A high proportion of respondents (74.0%) perceived themselves to be a leader. Factors associated with self-declaration as a leader were time since graduation, highest qualification attained, and leadership training. Leadership training was also associated with placing greater importance on achieving a leadership position. Some form of leadership training had been completed by 41.5% of respondents. Communication and professionalism were the most highly rated leadership characteristics in all three settings.

CONCLUSION

Physiotherapists who have had leadership training were more likely to perceive themselves to be leaders. Leadership training may support physiotherapists to assume leadership roles both clinically and nonclinically.

Ability of physiotherapists to undertake evidence-based practice steps: a scoping review

BACKGROUND

Evidence-based practice (EBP) is promoted to ensure quality of care. However, analysis of the skill of physiotherapists in undertaking the steps of EBP, or the impact of EBP on the work of physiotherapists is limited.

OBJECTIVES

To conduct a scoping review into physiotherapists performing the steps of EBP.

DATA SOURCE

Literature concerning the skill of physiotherapists in EBP between 1990 and June 2013 was searched using AMED, Academic Search Complete, CINAHL, PubMed, ERIC, PEDRO and EMBASE databases.

STUDY SELECTION

Twenty-five studies (six qualitative, one mixed methods and 18 quantitative) were selected.

DATA EXTRACTION AND SYNTHESIS

Quantitative and qualitative data were extracted using two appraisal tools to analyse each of the five steps of EBP.

RESULTS

Limited evidence exists to show that physiotherapists undertake the full EBP process. Despite formulating clinical questions and acquiring literature-based evidence, the drivers for conducting literature or evidence searches have not been clarified. The critical appraisal step was mainly assessed in the form of recognition of statistical terms. Only examples of guideline usage support the reflective final assessment step. Physiotherapists report using their peers and other trusted sources in preference to literature, primarily due to time but also due to divergence between the literature-based evidence and other evidence that they use and value (tacit knowledge). A positive impact of EBP on patient outcomes is lacking.

CONCLUSIONS

Understanding the information needs of physiotherapists may be necessary before adoption of the EBP process. The use of professional networks may offer a better means to identify knowledge gaps and translate acquired knowledge into practice, rather than focusing on individual skills in EBP.

Executive dysfunction and balance function post-stroke: A cross-sectional study

OBJECTIVES

This study investigated the: (1) prevalence of executive dysfunction (ED); (2) demographic and clinical differences between participants with ED and without ED and; (3) independent association between executive function (EF) and balance post-stroke.

DESIGN

Prospective observational cross-sectional study.

SETTING

Four large acute hospitals.

PARTICIPANTS

Convenience sample of people with first stroke.

MAIN OUTCOME

Balance function.

SECONDARY OUTCOMES

EF, stroke severity, depression and global cognition.

METHODS

Descriptive statistics were used to report the prevalence of ED post-stroke. Comparisons of demographic and clinical characteristics were made between participants with ED and participants without ED using independent t-tests. Hierarchical multiple linear regression analysis determined the association between EF and balance post-stroke.

RESULTS

Participant (n=100) age ranged from 31 to 98 years, time since stroke ranged from 4 to 180 days and the participants reported formal education ranging from 7 to 21 years. Participants with ED had more severe strokes (BADS) [median (IQR) vs. median (IQR), p-value] [(44 (16) vs. (51 (7), p<0.01], poorer global cognition [24 (6) vs. 29 (2), p<0.01] and poorer balance [29 (40) vs. 46.5 (17), p<0.01] in comparison with participants without ED. Age (β=-0.24, p<0.05), years in education, (β=-0.21, p<0.05), stroke severity (β=0.71, p<0.01), time since stroke, (β=-0.17, p<0.01) and EF (β=0.19, p<0.05) were independently associated with balance post-stroke. The total variance in balance explained by the model was 72%.

CONCLUSIONS

ED is independently associated with balance post-stroke. Physiotherapists should consider this when developing rehabilitation strategies to improve balance post-stroke.

Devastating decline of forest elephants in central Africa

African forest elephants- taxonomically and functionally unique-are being poached at accelerating rates, but we lack range-wide information on the repercussions. Analysis of the largest survey dataset ever assembled for forest elephants (80 foot-surveys; covering 13,000 km; 91,600 person-days of fieldwork) revealed that population size declined by ca. 62% between 2002-2011, and the taxon lost 30% of its geographical range. The population is now less than 10% of its potential size, occupying less than 25% of its potential range. High human population density, hunting intensity, absence of law enforcement, poor governance, and proximity to expanding infrastructure are the strongest predictors of decline. To save the remaining African forest elephants, illegal poaching for ivory and encroachment into core elephant habitat must be stopped. In addition, the international demand for ivory, which fuels illegal trade, must be dramatically reduced.

An ergonomic modular foot platform for isometric force/torque measurements in poststroke functional assessment: a pilot study

The main goal of this article is to present the design, technical development, and preliminary validation of an innovative mechatronic device for force/torque measurements taken from the human foot using pilot data. The device, formed by a mobile platform equipped with two six-axis force/torque sensors, was used to perform accurate quantitative measurements during isometric exercises, aimed at performing functional assessment tests in poststroke patients undergoing a rehabilitation treatment. Results from pilot data provide a validation of the device. A large clinical trial has been planned to test whether the platform can be used in the clinical practice. We suggest that measurements of ground reaction forces taken from the foot of poststroke patients during the initiation of activities of daily living tasks can provide information about their motor recovery and enlighten possible areas of application, ranging from isometric motor exercise in neurorehabilitation to foot-based human-machine interface.

Randomised controlled trial of the efficacy of a high-fluoride gel self-applied by toothbrushing in children at high caries risk

The primary objective of this clinical trial was to assess the caries-preventive efficacy of 2 years of twice weekly supervised brushing with a self-applied gel containing 12,500 ppm fluoride on schooldays compared with weekly supervised use in children at high caries risk (with prior caries experience on first permanent molars). The secondary objective was to assess efficacy compared with similar children who continued with their usual oral hygiene care. This was a single-centre, single-blind, randomised, parallel-groups trial comprising two test groups and one untreated control group. 1,075 pupils aged 12-13 years at baseline received a baseline and final examination 2 years later. For all children completing the trial no significant difference was found between groups. For children compliant with study protocol no significant difference was found in the primary outcome (D(1)FS caries increment), but significant differences were found between the three groups overall in the secondary outcome, D(3)FT caries increment, with a significant pairwise difference between control and twice per week gel brushing (29%, p = 0.023 D(3)FT visual + fibre-optic transillumination). Analysis of the relationship between number of gel applications and caries showed that children who brushed with the gel at least 60 times over a 2-year period developed significantly fewer carious lesions into dentine than children who followed their usual oral hygiene routine. Some caution is needed as greatest benefit was shown by compliant children. Where schools are co-operative, it is recommended that the gel be used twice a week within a school-based programme over a 2-year period.

Family-mediated exercise intervention (FAME): evaluation of a novel form of exercise delivery after stroke

BACKGROUND AND PURPOSE

Additional exercise therapy has been shown to have a positive impact on function after acute stroke and research is now focusing on methods to increase the amount of therapy that is delivered. This randomized controlled trial examined the impact of additional family-mediated exercise (FAME) therapy on outcome after acute stroke.

METHODS

Forty participants with acute stroke were randomly assigned to either a control group who received routine therapy with no formal input from their family members or a FAME group, who received routine therapy and additional lower limb FAME therapy for 8 weeks. The primary outcome measure used was the lower limb section of the Fugl-Meyer Assessment modified by Lindmark. Other measures of impairment, activity, and participation were completed at baseline, postintervention, and at a 3-month follow-up.

RESULTS

Statistically significant differences in favor of the FAME group were noted on all measures of impairment and activity postintervention (P<0.05). These improvements persisted at the 3-month follow-up but only walking was statistically significant (P<0.05). Participants in the FAME group were also significantly more integrated into their community at follow-up (P<0.05). Family members in the FAME group reported a significant decrease in their levels of caregiver strain at the follow-up when compared with those in the control group (P<0.01).

CONCLUSIONS

This evidence-based FAME intervention can serve to optimize patient recovery and family involvement after acute stroke at the same time as being mindful of available resources.

Capabilities of HPLC with APEX-Q nebulisation ICP-MS and ESI MS/MS to compare selenium uptake and speciation of non-malignant with different B cell lymphoma lines

The formation of intracellular dimethylselenide (DMSe) as a product of exposure of non-malignant (PBMCs) and lymphoma (RL and DHL-4) cell lines to methylseleninic acid (MSA) at clinical levels is suggested here for the first time. This was achieved by analysis of cell lysates by HPLC coupled to ICP-MS via APEX-Q nebulisation, enabling limits of detection for target methyl-Se species which are up to 12-fold lower than those obtained with conventional nebulisation. Methyl-Se-glutathione (CH₃Se-SG), although detected in lysates of cells exposed to MSA, was found to be a reaction product of MSA with glutathione. This was confirmed by HPLC-ESI MS (MS) analysis of lysates of control cells (unexposed to Se) spiked with MSA. The MS/MS data obtained by collision-induced dissociation fragmentation of the ion m/z 402 (for [M+H](+) ⁸⁰Se) were consistent with the presence of CH₃Se-SG. Formation of DMSe was not detected by HPLC-ICP-MS in these spiked lysates, and it was found to require live cells in cell media containing MSA. Interestingly, the ratio of DMSe to CH₃Se-SG was significantly higher in lymphoma cells exposed to MSA in comparison to non-malignant cells. Moreover, maximum Se uptake levels in lymphoma cell lines seemed to be reached much earlier (after 10 min of MSA exposure) than in non-malignant cells. Finally, the GC-TOF-MS speciation data obtained for cell headspace suggested that the major Se species (dimethyldiselenide) appeared to be present in lymphoma cell headspace at significantly higher concentrations than in non-malignant cell headspace after only 10 min of exposure to MSA. Evidence for the presence of dimethylselenidesulfide in lymphoma cell headspace is also provided for the first time.

The right to remain silent: a qualitative study of the medical and social ramifications of pregnancy disclosure for Gambian women

OBJECTIVES

Control of infectious diseases in developing countries often requires using drugs that are contraindicated during pregnancy. Avoiding inadvertent exposure to drugs involves women (a) recognising pregnancy early, (b) disclosing the pregnancy to health workers and (c) using medicines in an informed manner. We explored these factors to inform and improve the process by which health workers provide care and treatment to pregnant women.

DESIGN

Qualitative study.

SETTING

The Gambia.

POPULATION

Rural women and men.

METHODS

We conducted 41 interviews and 16 focus group discussions with women, adolescents, men and traditional birth attendants (TBAs).

MAIN OUTCOME MEASURE

Pregnancy disclosure.

RESULTS

Most women recognised early signs and symptoms of pregnancy and believed other people could easily do so. To avoid gossip, women hid their pregnancies and delayed antenatal care, even though husbands and TBAs insisted on attendance. Women acutely ill in early pregnancy hoped health workers would recognise pregnancy without explicit disclosure. Women said that they knew, and sought to avoid, some contraindicated drugs, but their knowledge was rudimentary. Health workers stressed the benefits, not the risks of prescribed drugs.

CONCLUSIONS

Despite public health and clinical benefits of preventing and treating pregnancy infections, women were ill informed and pressurised into taking drugs. These ethical issues should be more widely addressed.

The promotion of oral health within the Healthy School context in England: a qualitative research study

Background

Healthy Schools programmes may assist schools in improving the oral health of children through advocating a common risk factor approach to health promotion and by more explicit consideration of oral health. The objectives of this study were to gain a broad contextual understanding of issues around the delivery of oral health promotion as part of Healthy Schools programmes and to investigate the barriers and drivers to the incorporation of oral health promoting activities in schools taking this holistic approach to health promotion.

Methods

Semi-structured telephone interviews were carried out with coordinators of Healthy Schools programmes in the Northwest of England. Interview transcripts were coded using a framework derived from themes in the interview schedule.

Results

All 22 Healthy Schools coordinators participated and all reported some engagement of their Healthy Schools scheme with oral health promotion. The degree of this engagement depended on factors such as historical patterns of working, partnerships, resources and priorities. Primary schools were reported to have engaged more fully with both Healthy Schools programmes and aspects of oral health promotion than secondary schools. Participants identified healthy eating interventions as the most appropriate means to promote oral health in schools. Partners with expertise in oral health were key in supporting Healthy Schools programmes to promote oral health.

Conclusion

Healthy Schools programmes are supporting the promotion of oral health although the extent to which this is happening is variable. Structures should be put in place to ensure that the engagement of Healthy Schools with oral health is fully supported.

The impact of increased duration of exercise therapy on functional recovery following stroke--what is the evidence?

This article focuses on the impact of increased duration of exercise therapy on functional recovery after stroke. A comprehensive literature search using multiple databases was used to identify all relevant randomized controlled trials. Their quality was reviewed by two independent assessors, and a narrative systematic review and meta-analysis was completed. Methodological quality of all the 20 randomized controlled trials (RCTs) identified had a median of 6 points (range 5-8) on the 10-point PEDro scale. A meta-analysis was completed for studies that had a common outcome measure. For each outcome measure, the estimated effect size (ES) and the summary effect size (SES) were expressed as standardized mean differences (SMD). The results of the meta-analysis demonstrated that increased duration of exercise therapy time has a small but positive effect on activities of daily living as measured by the Barthel Index (SES 0.13; CI 0.01-0.25; Z = 2.15; p = .03) and that these improvements are maintained over a 6-month period (SES 0.15; CI 0.05-0.26; Z = 2.8; p = .00). Pooling reported differences in the various upper and lower extremity outcome measures demonstrated no significant SESs. However, the meta-analysis is supportive of the hypothesis that additional, focused exercise on the lower extremity has a favourable effect on lower extremity impairment and walking speed. The narrative review raises a number of issues that need to be considered in the development of future RCTs.

The effect of the GENTLE/s robot-mediated therapy system on arm function after stroke

OBJECTIVE

To evaluate the effect of robot-mediated therapy on arm dysfunction post stroke.

DESIGN

A series of single-case studies using a randomized multiple baseline design with ABC or ACB order. Subjects (n = 20) had a baseline length of 8, 9 or 10 data points. They continued measurement during the B - robot-mediated therapy and C - sling suspension phases.

SETTING

Physiotherapy department, teaching hospital.

SUBJECTS

Twenty subjects with varying degrees of motor and sensory deficit completed the study. Subjects attended three times a week, with each phase lasting three weeks.

INTERVENTIONS

In the robot-mediated therapy phase they practised three functional exercises with haptic and visual feedback from the system. In the sling suspension phase they practised three single-plane exercises. Each treatment phase was three weeks long.

MAIN MEASURES

The range of active shoulder flexion, the Fugl-Meyer motor assessment and the Motor Assessment Scale were measured at each visit.

RESULTS

Each subject had a varied response to the measurement and intervention phases. The rate of recovery was greater during the robot-mediated therapy phase than in the baseline phase for the majority of subjects. The rate of recovery during the robot-mediated therapy phase was also greater than that during the sling suspension phase for most subjects.

CONCLUSION

The positive treatment effect for both groups suggests that robot-mediated therapy can have a treatment effect greater than the same duration of non-functional exercises. Further studies investigating the optimal duration of treatment in the form of a randomized controlled trial are warranted.