Purpose: The objective of this study was to validate the choice of simulated activities in a group of newly trained PW users.
Methods: We recruited 17 new PW users, who practiced with the miWe simulator at home for two weeks. They then related their experience through the Short Feedback Questionnaire, the perceived Ease of Use Questionnaire, and semi-structured interviews.
Results: Participants in general greatly appreciated their experience with the simulator. During the interviews, this group made similar comments about the activities as our previous group of expert PW users had done. They also insisted on the importance of realism in the miWe activities, for their use in training.
Discussion: A PW simulator may be helpful if it supports the practice of activities in specific contexts (such as a bathroom or supermarket), to complement the basic skills training received in the clinic (such as driving forward, backward, turning, and avoiding obstacles).
- Implications for Rehabilitation
New power wheelchair users appreciate practicing on a virtual reality simulator and find the experience useful when the simulated diving activities are realistic and ecologically valid.
User-centred development can lead to simulated power wheelchair activities that adequately capture everyday driving challenges experienced in various environmental contexts.
Method: Twenty-two inpatients with bipolar disorder, and 22 age-, gender- and body mass index-matched inpatients with schizophrenia and healthy controls were included. All participants performed the Eurofit test battery and the International Physical Activity Questionnaire. One way analyses of variance with post hoc Scheffe were applied to examine differences.
Results: Both patient groups were significantly more physically inactive and had a significantly impaired speed of limb movement, explosive muscle strength and abdominal muscular endurance compared to the healthy controls. No significant differences between the patient groups were found.
Conclusions: The results suggest that physical fitness and physical activity participation are similar among inpatients with bipolar disorder and schizophrenia but markedly lower than healthy controls. Chronic inpatients with lower levels of physical activity may particularly benefit from rehabilitation interventions aimed at increasing physical fitness.
- Implications for Rehabilitation
Physical fitness should receive similar attention in the treatment of bipolar disorder and schizophrenia.
Sedentary patients with a longer duration of illness need additional support in changing lifestyle behaviours.
Rehabilitation should not only consider cardio-respiratory fitness but also muscular endurance, muscular strength and balance.
Objectives: To examine whether real time feedback can be used to influence manual wheelchair propulsion biomechanics.
Review methods: Clinical trials and case series comparing the use of real time feedback against no feedback were included. A general review was performed and methodological quality assessed by two independent practitioners using the Downs and Black checklist. The review was completed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta Analyses (PRISMA) guidelines.
Results: Six papers met the inclusion criteria. Selected studies involved 123 participants and analysed the effect of visual and, in one case, haptic feedback. Across the studies it was shown that participants were able to achieve significant changes in propulsion biomechanics, when provided with real time feedback. However, the effect of targeting a single propulsion variable might lead to unwanted alterations in other parameters. Methodological assessment identified weaknesses in external validity.
Conclusions: Visual feedback could be used to consistently increase push arc and decrease push rate, and may be the best focus for feedback training. Further investigation is required to assess such intervention during outdoor propulsion.
- Implications for Rehabilitation
Upper limb pain and injuries are common secondary disorders that negatively affect wheelchair users’ physical activity and quality of life.
Clinical guidelines suggest that manual wheelchair users should aim to propel with a semi-circular pattern with low a push rate and large push arc in the range in order to minimise upper limbs’ loading.
Real time visual and haptic feedback are effective tools for improving propulsion biomechanics in both complete novices and experienced manual wheelchair users.
Objective: To examine the associations between patients’ self-rated health and their sleep problems, somatic health complaints, and unmet needs in interpersonal relationships.
Design: We collected data via questionnaires for this cross-sectional study from general practice.
Setting: Primary health care in Norway.
Subjects: 1302 consecutive patients participated.
Main outcome measures: The questionnaire included a single question about SRH, the Bergen Insomnia Scale (BIS), five questions on somatic health complaints, and three questions from the Basic Psychological Needs Scale (BPNS) pertaining to the relationships domain. We analyzed our data using ordinal logistic regression models.
Results: Our response rate was 74%. The prevalence of fair/poor SRH was 26%, with no gender differences. We revealed a significant association between increasing age and reduced SRH. The study showed that sleep problems and somatic health complaints were strongly associated with SRH, and unmet needs in relationships were also significantly and independently associated with reduced SRH in a full model analysis.
Conclusion: Sleep problems, somatic health complaints, and unmet needs in interpersonal relationships were all associated with reduced SRH. These factors are all modifiable and could be managed both within and outside a primary care setting in order to improve SRH.
- Key Points
There was a high prevalence of reduced SRH in clinical general practice
Sleep problems, somatic health complaints, and unmet needs in interpersonal relationships were all associated with reduced SRH
These predictors are all modifiable with a potential to improve SRH
Materials and methods: Seventeen novice able-bodied subjects performed a 120-min uninstructed practice distributed over 4 weeks. During the initial and final sessions, upper limbs kinematics and hand-rim kinetics were continuously collected. Inverse kinematics and dynamics coupled to a three-dimensional linked-segment model were used to compute shoulder net moments.
Results: Participants increased the speed of the wheelchair with practice. In average, an increase of shoulder net moments and mechanical work during the push phase was observed. Conversely, during the recovery phase, participants slightly increased shoulder power but maintained a similar level of shoulder loading. However, individual evolutions allowed the definition of two groups defined as: “increasers”, who increased shoulder loading and mechanical work versus “decreasers”, who managed to limit shoulder loading while improving the wheelchair speed.
Conclusion: These findings underline that individual adaptation strategies are essential to take into account when designing a rehabilitation protocol for wheelchair users.
- Implications for Rehabilitation
The learning process of manual wheelchair locomotion is essential for the assimilation of motor tasks leading individuals to select their propulsion technique.
Novice users display different learning strategies: some people increase shoulder loading very early but others spontaneously manage to increase the wheelchair speed while maintaining a constant level of shoulder loading.
Wheelchair rehabilitation programs should be individualized to take into account the subject-specific learning strategy.
Methods: A volunteer with motor complete T11 paraplegia repeatedly propelled his manual wheelchair over level ground and simulated destabilizing conditions including sudden stops, bumps and rough terrain. Wireless inertial measurement units attached to the wheelchair frame and his sternum recorded associated accelerations and angular velocities. Algorithms based on mean, standard deviation and minimum Mahalanobis distance between conditions were constructed and applied to the data off-line to discriminate between events. Classification accuracy was computed to assess effects of sensor position and potential for automatically selecting a dynamic intervention to best stabilize the wheelchair user.
Results: The decision algorithm based on acceleration signals successfully differentiated destabilizing conditions and level over-ground propulsion with classification accuracies of 95.8, 58.3 and 91.7% for the chest, wheelchair and both sensors, respectively.
Conclusion: Mahalanobis distance classification based on trunk accelerations is a feasible method for detecting destabilizing events encountered by wheelchair users and may serve as an effective trigger for protective interventions. Incorporating data from wheelchair-mounted sensors decreases the false negative rate.
- Implications for Rehabilitation
SCI has a significant impact on quality of life, compromising the ability to participate in social or leisure activities, and complete other activities of daily living for an independent lifestyle.
Using inertial measurement units to build an event classifier for control the actions of a neuroprosthetic device for maintaining seated posture in wheelchair users.
Varying muscle activation increases user stability reducing the risk of injury.
Design: We conducted focus groups (FGs) with 17 GPs.
Setting: Norwegian primary health care.
Subjects: 17 GPs who attended a 5 d course on leadership in primary health care.
Results: Our study suggests that the GPs experience a need for more preparation and formal training for the leadership role, and that they experienced tensions between the clinical and leadership role. GPs recognized the need to take on leadership roles in primary care, but their lack of leadership training and credentials, and the way in which their practices were organized and financed were barriers towards their involvement.
Conclusions: GPs experience tensions between the clinical and leadership role and note a lack of leadership training and awareness. There is a need for a more structured educational and career path for GPs, in which doctors are offered training and preparation in advance.
- KEY POINTS
Little is known about doctors’ experiences and views about leadership in general practice and primary health care. Our study suggests that:
There is a lack of preparation and formal training for the leadership role.
GPs experience tensions between the clinical and leadership role.
GPs recognize leadership challenges at a system level and that doctors should take on leadership roles in primary health care.
Methods: Decision trees underwent a four-stage process: literature review and expert consultation, designing, two-rounds of expert panel review and revisions, and target audience testing.
Results: Fifteen lower limb prosthesis users (average age 61 years) reviewed the decision trees and completed an acceptability questionnaire. Participants reported agreement of 80% or above in five of the eight questions related to acceptability of the decision trees. Disagreement was related to the level of experience of the respondent.
Conclusions: Decision trees were found to be easy to use, illustrate correct solutions to common issues, and have terminology consistent with that of a new prosthesis user. Some users with greater than 1.5 years of experience would not use the decision trees based on their own self-management skills.
- Implications for Rehabilitation
Discomfort of the residual limb-prosthetic socket interface is the most common reason for clinician visits.
Prosthesis users can use decision trees to guide them through the process of obtaining a proper socket fit independently.
Newer users may benefit from using the decision trees more than experienced users.
Design: A retrospective interrupted times series study.
Setting: Two multidisciplinary general practitioner (GP) practices.
Intervention: An internist provided in-house patient consultations in two GP practices and participated in the multidisciplinary meetings.
Subjects: The referral data extracted from the electronic medical record system of the GP practices, including all referral letters from the GPs to specialist care in the hospital setting.
Main outcome measures: The number of referrals to internal medicine in the hospital setting. This study used an autoregressive integrated moving average model to estimate the effect of the intervention taking account of a time trend and autocorrelation among the observations, comparing the pre-intervention period with the intervention period.
Results: It was found that the referrals to internal medicine did not statistically significant decrease during the intervention period.
Conclusions: This small explorative study did not find any clues to support that an in-house internist at a primary care setting results in a decrease of referrals to internal medicine in the hospital setting.
- Key Points
An in-house internist at a primary care setting did not result in a significant decrease of referrals to specialist care in the hospital setting.
The GPs and internist experience a learning-effect, i.e. an increase of knowledge about internal medicine issues.
Design: Secondary analysis of cross-sectional data from the 2014 Commonwealth Fund International Health Policy Survey of Older Adults.
Setting: 11 western countries.
Subjects: Community-dwelling adults, aged 55 or older.
Main outcome measure: Assessment of goals and priorities.
Results: The final sample size consisted of 17,222 respondents, 54% of whom reported an assessment of their goals and priorities (AGP) by healthcare professionals. In logistic regression model 1, which was used to analyse the entire population, the determinants found to have moderate to large effects on the likelihood of AGP were information exchange on stress, diet or exercise, or both. Country (living in Sweden) and continuity of care (no regular professional or organisation) had moderate to large negative effects on the likelihood of AGP. In model 2, which focussed on respondents who experienced continuity of care, country and information exchange on stress and lifestyle were the main determinants of AGP, with comparable odds ratios to model 1. Furthermore, a professional asking questions also increased the likelihood of AGP.
Conclusions: Continuity of care and information exchange is associated with a higher probability of AGP, while people living in Sweden are less likely to experience these assessments. Further study is required to determine whether increasing information exchange and professionals asking more questions may improve goal setting with older patients.
- Key points
A patient goal-oriented approach can be beneficial for older patients with chronic conditions or multimorbidity; however, discussing goals with these patients is not a common practice.
The likelihood of discussing goals varies by country, occurring most commonly in the USA, and least often in Sweden.
Country-level differences in continuity of care and questions asked by a regularly visited professional affect the goal discussion probability.
Patient characteristics, including age, have less impact than expected on the likelihood of sharing goals.
Design: Randomised survey study.
Setting: Denmark.
Subjects: A random sample of women from the birth cohorts 1993, 1994 and 1995 drawn from the general population.
Interventions: A web-based questionnaire and information intervention. We randomised potential respondents to one of the following four different information modules about benefits and harms of cervical screening: no information; non-numerical information; and two numerical information modules. Moreover, we provided HPV-vaccinated women in one of the arms with numerical information about benefits and harms in two steps: firstly, information without consideration of HPV vaccination and subsequently information conditional on HPV vaccination.
Main outcome measure: Self-reported intention to participate in cervical screening.
Results: A significantly lower proportion intended to participate in screening in the two groups of women receiving numerical information compared to controls with absolute differences of 10.5 (95% CI: 3.3–17.6) and 7.7 (95% CI: 0.4–14.9) percentage points, respectively. Among HPV-vaccinated women, we found a significantly lower intention to participate in screening after numerical information specific to vaccinated women (OR of 0.38).
Conclusions: Women are sensitive to numerical information about the benefits and harms of cervical screening. Specifically, our results suggest that HPV-vaccinated women are sensitive to information about the expected changes in benefits and harms of cervical screening after implementation of HPV vaccination.
- KEY POINTS
Women were less likely to participate in cervical screening when they received numerical information about benefits and harms compared to non-numerical or no information.
Specifically, numerical information about the potential impact of the reduced risk of cervical cancer among HPV-vaccinated women reduced the intention to participate among vaccinated women.
Method: Data were collected and analysed according to Grounded Theory procedures, involving interviews with 24 participants, 17 weblogs, 17 autobiographical texts, and posts from 4 online forums.
Results: Prosthesis users are primarily concerned with being “just normal”: the condition of being and living in ways that persons variously perceive are “about right”; that are sufficient, fair, and generally how things “ought to be” for them. This concern is acted upon through: (i) “preserving”, where persons foresee and manage threats to being “just normal”, (ii) “redressing”, involving rectifying things judged not to be “just normal”, and (iii) “persevering”, where persons keep living “just normally” despite accompanying difficulties.
Conclusions: “Just normal” is a new means for rehabilitation practitioners to better understand a key concern of prosthesis users and the motivations underlying behaviours in their prosthesis use. It is also relevant and transferable to broader fields of assistive technology use and disability.
- Implications for Rehabilitation
The grounded theory of “just normal” invites practitioners to discover a key concern in prosthesis use, enabling a richer understanding of the needs and desires of service users.
Being “just normal” is presented as an important motivator underlying a range of diverse actions within prosthesis use.
The theory is relevant and transferable to broader areas of assistive technology use and disability.
Design: A qualitative methodology with semi-structured focus group interviews was employed.
Setting: General practice setting in Denmark.
Subjects: Thirty-one GPs from two Danish regions between 38 and 68 years of age participated in seven focus group interviews.
Results: Although understood to involve broad life conditions such as present and future being and identity, connectedness to a society and to other people, the existential dimension was primarily reported integrated in connection with life-threatening diseases and death. Furthermore, integration of the existential dimension was characterized as unsystematic and intuitive. Communication about religious or spiritual questions was mostly avoided by GPs due to shyness and perceived lack of expertise. GPs also reported infrequent referrals of patients to chaplains.
Conclusion: GPs integrate issues related to the existential dimension in implicit and non-standardized ways and are hindered by cultural barriers. As a way to enhance a practice culture in which GPs pay more explicit attention to the patients’ multidimensional concerns, opportunities for professional development could be offered (courses or seminars) that focus on mutual sharing of existential reflections, ideas and communication competencies.
- Key points
Although integration of the existential dimension is recommended for patient care in general practice, little is known about GPs’ understanding and integration of this dimension in the GP–patient encounter.
The existential dimension is understood to involve broad and universal life conditions having no explicit reference to spiritual or religious aspects.
The integration of the existential dimension is delimited to patient cases where life-threatening diseases, life crises and unexplainable patient symptoms occur. Integration of the existential dimension happens in unsystematic and intuitive ways.
Cultural barriers such as shyness and lack of existential self-awareness seem to hinder GPs in communicating about issues related to the existential dimension. Educational initiatives might be needed in order to lessen barriers and enhance a more natural integration of communication about existential issues.
Design: A cross-sectional population study.
Setting: The municipality of Naestved, Denmark.
Subjects: We studied 907 patients with type 2 diabetes identified from a random sample of 21,205 Danish citizens.
Main outcome measures: The proportion of patients who were not achieving goals for diabetes care based on their HbA1c, LDL-cholesterol, blood pressure, and lifestyle, and the proportion of patients who were treated with antihypertensive and cholesterol- and glucose-lowering medication.
Methods: We investigated the association of the socioeconomic factors such as age, gender, education, occupation, income, and civil status and attainment of treatment goals and pharmacotherapy in logistic regression analyses. We investigated effect modification of cardiovascular disease and kidney disease.
Results: Middle age (40–65 years), low education level (i.e. basic schooling), and low household income (i.e. less than 21,400 € per year) were associated with nonattainment of goals for diabetes care. The association of socioeconomic factors with attainment of individual treatment goals varied. Patients with low socioeconomic status were more often obese, physically inactive, smoking, and had elevated blood pressure. Socioeconomic factors were not associated with treatment goals for hyperglycemia. Socioeconomic factors were inconsistently associated with pharmacotherapy. There was no difference in contacts to general practitioners according to SES.
Conclusions: In a country with free access to health care, the socioeconomic factors such as middle age, low education, and low income were associated with nonattainment of goals for diabetes care.
- KEY POINTS
Middle age, low education, and low income were associated with nonattainment of goals for diabetes care, especially for lifestyle goals.
Patients with low socioeconomic status were more often obese, physically inactive, smoking, and had elevated blood pressure.
Association of socioeconomic factors with pharmacotherapy was inconsistent.
Method: One hundred and sixty-six subjects with mild to moderate stroke were recruited and interviewed using the PS-SES. The principal axis factoring analysis was run to examine the factor structure, and internal consistency was assessed by computing Cronbach’s alpha coefficient.
Results: The final measure is a 35-item scale with six subscales: (1) managing home participation, (2) staying organized, (3) planning and managing community participation, (4) managing work/productivity, (5) managing communication, and (6) advocating for resources. The instrument demonstrated high internal consistency.
Conclusion: The PS-SES is a reliable measure offering unique information regarding self-efficacy in managing participation.
- Implications for Rehabilitation
Post-stroke participation requires complex management of resources, information, and strategies.
There is a gap in instruments that can assess self-efficacy in managing participation following a stroke.
The PS-SES is a valid tool measuring self-efficacy in using participation strategies in home, work, and community contexts.
Design: Cross-sectional method comparison study.
Setting: From April 2014 to February 2015, we included patients coming to the general practice clinic “Lægerne Sløjfen”, Aalborg, Denmark for a routine ECG. Patients with severe dementia, mental illness or poor ECG readings were excluded. After oral and written informed consent an ECG and PEM recordings were obtained simultaneously. The PEM recordings were analyzed by two general practitioners (GPs) in training and ECG recordings were evaluated by a senior GP and a cardiologist. Both the PEM and the ECG recordings were analysed blinded.
Subjects: Ninety-three patients were included and four were excluded due to poor ECG readings.
Main outcome measures: The sensitivity and specificity of PEM compared to a standard 12-lead ECG.
Results: Eighty-nine of the 93 (95.7%) patients had ECGs of a satisfactory technical quality and were included in the study. The sensitivity of diagnosing AF by PEM recordings was 86.7% and the specificity was 98.7% when compared to a 12-lead ECG. According to the cardiologist, the misclassification of three PEM recordings were due to interpretation errors and not related to the PEM recording per se.
Conclusions: The inexpensive portable PEM device recording diagnosed AF with a high sensitivity and specificity.
- KEY POINTS
Simple ECG monitors could be useful to identify atrial fibrillation and thereby lead to a better prevention of stroke.
The PEM device was easy to use and 95.7% of the recordings were technically acceptable for detecting atrial fibrillation.
The PEM device has a high sensitivity and specificity in detecting atrial fibrillation compared to a standard 12-lead ECG.
Further studies should evaluate the clinical usefulness of the PEM device, e.g. to detect intermittent atrial fibrillation.
Method: Case notes of adult EPW users of a regional NHS service were reviewed retrospectively. Seating equipment complexity and type were categorized using the Edinburgh classification. Powered characteristics and functions, including control device type, were recorded.
Results: 482 cases were included; 53.9% female; mean duration EPW use 8.1 years (SD 7.4); rear wheel drive 88.0%; hand joystick 94.8%. Seating complexity: low 73.2%, medium 18.0%, high 8.7%. Most prevalent diagnoses: multiple sclerosis (MS) 25.3%, cerebral palsy (CP) 18.7%, muscular dystrophy (8.5%). Compared to CP users, MS users were significantly older at first use, less experienced, more likely to have mid-wheel drive and less complex seating. Additional costs for muscular dystrophy and spinal cord injury users were 3–4 times stroke users.
Conclusions: This is the first large study of a general EPW user population using a seating classification. Significant differences were found between diagnostic groups; nevertheless, there was also high diversity within each group. The differences in provision and the equipment costs across diagnostic groups can be used to improve service planning.
- Implications for Rehabilitation
At a service planning level, knowledge of a population’s diagnostic group and age distribution can be used to inform decisions about the number of required EPWs and equipment costs.
At a user level, purchasing decisions about powered characteristics and functions of EPWs and specialised seating equipment need to be taken on a case by case basis because of the diversity of users’ needs within diagnostic groups.
The additional equipment costs for SCI and MD users are several times those of stroke users and add between 60 and 70% of the cost of basic provision.
Methods: This observational study involved users who received services and assistive products provided by our center of rehabilitation. Users were identified using the records of the center and their responses about the abandonment were collected through face-to-face interviews.
Results: The abandonment level of assistive products was 19.38%. 83.5% of the users use at least one of the assistive products they have received. Rigid and folding frame wheelchairs, with and without postural support devices, as well as shower wheelchairs, presented the lowest abandonment levels, followed by canes and lower limb orthoses. Upper limb orthoses, Knee Ankle Foot Orthosis(KAFO), walkers, crutches and lower and upper limb prostheses all presented higher abandonment levels.
Conclusion: The simultaneous use of mutiple assistive products, users perception on the importance of using them, and completing the rehabilitation treatment were found to impact on the short and long-term use of products. The study offers inputs to decision making and planning for assistive technology provision in developing countries with regard to expected demand and service delivery.
- Implications for Rehabilitation
Data about the abandonment of assistive products in Sao Paulo, Brazil, could assist informing decision making on provision and servicing of these products in similar settings.
The strong correlation found between abandonment levels and the simultaneous use of multiple devices should be taken into account by health professionals when prescribing assistive products and providing guidance to users.
The need for follow up on the use of assistive products after discharge from rehabilitation treatment becomes strikingly clear, as data show that completing treatment is significantly relevant when evaluating abandonment levels.
As assistive products users’ perception about the importance of using these devices is shown to be significant in explaining abandonment, it is mandatory that health and rehabilitation professionals take it into account when providing guidance and training users.
Design: Population-based questionnaire study.
Setting: Central Denmark Region with approximately 1.3 million inhabitants.
Subjects: All 843 active GPs in the Central Denmark Region were sent a questionnaire by mail.
Main outcome measures: Responses to 18 items concerning four aspects: provision of EOL care to patients with different diagnosis, confidence with being a key worker, organisation of EOL care and EOL skills (medical and psychosocial).
Results: In total, 573 (68%) GPs responded. Of these, 85% often/always offered EOL care to cancer patients, which was twice as often as to patients with non-malignancies (34–40%). Moreover, 76% felt confident about being a key worker, 60% had a proactive approach, and 58% talked to their patients about dying. Only 9% kept a register of patients with EOL needs, and 19% had specific EOL procedures. GP confidence with own EOL skills varied; from 55% feeling confident using terminal medications to 90% feeling confident treating nausea/vomiting. Increasing GP age was associated with increased confidence about being a key worker and provision of EOL care to patients with non-malignancies. In rural areas, GPs were more confident about administering medicine subcutaneously than in urban areas.
Conclusion: We found considerable diversity in self-reported EOL care competences. Interventions should focus on increasing GPs’ provision of EOL care to patients with non-malignancies, promoting better EOL care concerning organisation and symptom management.
- KEY POINTS
GPs are pivotal in end-of-life (EOL) care, but their involvement has been questioned. Hence, GPs’ perceived competencies were explored.
GPs were twice as likely to provide EOL care for patients with cancer than for patients with non-malignancies.
EOL care was lacking clear organisation in general practice in terms of registering palliative patients and having specific EOL procedures.
GPs were generally least confident with their skills in terminal medical treatment, for example, using medicine administered subcutaneously.