Occupational therapy to improve outdoor mobility after stroke

People who have suffered a stroke can become housebound and miserable because they cannot access suitable transport. They can have difficulty getting to the shops, doctors and hospital and this can have an effect on their quality of life. Occupational therapists routinely aim to help these people overcome their outdoor mobility problems by providing information and verbal instructions but these interventions do not appear to be effective. The aim of this research was to design and evaluate a new occupational therapy outdoor mobility intervention. The intervention was modeled on travel training that is provided for other conditions and the outdoor mobility experiences and needs of people with stroke. Qualitative semi structured interviews were used to investigate 24 peoples experiences of both using transport and their outdoor mobility after they had suffered a stroke. It was found that people wanted to travel for a variety of reasons; shopping, work, getting to the doctors, social reasons, meeting friends, visiting family and just for the sake of traveling. People were prevented from traveling because of physical difficulties such as stepping onto the bus, psychological problems such as confidence and environmental barriers such as the weather or lack of information. The results were used to define the main components of an Occupational Therapy Outdoor Mobility Intervention. A randomised controlled trial was used to evaluate the effects of this Occupational Therapy Outdoor Mobility Intervention (OTOMI) by comparing it to the routine occupational therapy intervention. Participants with stroke in the last 36 months were recruited from primary care services and randomly allocated to receive either the OTOMI or the routine occupational therapy. Participants in the OTOMI received up to seven individualised occupational therapy sessions. The sessions aimed to increase confidence, encourage use of different types of transport and provided tailor-made information. Outcomes were measured by postal assessment 4 and 10 months after recruitment. The primary outcome measure was a yes/ no question, Do you get out of the house as much as you would like? Secondary outcomes included the number of journeys, mood, performance of activities of daily living and leisure. 168 participants who had had a stroke in the last 36 months were recruited into the study over eighteen months, 82 in the control group and 86 to the OTOMI group. 10 people were unable to provide follow-up information at the four month assessment and 21 people at the ten month assessment. Intention-to-treat analyses were undertaken. For the principal outcome measure, participants who were dead at the point of assessment were allocated the worst outcome, and for others lost to follow up their baseline or last recorded responses were used. For the other analyses all missing values were imputed using baseline values. Participants in the treatment group were more likely to get out of their house as often as they wanted at 4 months (RR 1.72,95% CI 1.25 to 2.37) and at 10 months (RR 1.74,95 Cl 1.24 to 2.44). The treatment group recorded more journeys outdoors in the month prior to assessment at 4 months (intervention group median 37, control group median 14, Mann-Whitney p<0.01) and at 10 months (intervention group median 42, control group median 14, Mann-Whitney: p<0.01). At 4 months the NEADL mobility scores were significantly higher in the intervention group, but there were no significant differences in the other secondary outcomes. There were no significant differences in these measures at 10 months. The interview study demonstrated that participating in outdoor mobility is a major problem for people who have had a stroke. The randomised controlled trial demonstrated that a relatively simple and feasible, individualized, properly organised, focused and adequately resourced occupational therapy outdoor mobility intervention can increase participation in outdoor mobility activities, allowing people to get out of the house as much as they wish

The association of specific executive functions and falls risk in people with mild cognitive impairment and early-stage dementia

Background/Aims: Impairment in executive function is associated with a heightened risk for falls in people with mild cognitive impairment (MCI) and dementia. The purpose of this study was to determine which aspects of executive function are associated with falls risk. Methods: Forty-two participants with a mean age of 81.6 years and a diagnosis of MCI or mild dementia completed five different executive function tests from the computerised CANTAB test battery and a comprehensive falls risk assessment. Results: A hierarchical regression analysis showed that falls risk was significantly associated with spatial memory abilities and inhibition of a pre-potent response. Conclusion: The concept of executive function may be too general to provide meaningful results in a research or clinical context, which should focus on spatial memory and inhibition of a pre-potent response

Identification and characterization of glycoproteins on the spore surface of Clostridium difficile

In this study, we identify a major spore surface protein, BclA, and provide evidence that this protein is glycosylated. Following extraction of the spore surface, solubilized proteins were separated by one-dimensional PAGE and stained with glycostain to reveal a reactive high-molecular-mass region of approximately 600 kDa. Tandem mass spectrometry analysis of in-gel digests showed this band to contain peptides corresponding to a putative exosporangial glycoprotein (BclA3) and identified a number of glycopeptides modified with multiple N-acetyl hexosamine moieties and, in some cases, capped with novel glycans. In addition, we demonstrate that the glycosyltransferase gene sgtA (gene CD3350 in strain 630 and CDR3194 in strain R20291), which is located immediately upstream of the bclA3 homolog, is involved in the glycosylation of the spore surface, and is cotranscribed with bclA3. The presence of anti-β-O-GlcNAc-reactive material was demonstrated on the surface of spores by immunofluorescence and in surface extracts by Western blotting, although each strain produced a distinct pattern of reactivity. Reactivity of the spore surface with the anti-β-O-GlcNAc antibody was abolished in the 630 and R20291 glycosyltransferase mutant strains, while complementation with a wild-type copy of the gene restored the β-O-GlcNAc reactivity. Phenotypic testing of R20291 glycosyltransferase mutant spores revealed no significant change in sensitivity to ethanol or lysozyme. However, a change in the resistance to heat of R20291 glycosyltransferase mutant spores compared to R20291 spores was observed, as was the ability to adhere to and be internalized by macrophages

Developing the React to Falls resources to support care home staff in managing falls

Objectives: Care home residents are falling three times more often than elderly frail people living in their own homes and as such, the management of falls is an important area for care home staff to consider. This paper outlines the development of the ‘React to Falls’ training resources to support care home staff in the management of falls. Methods: The ‘React to Falls’ resources were developed in collaboration with falls prevention researchers, expert clinicians working in the field of falls management in care homes and care home staff and residents. Results: A freely accessible online and paper based resource was developed to meet the needs of different care home settings. Expert clinicians and care homes emphasised the importance of promoting activity and quality life and ensuring the resources were a learning tool that supported positive risk taking. Expert clinicians highlighted the need to convey the importance of continually reacting to reducing risk in the management of falls. Conclusions: This study has developed a set of training resources on falls management to support care home staff to continually react and consider the risks and management of falls. An evaluation of the impact of the resource on care staff behaviour and organisational changes is recommended

The Community In-Reach and Care Transition (CIRACT) clinical and cost-effectiveness study: study protocol for a randomised controlled trial

Background Older people represent a significant proportion of patients admitted to hospital. Their care compared to younger patients is more challenging, length of stay is longer, risk of hospital-acquired problems higher and the risk of being re-admitted within 28 days greater. This study aims to compare a Community In-Reach and Care Transition (CIRACT) service with Traditional Hospital Based rehabilitation (THB-Rehab) provided to the older person. The CIRACT service differs from the THB-rehab service in that they are able to provide more intensive hospital rehabilitation, visiting patients daily, and are able to continue with the patient’s rehabilitation following discharge allowing a seamless, integrated discharge working alongside community providers. A pilot comparing the two services showed that the CIRACT service demonstrated reduced length of stay and reduced re-admission rates when analysed over a four-month period. Methods/Design This trial will evaluate the clinical and cost-effectiveness of the CIRACT service, conducted as a randomised controlled trial (RCT) with an integral qualitative mechanism and action study designed to provide the explanatory and theoretical components on how the CIRACT service compares to current practice. The RCT element consists of 240 patients over 70 years of age, being randomised to either the THB therapy group or the CIRACT service following an unplanned hospital admission. The primary outcome will be hospital length of stay from admission to discharge from the general medical elderly care ward. Additional outcome measures including the Barthel Index, Charlson Co-morbidity Scale, EuroQoL-5D and the modified Client Service Receipt Inventory will be assessed at the time of recruitment and repeated at 91 days post-discharge. The qualitative mechanism and action study will involve a systematic programme of organisational profiling, observations of work processes, interviews with key informants and care providers and tracking of participants. In addition, a within-trial economic evaluation will be undertaken comparing the CIRACT and THB-rehab services to determine cost-effectiveness. Discussion The outcome of the study will inform clinical decision-making, with respect to allocation of resources linked to hospital discharge planning and re-admissions, in a resource intensive and growing group of patients

A spatial model for social networks

We study spatial embeddings of random graphs in which nodes are randomly distributed in geographical space. We let the edge probability between any two nodes to be dependent on the spatial distance between them and demonstrate that this model captures many generic properties of social networks, including the ``small-world'' properties, skewed degree distribution, and most distinctively the existence of community structures.Comment: To be published in Physica A (2005

Community falls prevention for people who call an emergency ambulance after a fall: randomised controlled trial

Objective To evaluate whether a service to prevent falls in the community would help reduce the rate of falls in older people who call an emergency ambulance when they fall but are not taken to hospital

Conceptual framework for balancing society and nature in net-zero energy transitions

Transitioning to a low carbon energy future is essential to meet the Paris Agreement targets and Sustainable Development Goals (SDGs). To understand how societies can undertake this transition, energy models have been developed to explore future energy scenarios. These models often focus on the techno-economic aspects of the transition and overlook the long-term implications on both society and the natural environment. Without a holistic approach, it is impossible to evaluate the trade-offs, as well as the co-benefits, between decarbonisation and other policy goals. This paper presents the Energy Scenario Evaluation (ESE) framework which can be used to assess the impact of energy scenarios on society and the natural environment. This conceptual framework utilises interdisciplinary qualitative and quantitative methods to determine whether an energy scenario is likely to lead to a publicly acceptable and sustainable energy transition. Using the SDGs, this paper illustrates how energy transitions are interconnected with human development and the importance of incorporating environmental and socio-economic data into energy models to design energy scenarios which meet other policy priorities. We discuss a variety of research methods which can be used to evaluate spatial, environmental, and social impacts of energy transitions. By showcasing where these impacts will be experienced, the ESE framework can be used to facilitate engagement and decision-making between policymakers and local communities, those who will be directly affected by energy transitions. Outputs of the ESE framework can therefore perform an important role in shaping feasible and energy transitions which meet the Paris Agreement targets and SDGs

Acute medical unit comprehensive geriatric assessment intervention study (AMIGOS): Study protocol for a randomised controlled trial

BackgroundMany older people presenting to Acute Medical Units (AMU) are discharged after only a short stay ( 70 years and scoring positive on a risk screening tool ('Identification of Seniors At Risk') who are discharged within 72 hours of attending an AMU with a medical crisis, recruited prior to discharge. Sample size is 400. Carers of participants will also be recruited.Intervention: Assessment on the AMU and further out-patient management by a specialist physician in geriatric medicine. Assessment and further management will follow the principles of Comprehensive Geriatric Assessment, providing advice and support to primary care services.Design: Multi-centre, individual patient randomised controlled trial comparing intervention with usual care.Outcome measurement: Follow up is by postal questionnaire 90 days after randomisation, and data will be entered into the study database by a researcher blind to allocation. The primary outcome is the number of days spent at home (for those admitted from home), or days spent in the same care home (if admitted from a care home). Secondary outcomes include mortality, institutionalisation, health and social care resource use, and scaled outcome measures, including quality of life, disability, mental well-being. Carer strain and well being will also be measured at 90 days.Analyses: Comparisons of outcomes and costs, and a cost utility analysis between the intervention and control groups will be carried out.Trial RegistrationISRCTN: ISRCTN2180048

Developing the Principles of Falls Management in Care Homes: An expert Consensus Process

Context: Managing falls in care homes requires an individualised approach for each resident with involvement of staff from care homes and the wider health and social care system. A large randomised controlled trial evaluating an individualised falls management programme (Action FALLS) demonstrated positive findings. However, the delivery of the key components of such programmes is still unclear. Greater understanding of the core components of falls management programmes is needed to support future implementation research.Objective: To establish expert consensus on the core components of falls management for older care home residents.Methods: A modified Nominal Group Technique included the development of a draft set of principles through a scoping review of the grey literature (published elsewhere) and a one-off online nominal group with care home staff and clinicians. Following the group, a single online survey was circulated to gain agreement on the final principles.Findings: 10 participants (including healthcare professionals, care home managers, and care home staff) took part in the online nominal group. Thirty-five core principles of falls management were developed within the domains of theoretical approach, assessments, interventions, training, time points, wider systems, and governance and reporting.Limitations: Since a small number of experts took part in this consensus process from a large and diverse care home sector, it is important to consider the principles as providing support for future implementation work.Implications: These core principles provide a foundation to guide care homes in managing falls in care home residents. Further research is needed to develop implementation strategies and test the feasibility of embedding the principles in routine practice