Does the ankle affect knee hyperextension during gait in hemiparetic stroke? A pilot study.

Background: Knee hyperextension is common following stroke because of changes in joint range of motion (ROM), muscle tone and strength on the hemiparetic side. There is no clear consensus in the literature as to the cause of knee hyperextension during the stance phase of gait. Objectives: Our study aimed to determine the feasibility of methods to investigate the association between ankle joint function and knee hyperextension in patients with hemiparetic stroke during the stance phase of gait. Methods: We used a cross-sectional observational study to assess bilateral ankle muscle strength using a handheld dynamometer, ROM using a digital inclinometer and muscle tone using the Modified Tardieu Scale. The knee angles of the hemiparetic leg during the stance phase of gait were assessed using the Kinovea movement analysis software. Data were analysed using the Statistical Package for the Social Sciences with significance level set at 0.05 and 95% confidence intervals. Results: Twelve participants were included, and no alterations were necessary to the planned methodology. We found positive associations in six participants between the tibialis anterior muscle tone and the hemiparetic knee angles during heel strike, terminal stance and pre-swing phases (p < 0.05, p < 0.01 and p < 0.01, respectively). Conclusion: The results of the data analysis suggests that there may be a correlation between tibialis anterior muscle tone and knee hyperextension, a larger study will be imperative to confirm this association. Clinical implications: The methods described in our pilot study are feasible for a larger study to be conducted with the recommendations considered.

The nature and impact of urinary incontinence experienced by patients receiving community nursing services: a cross-sectional cohort study.

BACKGROUND: Nurses have played a pivotal role in the delivery of continence services yet little is known about the nature or impact of urinary symptoms experienced by patients in receipt of such care. AIM: To define the nature and impact of urinary symptoms experienced by patients in receipt of community nursing services. METHOD: The Leicestershire Urinary Symptoms Questionnaire was administered to 1078 patients with incontinence identified from 176 community nurses' caseloads in 157 general practices in England. Information included type and severity of urinary symptoms, impact on quality of life, help with coping, use of continence products and health service resources. RESULTS: Nine hundred and ninety nine (92.7%) patients (median age 79.0 years) returned completed questionnaires. Most patients had incontinence between 1 and 5 years duration, women were more likely than men to have had long standing ( > 5 years) symptoms and more than half the sample reported severe leakage. Women were more likely than men to report symptoms of stress incontinence (71.7% and 46.8%, respectively, p < 0.001) and urge incontinence UI (86.3% vs. 74.8%, respectively, p < 0.01). Half of the men and most women also experienced leakage as a result of difficulty getting to, on or off, a toilet/commode. Men were more likely than women to report getting up three or more times a night to pass urine (53.6% vs. 37.0%, respectively, p < 0.05). Most patients reported that their symptoms had a significant impact on many aspects of quality of life, and 45.7% would be very dissatisfied to continue "the way they are now". Professional help appeared principally one of containment. CONCLUSION: Many people with incontinence receiving community nursing services experience two or more urinary symptoms which, in the majority, have a significant impact on quality of life. Many older patients were not satisfied to "put up" with their urinary symptoms. Current service provision appears to be failing those who are most in need of such care.

Cluster randomized controlled trial of the effectiveness of audit and feedback and educational outreach on improving nursing practice and patient outcomes.

BACKGROUND: Current understanding of implementation methods is limited, and research has focused on changing doctors' behaviors. AIM: Our aim was to evaluate the impact of audit and feedback and educational outreach in improving nursing practice and patient outcomes. METHODS: Using a factorial design, cluster randomized controlled trial, we evaluated 194 community nurses in 157 family practices and 1078 patients with diagnosis of urinary incontinence (UI) for nurses compliance with evidence-linked review criteria for the assessment and management of UI and impact on psychologic and social well-being and symptoms. In the outreach arms, nurses' self-reported barriers informed development of tailored strategies. RESULTS: In comparison with educational materials alone, the implementation methods tested did not improve care at 6 months follow-up. Moderate rates of improvement (10-17% of patients) in performance for the assessment of UI and greater rates of improvement (20-30% of patients) for the management of care were found but effects were similar across arms. Improvement in patient outcomes was more consistently positive for educational outreach than for audit and feedback but differences were not significant. Adjustment for caseload size, severity or duration of UI and patients' age did not alter results. CONCLUSIONS: Printed educational materials alone may be as effective as audit and feedback and educational outreach in improving nurses' performance and outcomes of care for people with UI. Greater understanding of the underlying processes in improving performance within multidisciplinary teams through further, theory-driven studies with "no intervention" control groups and longer follow-up are needed.