Flipping the ICF: Exploring the Interplay of Theory and the Lived Experience to Reconsider Physical Activity in Community-Dwelling People With Multiple Sclerosis.

People with multiple sclerosis (MS) report lower physical activity levels and are at a risk of becoming sedentary. As such, they are at an increased risk of developing secondary health conditions associated with inactivity. This is of major public health concern. Attempts to improve the physical activity levels in people with MS remain a challenge for health professionals. One key reason might be the lack of understanding about the meanings people with MS ascribe to exercise and physical activity. This paper draws on the key findings of a three-phased interconnected mixed methods sequential explanatory study to examine the meanings of exercise and physical activity from the perspectives of people with MS and health professionals. Phase 1 used a four-round Delphi questionnaire to scope and determine the consensus of priorities for exercise and physical activity and the reasons why people with MS (N = 101) engaged in these activities. Phase 2 used face-to-face semistructured interviews of people with MS (N = 16) to explore the meanings ascribed to exercise and physical activity. Phase 3 explored the perceptions of physiotherapists (N = 14) about exercise and physical activity using three focus groups. Using the International Classification of Functioning, Disability, and Health as a theoretical framework to underpin this study, the authors discuss the key factors, for example, emphasis on the contextual factors, that drive decision making around exercise and physical activity participation in people with MS and explore the clinical implications to health professionals.

Clinical features of electric powered indoor/outdoor wheelchair users with spinal cord injuries: A cross-sectional study.

This article aims to describe the characteristics of those with a primary diagnosis of spinal cord injury (SCI) attending a specialist wheelchair service providing electric powered indoor/outdoor chairs (EPIOCs). This cross-sectional study, with retrospective review of electronic and case note records, explores the complexities of additional clinical features associated with SCI and disability influencing prescription. Data were extracted under three themes; demographics, diagnostic/clinical information and wheelchair factors. There were 57 participants (35 men, 22 women) (mean age 53.51 ± 11.93, range 29-79 years) comprising 20 with paraplegia, 34 with tetraplegia and 3 with undocumented level. Paraplegics were significantly older than tetraplegics (p < 0.05). Thirty users had a complete SCI (mean age 49.87 ± 12.27 years) and 27 had another SCI lesion (mean age 57.56 ± 10.32 years). Those with a complete SCI were significantly younger than the rest (p < 0.02). Only 10 (9 tetraplegic) had SCI as the sole diagnosis. Twenty (15 tetraplegic) had one additional clinical feature, 14 had 2-3 (6 tetraplegic) and 13 (4 tetraplegic) had 4 or more. Ten users required specialised seating, 22 needed tilt-in-space EPIOCs while six required complex controls. The range and complexity of wheelchair and seating needs benefitted from a holistic assessment and prescription by a specialist multidisciplinary team.

Clinical features of children and adults with a muscular dystrophy using powered indoor/outdoor wheelchairs: disease features, comorbidities and complications of disability.

PURPOSE: To describe the clinical features of electric powered indoor/outdoor wheelchair users with a muscular dystrophy, likely to influence optimal prescription; reflecting features of muscular dystrophies, conditions secondary to disability, and comorbidities impacting on equipment provision. METHODS: Cross-sectional retrospective case note review of recipients of electric powered indoor/outdoor wheelchairs provided by a specialist regional wheelchair service. Data on demography, diagnostic/clinical, and wheelchair prescription were systematically extracted. RESULTS: Fifty-one men and 14 women, mean age 23.7 (range 10-67, s.d. 12.95) years, were studied. Forty had Duchenne muscular dystrophy, 22 had other forms of muscular dystrophy, and three were unclassified. Twenty-seven were aged under 19. Notable clinical features included problematic pain (10), cardiomyopathy (5), and ventilatory failure (4). Features related to disability were (kypho)scoliosis (20) and edema/cellulitis (3) whilst comorbidities included back pain (5). Comparison of younger with older users revealed younger users had more features of muscular dystrophy affecting electric powered chair provision (56%) whilst older users had more comorbidity (37%). Tilt-in-space was prescribed for 81% of users, specialized seating for 55% and complex controls for 16%. CONCLUSIONS: Muscular dystrophy users were prescribed electric powered indoor/outdoor chairs with many additional features reflecting the consequences of profound muscle weakness. In addition to facilitating independence and participation, electric powered indoor/outdoor chairs have major therapeutic benefits. Implications for rehabilitation Powered wheelchairs have therapeutic benefits in managing muscular dystrophy pain and weakness. The use of specialized seating needs careful consideration in supporting progressive muscle weakness and the management of scoliosis. Pain, discomfort, pressure risk, and muscle fatigue may be reduced by use of tilt-in-space.

Problematic clinical features of children and adults with cerebral palsy who use electric powered indoor/outdoor wheelchairs: A cross-sectional study.

This article aims to describe the clinical features of electric powered indoor/outdoor wheelchair (EPIOC) users with cerebral palsy (CP) that are problematic to optimal prescription and to explore comorbidities, features of CP, and conditions secondary to disability impacting on equipment provision for children and adults. The method is a cross-sectional study of EPIOC users (n = 102) with a primary diagnosis of CP. This is a retrospective review of electronic and case note records of EPIOC recipients attending a specialist wheelchair service in 2007-2008. Records were reviewed by a rehabilitation consultant. Data were extracted under three themes; demographic, diagnostic/clinical and wheelchair factors. There were 48 males mean age 27.5 (range 8-70, SD 13.9) years and 54 females, mean age 29.5 (range 7-68, SD 14.6) years with CP. Sixteen comorbidities, nine features of CP, and five features of disability influenced wheelchair prescription. Sixty-four users were provided with specialized seating (SS) and 47 with tilt-in-space (TIS) seats. Complex controls were provided to 16 users, 12 tray-mounted. The majority of users had both SS and TIS. Powered wheelchair prescription has important therapeutic roles in clinical management in addition to enhancing mobility, independence and participation. Clinical features such as spasticity and problematic pain appeared less well managed in adults than in children.

Rare diseases: matching wheelchair users with rare metabolic, neuromuscular or neurological disorders to electric powered indoor/outdoor wheelchairs (EPIOCs).

PURPOSE: To describe the clinical features of electric powered indoor/outdoor wheelchair (EPIOC) users with rare diseases (RD) impacting on EPIOC provision and seating. METHOD: Retrospective review by a consultant in rehabilitation medicine of electronic and case note records of EPIOC recipients with RDs attending a specialist wheelchair service between June 2007 and September 2008. Data were systematically extracted, entered into a database and analysed under three themes; demographic, diagnostic/clinical (including comorbidity and associated clinical features (ACFs) of the illness/disability) and wheelchair factors. RESULTS: Fifty-four (27 male) EPIOC users, mean age 37.3 (SD 18.6, range 11-70) with RDs were identified and reviewed a mean of 64 (range 0-131) months after receiving their wheelchair. Diagnoses included 27 types of RDs including Friedreich's ataxia, motor neurone disease, osteogenesis imperfecta, arthrogryposis, cerebellar syndromes and others. Nineteen users had between them 36 comorbidities and 30 users had 44 ACFs likely to influence the prescription. Tilt-in-space was provided to 34 (63%) users and specialised seating to 17 (31%). Four users had between them complex control or interfacing issues. CONCLUSIONS: The complex and diverse clinical problems of those with RDs present unique challenges to the multiprofessional wheelchair team to maintain successful independent mobility and community living. Implications for Rehabilitation Powered mobility is a major therapeutic tool for those with rare diseases enhancing independence, participation, reducing pain and other clinical features. The challenge for rehabilitation professionals is reconciling the physical disabilities with the individual's need for function and participation whilst allowing for disease progression and/or growth. Powered wheelchair users with rare diseases with a (kypho) scoliosis require a wheelchair system that balances spine stability and movement to maximise residual upper limb and trunk function. The role of specialised seating needs careful consideration in supporting joint derangements and preventing complications such as pressure sores.

Translation into Greek and initial validity and reliability testing of a modified version of the SCIM III, in both English and Greek, for self-use.

PURPOSE: To translate and culturally adapt the Spinal Cord Injury Measure version III (SCIM III) into Greek (GR-SCIM III). To conduct initial testing of psychometric properties of both measures by self-report. METHOD: Forward-backward translation was conducted to produce the GR-SCIM III. Participants completed the English or Greek versions in 2008-2009. Both versions were examined for multidimensionality, internal consistency and concurrent/criterion validity with the EQ-5D. RESULTS: Forty-five Greek adults with spinal cord injury (SCI) (23 males), mean age 61 (SD17) years; mean time since injury 11 (SD9) years, completed the GR-SCIM III. One hundred and seventy four English-speaking adults with SCI (111 males), mean age 47 (SD12) years; mean time since injury 12 (SD11) years, completed the SCIM III. Unidimensionality was confirmed for both versions. Internal consistency was acceptable (α = 0.78 for both). Validity was strong for the "self-care" subscale (GR-SCIM III ρ = -0.78, SCIM III ρ = -0.75) and moderate for the "mobility" subscale (GR-SCIM III ρ = -0.58, SCIM III ρ = -0.45). CONCLUSIONS: This has been the first function scale translated and validated in Greek for people with SCI. Both the GR-SCIM III and SCIM III are reliable for use by self-report. More studies are needed to further examine their psychometric properties and compare with observation or interview. IMPLICATIONS FOR REHABILITATION: The Greek version of the Spinal Cord Independence Measure version III (SCIM) is valid and reliable for self-report. Further testing is needed to assess psychometric qualities not assessed in the present study. Researchers and therapists in Greece can use a specific measure to assess functional independence in people with Spinal Cord Injury (SCI). Consideration needs to be given to the participants' type of injury, which may affect the results of SCIM III.

Problematic clinical features of powered wheelchair users with severely disabling multiple sclerosis.

PURPOSE: The aim of this study is to describe the clinical features of powered wheelchair users with severely disabling multiple sclerosis (MS) and explore the problematic clinical features influencing prescription. METHOD: Retrospective review of electronic and case note records of recipients of electric-powered indoor/outdoor powered wheelchairs (EPIOCs) attending a specialist wheelchair service between June 2007 and September 2008. Records were reviewed by a consultant in rehabilitation medicine, data systematically extracted and entered into a computer database. Further data were entered from clinical records. Data were extracted under three themes; demographic, diagnostic, clinical and wheelchair factors. RESULTS: Records of 28 men mean age 57 (range 37-78, SD 12) years and 63 women mean age 57 (range 35-81, SD 11) years with MS were reviewed a mean of 64 (range 0-131) months after receiving their wheelchair. Twenty two comorbidities, 11 features of MS and 8 features of disability were thought to influence wheelchair prescription. Fifteen users were provided with specialised seating and 46 with tilt-in-space seats. CONCLUSIONS: Our findings suggest that people with severe MS requiring an EPIOC benefit from a holistic assessment to identify problematic clinical features that influence the prescription of the EPIOC and further medical and therapeutic interventions. IMPLICATIONS FOR REHABILITATION: People with multiple sclerosis (MS), referred for an EPIOC, require a full clinical assessment to identify problematic clinical features that are potentially treatable and/or can be accommodated through specialised seating and tilt. The beneficial effects of TIS should be considered for all EPIOC users with MS and particularly for those with comorbidity Poorly controlled spasticity, when identified in people with MS, should be managed through positioning in the chair, pressure-relieving cushion and referral for medical management.

A systematic review of the prevalence of musculoskeletal pain, back and low back pain in people with spinal cord injury.

PURPOSE: To review and summarise the prevalence of chronic back pain (CBP), chronic low back pain (CLBP) and chronic musculoskeletal pain (CMSKP) in people with spinal cord injury (SCI) and evaluate how pain is assessed. METHOD: A systematic literature review between 1990 and 2012 in English language journals. Twelve databases were searched including CINAHL, Cochrane, Embase, PubMed and Science direct. Data were analysed using descriptive statistics and 95% confidence interval (CI). RESULTS: Eight studies fulfilled the inclusion criteria. Four reported on CMSKP, four on CBP and only two on CLBP. Among people with SCI and pain, the prevalence of CMSKP was 49% (95% CI: 44-55%), CBP was 47% (95% CI: 43-50%) and CLBP was 49% (95% CI: 44-55%). There were variations in both the pain classification systems used and the data collected. The type of pain reported in the back and low back areas could not be established due to insufficient evidence. CONCLUSION: The main finding is that the prevalence of CMSKP, and more particularly CBP and CLBP are not sufficiently reported in SCI literature. Implications for Rehabilitation There is sufficient evidence, though modest in quality and quantity, to indicate that chronic musculoskeletal pain (CMSKP), back pain (CBP) and low back pain (CLBP) are common in people with spinal cord injury (SCI). This deserves consideration by health professionals treating such patients. Pain assessment, including BP and LBP, for people with SCI should become part of the overall clinical assessment and it is preferable that standardised pain assessment tools are used. Where people with SCI suffer from CMSKP, and particularly CBP and CLBP, further consideration should be made, likely to include posture, strengthening and seating as is referral for pain medication.

Recipients of electric-powered indoor/outdoor wheelchairs provided by a national health service: a cross-sectional study.

OBJECTIVE: To describe the characteristics across all ages of powered wheelchair users and the assistive technology prescribed by a regional specialist wheelchair service. DESIGN: Cross-sectional study. SETTING: Regional wheelchair service. PARTICIPANTS: Electric-powered indoor/outdoor wheelchair (EPIOC) users (N=544) with 262 boys and men (mean age ± SD, 41.7±20.7y; range, 8-82y) and 282 girls and women (mean age ± SD, 47.2±19.7y; range, 7-92y). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Demographic, clinical/diagnostic details of EPIOC recipients, including pain, (kypho)scoliosis, and ventilators. Technical features, including specialized (adaptive) seating, tilt in space, and modified control systems. Factors were related to age groups: 1 (0-15y), 2 (16-24y), 3 (25-54y), 4 (55-74y), and 5 (≥75y). RESULTS: Neurologic/neuromuscular conditions predominated (81%) with cerebral palsy (18.9%) and multiple sclerosis (16.4%). Conditions presenting at birth or during childhood constituted 39%. Of the participants, 99 had problematic pain, 83 had (kypho)scoliosis, and 11 used ventilators. Specialized (adaptive) seating was provided to 169 users (31%); most had cerebral palsy or muscular dystrophy. Tilt in space was used by 258 (53%) participants. Younger people were more likely to receive tilt in space than older ones. Only 92 had specialized (adaptive) seating and tilt in space (mean age ± SD, 29±17.8y; range, 8-72y). Of the participants, 52 used modified control systems. CONCLUSIONS: The diversity of EPIOC users across age and diagnostic groups is shown. Their complex interrelations with these technical features of EPIOC prescriptions are explored. Younger users were more complex because of age-related changes. This study provides outcomes of the EPIOC prescription for this heterogeneous group of very severely disabled people.

Transcranial direct current stimulation of the motor cortex in the treatment of chronic nonspecific low back pain: a randomized, double-blind exploratory study.

OBJECTIVES: To test the proof of principle that active anodal transcranial direct current stimulation (tDCS) applied to the motor cortex reduces pain significantly more than sham stimulation in a group of participants with chronic nonspecific low back pain. METHODS: The study utilized a within-participants sham-controlled, interrupted time series design. A sample of 8 participants was recruited. After 3 days of baseline measures, patients entered a 15-day experimental period (Mondays to Fridays) for 3 consecutive weeks. During this period each patient received sham stimulation daily until a randomly allocated day when active stimulation was commenced. Active stimulation was then given daily for the remaining days of the experimental period. Both the participants and the assessors were blinded. The primary outcomes were average pain intensity and unpleasantness in the last 24 hours measured using a visual analogue scale. Secondary outcomes included self-reported disability, depression and anxiety, a battery of cognitive tests to monitor for unwanted effects of stimulation, and patients' perceptions of whether they had received active or sham stimulation. Data were analyzed using generalized estimating equations. RESULTS: No significant effect was seen in the primary outcomes between active and sham stimulation (average pain intensity P = 0.821, unpleasantness P = 0.937) or across any other clinical variables. There was evidence that patients may have been able to distinguish between the active and sham conditions (P = 0.035). DISCUSSION: These results do not provide evidence that tDCS is effective in the treatment of chronic back pain. The use of a small convenience sample limits the generalizability of these findings and precludes definitive conclusions on the efficacy of tDCS in chronic nonspecific low back pain.

Rethinking clinical trials of transcranial direct current stimulation: participant and assessor blinding is inadequate at intensities of 2mA.

BACKGROUND: Many double-blind clinical trials of transcranial direct current stimulation (tDCS) use stimulus intensities of 2 mA despite the fact that blinding has not been formally validated under these conditions. The aim of this study was to test the assumption that sham 2 mA tDCS achieves effective blinding. METHODS: A randomised double blind crossover trial. 100 tDCS-naïve healthy volunteers were incorrectly advised that they there were taking part in a trial of tDCS on word memory. Participants attended for two separate sessions. In each session, they completed a word memory task, then received active or sham tDCS (order randomised) at 2 mA stimulation intensity for 20 minutes and then repeated the word memory task. They then judged whether they believed they had received active stimulation and rated their confidence in that judgement. The blinded assessor noted when red marks were observed at the electrode sites post-stimulation. RESULTS: tDCS at 2 mA was not effectively blinded. That is, participants correctly judged the stimulation condition greater than would be expected to by chance at both the first session (kappa level of agreement (κ) 0.28, 95% confidence interval (CI) 0.09 to 0.47 p=0.005) and the second session (κ=0.77, 95%CI 0.64 to 0.90), p=<0.001) indicating inadequate participant blinding. Redness at the reference electrode site was noticeable following active stimulation more than sham stimulation (session one, κ=0.512, 95%CI 0.363 to 0.66, p<0.001; session two, κ=0.677, 95%CI 0.534 to 0.82) indicating inadequate assessor blinding. CONCLUSIONS: Our results suggest that blinding in studies using tDCS at intensities of 2 mA is inadequate. Positive results from such studies should be interpreted with caution.

The pain experiences of powered wheelchair users.

PURPOSE: To explore the experience of pain and discomfort in users of electric-powered indoor/outdoor wheelchairs (EPIOCs) provided by a National Health Service. METHODS: EPIOC users receiving their chair between February and November 2002 (N = 74) were invited to participate in a telephone questionnaire/interview and 64 (aged 10-81 years) agreed. Both specific and open-ended questions examined the presence of pain/discomfort, its severity, minimizing and aggravating factors, particularly in relation to the EPIOC and its use. RESULTS: Most EPIOC users described experiences of pain with 17% reporting severe pain. Over half felt their pain was influenced by the wheelchair and few (25%) considered their chair eased their symptoms. The most common strategy for pain relief was taking medication. Other self-help strategies included changing position, exercise and complementary therapies. Respondents emphasized the provision of backrests, armrests, footrests and cushions which might alleviate or exacerbate pain, highlighting the importance of appropriate assessment for this high dependency group. CONCLUSIONS: Users related pain to their underlying medical condition, their wheelchair or a combination of the two. User feedback is essential to ensure that the EPIOC meets health needs with minimal pain. This becomes more important as the health condition of users changes over time.

Predicting outcome in acute low back pain using different models of patient profiling.

STUDY DESIGN: Prospective observational study of prognostic indicators, using data from a randomized, controlled trial of physiotherapy care of acute low back pain (ALBP) with follow-up at 6 weeks, 3 months, and 6 months. OBJECTIVE: To evaluate which patient profile offers the most useful guide to long-term outcome in ALBP. SUMMARY OF BACKGROUND DATA: The evidence used to inform prognostic decision-making is derived largely from studies where baseline data are used to predict future status. Clinicians often see patients on multiple occasions so may profile patients in a variety of ways. It is worth considering if better prognostic decisions can be made from alternative profiles. METHODS: Clinical, psychological, and demographic data were collected from a sample of 54 ALBP patients. Three clinical profiles were developed from information collected at baseline, information collected at 6 weeks, and the change in status between these 2 time points. A series of regression models were used to determine the independent and relative contributions of these profiles to the prediction of chronic pain and disability. RESULTS: The baseline profile predicted long-term pain only. The 6-week profile predicted both long-term pain and disability. The change profile only predicted long-term disability (P < 0.01). When predicting long-term pain, after the baseline profile had been added to the model, the 6-week profile did not add significantly when forced in at the second step (P > 0.05). A similar result was obtained when the order of entry was reversed. When predicting long-term disability, after the 6-week profile was entered at the first step, the change profile was not significant when forced in at the second step. However, when the change profile was entered at the first step and the 6-week clinical profile was forced in at the second step, a significant contribution of the 6-week profile was found. CONCLUSION: The profile derived from information collected at 6 weeks provided the best guide to long-term pain and disability. The baseline profile and change in status offered less predictive value.

Therapists' experiences and perceptions of teamwork in neurological rehabilitation: critical happenings in effective and ineffective teamwork.

This paper reports the second part of an exploratory study into occupational therapists' and physiotherapists' perceptions and experiences of teamwork in neurological rehabilitation: the factors that were thought to influence effective and ineffective teamwork, and the meaning behind effective and ineffective teamwork in neurological rehabilitation. The study was undertaken through semi-structured interviews of 10 therapists from three different neurological rehabilitation teams based in the United Kingdom, and used the critical incident technique. Through analysis of the data, several main themes emerged regarding the perceived critical happenings in effective and ineffective teamwork. These were: team events and characteristics, team members' characteristics, shared and collaborative working practices, communication, specific organizational structures, environmental, external, and patient and family-related factors. Effective and ineffective team-work was perceived to impact on a number of levels: having implications for the team, the patient, individual team members, and the neurological rehabilitation service. The study supported the perceived value of team work within neurological rehabilitation. It also indicated the extensive and variable factors that may influence the team-working process as well as the complex and diverse nature of the process.

Experiences of living with chronic back pain: the physical disabilities.

PURPOSE: Back-related functional limitations are largely assessed using lists of activities, each scored on a yes/no basis and the scores then summed. This provides little information about how chronic back pain (CBP) patients live with their condition. This study describes the consequences of living day-to-day with CBP and documents the 'insider' accounts of its impact on daily life. METHOD: Unstructured interviews, using the 'Framework' approach with topic guide, were recorded and transcribed verbatim. Subjects were sampled for age, sex, ethnicity and occupation from new referrals with back pain to a rheumatology outpatient clinic. Eleven subjects (5 male, 6 female) were interviewed either in English (n = 9) or their preferred language (n = 2). Interviews were read in-depth twice to identify the topics. Data were extracted in phrases and sentences using thematic content analysis. RESULTS: Four themes emerged: sleep/rest, mobility, independence and leisure. All subjects reported issues about sleep and rest, nine about mobility, seven about independence and six on leisure. Most descriptions concerned loss and limitation in daily life. Strategies for coping with sleep disruption and physical limitations were described. CONCLUSIONS: Subjects provided graphic 'in-depth' descriptions of experiences living with CBP every day; expressed regret at the loss of capabilities and distress at the functional consequences of those losses. Facilitating 'adjustment' to 'loss' may be more helpful than inferring the potential for a life free of pain as a result of therapeutic endeavours.

Early intervention for the management of acute low back pain: a single-blind randomized controlled trial of biopsychosocial education, manual therapy, and exercise.

STUDY DESIGN: A single blind randomized controlled trial comparing two models of care for patients with acute simple low back pain. OBJECTIVES: To compare two research-based models of care for acute low back pain and investigate the effect of the timing of physical intervention. SUMMARY OF BACKGROUND DATA: National guidelines offer conflicting information on the delivery of physical treatment in the management of acute low back pain. The guidelines suggest two different models of care. Direct comparisons between these models are lacking in the literature. The present study aims to compare these approaches to the management of acute low back pain. METHODS: Among 804 referred patients, 102 subjects met the specific admission criteria and were randomly assigned to an "assess/advise/treat" group or an "assess/advise/wait" group. The intervention consisted of biopsychosocial education, manual therapy, and exercise. Assessment of short-term outcome enables comparison to be made between intervention and advice to stay active. Assessment of long-term outcome enables comparison to be made between early and late intervention. Study outcomes of reported pain (Visual Analogue Scale), functional disability (the Roland and Morris Disability Questionnaire), mood (Modified Zung Self Rated Depression Score, Modified Somatic Perception Questionnaire, State-Trait Anxiety Inventory), general health (Euroqol), and quality of life (Short Form 36) were assessed at baseline, 6 weeks, 3 months, and 6 months. RESULTS: At 6 weeks, the assess/advise/treat group demonstrated greater improvements in disability, mood, general health, and quality of life than patients in the assess/advise/wait group (P < 0.05). Disability and pain were not significantly different between the groups at long-term follow up (P > 0.05). However, mood, general health, and quality of life remained significantly better in the assess/advise/treat group (P < 0.05). CONCLUSIONS: At short-term, intervention is more effective than advice on staying active, leading to more rapid improvement in function, mood, quality of life, and general health. The timing of intervention affects the development of psychosocial features. If treatment is provided later, the same psychosocial benefits are not achieved. Therefore, an assess/advise/treat model of care seems to offer better outcomes than an assess/advise/wait model of care.