The Hospital Anxiety and Depression Scale: a pilot study to examine its latent structure and the link between psychological state and symptom severity in transient ischaemic attack patients.

Transient ischaemic attack (TIA) is often associated with anxiety and depression, which may precipitate secondary stroke and interfere with treatment. The Hospital Anxiety and Depression Scale (HADS) is widely used to assess these states and to inform the management of any associated psychological problems, but there is considerable debate about what it actually measures. The HADS scores from a range of different clinical groups have been reviewed in order to assess its psychometric properties, but so far, no research has examined either its latent structure when used with TIA patients, or the association between symptom severity and the test's validity. The aims of this study, therefore, were to investigate: (a) the underlying structure of the HADS when used with TIA patients; and (b) the impact of symptom severity on the validity of the HADS. The HADS and a functional capacity measure were administered by post to a sample of 542 confirmed TIA patients. Exploratory factor analysis was conducted on the HADS scores to establish its underlying structure for this clinical group, and then, sub-sample correlations were undertaken between the anxiety/depression scores for different levels of functional capacity. Two factors emerged, with 13 of the 14 HADS items loading significantly on both, suggesting there is a common affective state underlying the standard anxiety and depression scales. Further data-exploration indicated that convergence between these affective states increased as functional capacity deteriorated. The results suggest firstly that the HADS measures general subjective distress when used with TIA patients, and secondly that the higher reported symptom severity in this clinical group may be associated with reduced affective differentiation. As the ability to retain clear affective discrimination is associated with health and well-being, this could provide a focus for post-TIA rehabilitation.

Subjective experiences of transient ischaemic attack: a repertory grid approach.

PURPOSE: Research on the psychosocial reactions to stroke has been used to inform rehabilitation programmes. Yet much less research has been conducted into experiences of, and reactions to, transient ischaemic attack (TIA), despite its link with secondary stroke. This study aimed to investigate the subjective psychological experiences of TIA. METHOD: Repertory grid technique was used because of its capacity to make individual implicit experiences explicit. Using the standard repertory grid protocol, 12 post-TIA patients were asked to consider how five everyday activities had been affected by TIA. Each participant generated six constructs or personal perspectives, which were analysed using proprietary (RepGrid IV) software. RESULTS: Despite the individualised nature of the responses, six themes emerged from the constructs. These included deep-seated anxiety about future uncertainties/disruption to normality, loss of confidence, frustration, TIA as a wake-up call, a sense of loss and sadness, and embarrassment. IMPLICATIONS FOR REHABILITATION: Research has shown that the patient's subjective experience and perspective are important to the rehabilitation process post-stroke. Relatively little research has been conducted into the subjective experiences of TIA patients. This study has revealed a range of subjective reactions to TIA, which could be used to inform individualised post-TIA management, adaptation and rehabilitation.

Factors associated with mobility outcomes in older people post-ankle fracture: an observational cohort study focussing on peripheral vessel function.

INTRODUCTION: There are increasing numbers of older persons sustaining ankle fractures. This injury often results in a degree of functional limitation, particularly in older patients. There is currently limited research into factors associated with mobility outcomes. DESIGN: Observational cohort study. SETTING: Hospital Trauma Department, UK. PARTICIPANTS: Persons aged 60 years or over who sustained an unstable ankle fracture with no established peripheral arterial disease pre-injury. METHODS: This study investigated the association between ankle-brachial pressure index (ABPI) and extended timed 'up and go' (TUG) measures. Associations between TUG outcomes and age, pre-morbid functional mobility (Olerud-Molander Ankle Score) and fracture severity (number of malleoli injured) were also explored. ANALYSIS: Complete cases (n=76; 84% of cohort) were entered into univariate and multivariate linear regression. RESULTS: No association was found between ABPI and TUG at 6 months in unadjusted and adjusted analyses. Pre-morbid functional mobility (B=-0.34, 95% confidence interval (CI) -0.45 to -0.23, p<0.001) and age (B=0.46, 95% CI 0.25-0.66, p<0.001) were associated with extended TUG values (r2=0.53, p<0.001). Fracture severity was not a significant independent predictor variable. CONCLUSIONS: Peripheral vessel function and fracture severity may have a limited independent influence on mobility outcome after ankle fracture in those patients who do not have established pre-injury peripheral arterial disease. Age and pre-morbid mobility gave an indication of mobility outcome, but a substantial amount of variance remains unexplained. Limitations of this study, including missing data and potential residual confounding, indicate the need for caution in generalising these results. The study provides a basis on which to plan larger studies of the factors associated with mobility outcome after ankle fracture in older populations.

A Q-Methodology Study of Patients' Subjective Experiences of TIA.

Background. An expanding body of research has focused on a range of consequences of TIA. However, no work has been conducted on the patient's subjective experience of TIA. Aim. To capture patients' first-hand experiences of TIA. Method. Using Q-methodology which employs both qualitative and quantitative approaches, 39 statements relating to the clinical, physical, affective, and psychological impact of TIA were distilled from the literature and from patient narratives. Consistent with conventional Q-methodology, a purposive sample of twentythree post-TIA patients sorted these statements into a normally-distributed 39-cell grid, according to the extent to which each represented their experience of TIA. Results. Casewise factoranalysis was conducted on the sorted statements. Eight factors emerged which were labelled: lack of knowledge/awareness of TIA; life impact; anxiety; interpersonal impact; depression; physical consequences; cognitive avoidance/denial; constructive optimism. Conclusions. Five of the eight factors confirmed existing research on the impact of TIA, but three new issues emerged: deep-seated anxiety, denial and constructive optimism. The emerging perspectives highlight areas to target in the management of TIA and could inform health education messages, patient information, individualised caremanagement, and enhancement of coping strategies. With development, the findings could be used as a basis for psychometric risk assessment of TIA patients.

Physiotherapy rehabilitation following lumbar spinal fusion: a systematic review and meta-analysis of randomised controlled trials.

OBJECTIVE: To evaluate the effectiveness of physiotherapy intervention following lumbar spinal fusion. DESIGN: Systematic review and meta-analysis. 2 independent reviewers searched information sources, assessed studies for inclusion and evaluated risk of bias. Quantitative synthesis using standardised mean differences was conducted on comparable outcomes across trials with similar interventions. INFORMATION SOURCES: Predefined terms were employed to search electronic databases. Additional studies were identified from key journals, reference lists, authors and experts. ELIGIBILITY CRITERIA FOR INCLUDED STUDIES: Randomised control trials published in English prior to 30 September 2011 investigating physiotherapy outpatient management of patients (>16 years), following lumbar spinal fusion, with measurements reported on one or more outcome of disability, function and health were included. RESULTS: 2 Randomised control trials (188 participants) from two countries were included. Both trials included a behavioural and an exercise intervention. 1 trial was evaluated as high risk of bias and one as unclear. 159 participants were incorporated in the meta-analysis. Although evidence from both trials suggested that intervention might reduce back pain short term (6 months) and long term (12 months and 2 years), and a behavioural intervention might be more beneficial than an exercise intervention, the pooled effects (0.72, 95% CI -0.25 to 1.69 at 6 months; 0.52, 95% CI -0.45 to 1.49 at 12 months and 0.75, 95% CI -0.46 to 1.96 at 2 years) did not demonstrate statistically significant effects. There was no evidence that intervention changes pain in the short (6 months) or long term (12 months and 2 years). The wide CI for pooled effects indicated that intervention could be potentially beneficial or harmful. Considerable heterogeneity was evident. CONCLUSIONS: Inconclusive, very low-quality evidence exists for the effectiveness of physiotherapy management following lumbar spinal fusion. Best practice remains unclear. Limited comparability of outcomes and retrieval of only two trials reflect a lack of research in this area that requires urgent consideration.

Vibration testing: a pilot study investigating the intra-tester reliability of the Vibrameter for the Median and Ulnar nerves.

The measurement of vibration thresholds (VTs) is a sensitive test for identifying and monitoring neuropathies. Such a test needs established reliability. The purpose of this research was to evaluate the intra-tester reliability of VT measurements of the Median and Ulnar nerves in asymptomatic participants. A double blinded repeated measures study was carried out. The VTs of the Median and Ulnar nerves were measured on two occasions with seven days between measurements. Participants were trained in identifying the sensation before commencing measurement. 22 participants who fulfilled the inclusion criteria were recruited. Intra-rater reliability was analysed used the intra-class correlation. The median nerve showed excellent reliability (ICC = .922; standard error of the mean = .0225 µm; 'true' SEM = .045 µm; smallest real difference = .062 µm). Ulnar nerve reliability was 'substantial' (ICC = .632; standard error of the mean = .0225 µm; 'true' SEM = .055 µm; smallest real difference = .085 µm). The VT measurements showed excellent to substantial reliability. The Vibrameter has the potential for excellent reliability providing manual therapists practice the technique of using it. It could usefully be considered by manual therapists to support their practice.

A systematic review of the incidence and prevalence of long-term neurological conditions in the UK.

BACKGROUND: Updated, robust estimates of the incidence and prevalence of rare long-term neurological conditions in the UK are not available. Global estimates may be misrepresentative as disease aetiology may vary by location. OBJECTIVES: To systematically review the incidence and prevalence of long-term neurological conditions in the UK since 1988. SEARCH STRATEGY: Medline (January 1988 to January 2009), Embase (January 1988 to January 2009), CINAHL (January 1988 to January 2009) and Cochrane CENTRAL databases. SELECTION CRITERIA: UK population-based incidence/prevalence studies of long-term neurological conditions since 1988. Exclusion criteria included inappropriate diagnoses and incomprehensive case ascertainment. DATA COLLECTION AND ANALYSIS: Articles were included based on the selection criteria. Data were extracted from articles with ranges of incidence and prevalence reported. MAIN RESULTS: Eight studies met the criteria (3 on motor neurone disease; 4 on Huntington's disease; 1 on progressive supranuclear palsy). The incidence of motor neurone disease ranged from 1.06 to 2.4/100,000 person-years. The prevalence ranged from 4.02 to 4.91/100,000. The prevalence of Huntington's disease ranged from 4.0 to 9.94/100,000. The prevalence of progressive supranuclear palsy ranged from 3.1 to 6.5/100,000. CONCLUSIONS: The review updates the incidence/prevalence of long-term neurological conditions. Future epidemiological studies must incorporate comprehensive case ascertainment methods and strict diagnostic criteria.

The craniocervical flexion test: intra-tester reliability in asymptomatic subjects.

BACKGROUND AND PURPOSE: The deep neck flexor muscles (DNFs) stabilize the cervical spine and cervicogenic pain appears to adversely affect their endurance capacity. They are inaccessible to direct palpation, thereby making assessment difficult. However, the cranio-cervical flexion test (CCFT) provides an indirect method of assessing the endurance capacity of the DNFs. The purpose of the present study was to evaluate the intratester reliability of the CCFT in asymptomatic subjects. METHOD: The clinical protocol of the CCFT was measured on two occasions with 7 days between measurements. Prior to testing, participants were trained and compensation strategies were corrected. Nineteen asymptomatic participants (mean age 24.9 years; range 22-36) were recruited. RESULTS: The test had excellent intratester reliability (intraclass correlation coefficient = 0.983; standard error of the mean = 8.94; smallest real difference = 24.7). A Bland and Altman's limits of agreement analysis confirmed the high reliability of the test. CONCLUSION: The CCFT results demonstrated excellent intra-tester reliability in asymptomatic subjects, thus contributing to the normative data regarding the test.