A multi-centre randomised controlled trial of rehabilitation aimed at improving outdoor mobility for people after stroke: study protocol for a randomised controlled trial.

BACKGROUND: Up to 42% of all stroke patients do not get out of the house as much as they would like. This can impede a person's quality of life. This study is testing the clinical effectiveness and cost effectiveness of a new outdoor mobility rehabilitation intervention by comparing it to usual care. METHODS/DESIGN: This is a multi-centre parallel group individually randomised, controlled trial. At least 506 participants will be recruited through 15 primary and secondary care settings and will be eligible if they are over 18 years of age, have had a stroke and wish to get out of the house more often. Participants are being randomly allocated to either the intervention group or the control group. Intervention group participants receive up to 12 rehabilitation outdoor mobility sessions over up to four months. The main component of the intervention is repeated practice of outdoor mobility with a therapist. Control group participants are receiving the usual intervention for outdoor mobility limitations: verbal advice and provision of leaflets provided over one session.Outcome measures are being collected using postal questionnaires, travel calendars and by independent assessors. The primary outcome measure is the Social Function domain of the SF36v2 quality of life assessment six months after recruitment. The secondary outcome measures include: functional ability, mobility, the number of journeys (monthly travel diaries), satisfaction with outdoor mobility, mood, health-related quality of life, resource use of health and social care. Carer mood information is also being collected.The mean Social Function score of the SF-36v2 will be compared between treatment arms using a multiple membership form of mixed effects multiple regression analysis adjusting for centre (as a fixed effect), age and baseline Social Function score as covariates and therapist as a multiple membership random effect. Regression coefficients and 95% confidence intervals will be presented. DISCUSSION: This study protocol describes a pragmatic randomised controlled trial that will hopefully provide robust evidence of the benefit of outdoor mobility interventions after stroke for clinicians working in the community. The results will be available towards the end of 2012. TRIAL REGISTRATION: ISRCTN58683841.

Community capacity for adaptation to climate-induced water shortages: linking institutional complexity and local actors.

There is growing concern for the capacity of urban and rural communities to manage current water shortages and to prepare for shortages that may accompany predicted changes in climate. In this paper, concepts relating to the notion of climate adaptation and particularly "capacity building" are used to elucidate several determinants of community-level capacity for water management. These concepts and criteria are then used to interpret empirically derived insights relating to local management of water shortages in Ontario, Canada. General determinants of water-related community capacity relate to upper tier political and institutional arrangements; the characteristics of, and relationships among, pertinent agencies, groups, or individuals involved in water management; and the adequacy of financial, human, information, and technical resources. The case analysis illustrates how general factors play out in local experience. The findings point to geographically specific factors that influence the effectiveness of management. Key factors include collaboration between water managers, clarification of agency roles and responsibilities, integration of water management and land-use planning, and recognition and participation of both urban and rural stakeholders, whose sensitivities to water shortages are spatially and temporally variable.

Groundwater management by watershed agencies: an evaluation of the capacity of Ontario's conservation authorities.

Watershed-based resource management organizations around the world are becoming more involved in groundwater management. This reflects, among other considerations, growing awareness of the critical role that these local agencies can and should play in the management of groundwater resources. Ontario's conservation authorities (CAs) are an important example. CAs are taking on new responsibilities for groundwater data collection, monitoring and planning. Unfortunately, not all local organizations are equally capable of participating effectively in groundwater management. This certainly is the case among Ontario's 38 CAs, which have highly variable levels of financial and staff resources. Local capacity for water management can be explored from the perspective of the institutional environment, the watershed community, and the financial, technical and staff resources of the organizations. This paper presents an evaluation of the groundwater management capacity of Ontario's conservation authorities, drawing on two detailed case studies (the Upper Thames River CA and the Ganaraska Region CA), and additional data gathered from all 38 CAs. Institutional issues, such as the clarity of management roles and senior government commitment to local management, as well as resourcing concerns, local working relationships, and public support, largely determine the capacity of CAs to expand their involvement in groundwater management. Strengthening the capacity of watershed-based agencies to participate in groundwater management is an important challenge in all jurisdictions, as these agencies are well placed to reinforce municipal groundwater management by identifying local needs and trends, facilitating communication and cooperation, and promoting best management practices.