Co-Design of a website for women with pelvic organ prolapse: A study protocol.

Background: Despite high reported prevalence of pelvic organ prolapse (POP), women report difficulties accessing evidence-based and reliable information about the condition. Many rely on social media and other popular and highly visible internet platforms which have been found to contain poor quality information that is difficult for the average patient to understand. The aim of the study is to co-design an information website for premenopausal women with POP. The website design will be based on the Website Developmental Model for the Healthcare Consumer (WDMHC) framework. Methods: A four phase process will be utilised as per the WDMHC framework: 1) User, task and environmental analysis; 2) Functional and representational analysis; 3) Cognitive walkthrough, keystroke level model, heuristic testing; 4) Content based testing, expert testing and user-based testing.Ethics approval has been obtained (LS-23-19-Carroll-Ful). Two groups of stakeholders will be recruited (i) patient group (ii) healthcare professional (HCP) group. Patient participants will be recruited from an online pelvic floor dysfunction (PFD) support group (n=950 members). A website designer and HCP stakeholders involved in the multidisciplinary team caring for women with POP will be invited to participate.Both groups will participate in separate co-design online workshops. Focus group workshops will be video-recorded, transcribed and imported into NVivo. Themes and subthemes will be developed.The website will be designed and disseminated to all participants for feedback. Cognitive walkthrough and heuristic testing will be undertaken. Following this, necessary modifications will be made to the website. Participants will then complete a modified System Usability Scale (SUS) and the eHealth Impact Questionnaire, while five HCPs will complete the DISCERN instrument. Conclusion: This study will inform the design and testing of an information website for women with POP. The website design and content will be informed by patient and HCP stakeholder voices and the health literacy literature.

"Otherwise he will be a beggar": a focus group study to understand the Perspectives of physiotherapists about measuring rehabilitation outcomes and impact in low-resource and conflict-affected settings.

PURPOSE: Rehabilitation outcomes are important for patients, professionals and policy makers. Most outcome measures (OMs) were developed for "Western" contexts and may be inadequate for low-resource and conflict settings, where the ability to demonstrate impact would be critical to strengthening the sector. This study aims to understand perspectives of physiotherapists from challenging environments regarding current practices, value, barriers, and facilitators of measuring rehabilitation outcomes. MATERIALS & METHODS: Focus group discussions were held in English with 35 physiotherapists from 18 countries. Audio recordings were transcribed verbatim, anonymised, and analysed using reflexive thematic analysis. RESULTS: Four themes emerged illustrating the levels at which outcomes and measures were discussed: User (patients, families), provider (physiotherapists, rehabilitation workers), application (OMs), and structure (management, health system). Participants discussed diversity in current practices and patient populations, utility of OMs and a neglected rehabilitation sector lacking investment. Barriers to progressing outcome measurement included lacking patient health literacy, rehabilitation provider training, valid OMs, and leadership. Participants suggested improved patient involvement, routine outcome measurement by using, developing, or adapting simple, context- and stakeholder-relevant OMs, and support from management. CONCLUSIONS: These insights illustrate the need of and provide robust recommendations for context-adapted development of rehabilitation outcome measurement in various challenging contexts.

Rehabilitation outcomes are important to show impact in low-resource and conflict settings, but most outcome measures originate from "Western" contextsExperience of physiotherapists from low-resource and conflict settings reveals the barriers and facilitators to measuring rehabilitation outcomes in their workplacesParticipants' suggest to use or develop simple scales that are contextualised and stakeholder-relevant for standard, routine measurementThis study highlights the need to improve the measurement of rehabilitation outcomes in challenging contexts and provides guidance on how to do so.

Biopsychosocial profile of women with pelvic organ prolapse: A systematic review.

Female pelvic organ prolapse is a common condition associated with significant impact on women's lives from a biopsychosocial perspective. The aim of this systematic review is to identify, appraise and summarize the biopsychosocial profile of women with pelvic organ prolapse. Searches were completed from inception to October 2022 from PubMed, Web of Science, EMBASE, CINAHL, Cochrane, PsycINFO and PEDro using a search string and in line with the Preferred Reporting Information for Systematic reviews and Meta-Analyses protocol. English language studies (randomized controlled trials, cohort studies, case-control studies, qualitative research) investigating female pelvic organ prolapse and using a validated patient-reported outcome measure and validated pelvic organ prolapse objective measurement were examined. Two reviewers independently screened titles, abstracts and full articles for eligibility. Data extraction included participant characteristics, pelvic organ prolapse grading and outcome measures. Risk of bias was assessed using the appropriate Joanna Briggs Institute Tool. Baseline mean score for each questionnaire or questionnaire domain in each category was presented in tertiles (low, moderate and high impact) to allow simple classification of impact. Of 8341 articles identified, 18 were included (n = 2075 women, age range = 22-85 years, parity range = 0-10). One objective outcome measure graded pelvic organ prolapse: Pelvic Organ Prolapse Quantification measurement. Eleven validated patient-reported outcome measures were utilized; two pelvic organ prolapse-specific (Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire, Pelvic Organ Prolapse Quality of Life Questionnaire), the remainder pelvic health (International Consultation on Incontinence Questionnaire-Vaginal Symptoms, International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form, Pelvic Floor Distress Inventory-20, Incontinence Impact Questionnaire-7, Female Sexual Function Index, Urinary Distress Inventory-6, Kings Health Questionnaire, Pelvic Floor Impact Questionnaire-7) or general health questionnaires (Short Form-36). Patient-reported outcome measures included in the review reported moderate levels of pain with sexual intercourse and low levels of bodily pain. Pelvic organ prolapse had a low to moderate impact in sleep/energy and quality of life and sexual function domains. Its impact on physical symptoms and general health perception domains was low. Patient-reported outcome measures results for physical functioning varied from low to high impact. More impact was demonstrated when using pelvic organ prolapse-specific patient-reported outcome measures. There are opportunities for improvement in the use of patient-reported outcome measures in clinical research which would facilitate increased understanding of the biopsychosocial profile of women with pelvic organ prolapse.

"I've got a spring in my step" participants experience of action observation therapy and eccentric exercises, a telehealth study for mid-portion Achilles Tendinopathy: a qualitative study.

BACKGROUND: Quantitative research has dominated the field of Achilles Tendinopathy. The use of qualitative research allows in-depth exploration of participants' perspectives, offering great insight in the evaluation of a trial's processes, particularly when exploring a novel intervention such as Action Observation Therapy combined with eccentric exercises which has not been previously researched. This study aimed to qualitatively explore participants' experiences of partaking in a telehealth study including the acceptability of the intervention, motivators for participation, and perspectives on the trial processes. METHOD: A thematic analysis as guided by Braun and Clarke was used to analyse the semi-structured interviews conducted on a purposive sample of participants with mid-portion Achilles Tendinopathy who recently completed a pilot feasibility study. The study adhered to the criteria for reporting qualitative research guidelines (COREQ). RESULTS/DISCUSSION: Sixteen participants were interviewed. The five themes identified were: (i) The impact of Achilles Tendinopathy is commonly not prioritised with 'The acceptance and minimisation of pain' as a sub-theme (ii) Therapeutic alliance has the greatest impact on support (iii) Factors which influenced adherence (iv) Action Observation Therapy is valued and recommended (v) Recommendations for future interventions. CONCLUSION: This study provides insightful recommendations around; exploring the use of Action Observation Therapy in Achilles Tendinopathy, the relative importance of therapeutic alliance rather than mode of therapy delivery, and that sufferers of Achilles Tendinopathy may not prioritise health seeking for this condition.

Pelvic organ prolapse: The lived experience.

BACKGROUND: Up to 50% of women will develop pelvic organ prolapse (POP) over their lifetime. Symptoms include pain, bulge, urinary, bowel and sexual symptoms affecting all aspects of a woman's life. This study explores the lived experience of women with POP. METHODOLOGY: A qualitative study was undertaken. Following institutional ethical approval women from an online peer support group (n = 930 members) were recruited to participate in semi-structured interviews. Inclusion criteria stipulated women (> 18years), pre-menopausal, at least one-year post-partum, diagnosed with POP and aware of their diagnosis. Semi-structured interviews were undertaken with a clinician specialising in pelvic health. A battery of questions was designed to elicit discussion on their experience of being diagnosed with POP and its impact on daily life and relationships. Interviews were carried out via Zoom, recorded and transcribed. Thematic analysis was undertaken. FINDINGS: Fourteen women (32-41 years), para 1-3 participated. All had at least one vaginal birth; three had vacuum, four had forceps operative births. All had Grade 1-3 POP. Interviews lasted 40-100 minutes. Three core themes with subthemes were identified; biological/physical, psychological and social. Women were particularly affected in terms of sport and exercise participation, their own perceptions of their ability as mothers and fear of their condition worsening. They described societal attitudes, reporting stigma around POP and women's pelvic health in general, expectations placed on women to put up with their symptoms and an idealised perception of new motherhood. CONCLUSIONS: The impact of POP from a biopsychosocial perspective reflects other chronic conditions. Prevention, early education and supports for developing strong self-management approaches would be beneficial for long term management of this condition.

Ways to improve surgical outcomes in low- and middle-income countries.

Global surgery initiatives such as the Lancet Commission on Global Surgery have highlighted the need for increased investment to enhance surgical capacity in low- and middle-income countries. A neglected issue, however, is surgery-related rehabilitation, which is known to optimize functional outcomes after surgery. Increased investment to enhance surgical capacity therefore needs to be complemented by promotion of rehabilitation interventions. We make the case for strengthening surgery-related rehabilitation in lower-resource countries, outlining the challenges but also potential solutions and policy directions. Proposed solutions include greater leadership and awareness, augmented by recent global efforts around the World Health Organization's Rehabilitation 2030 initiative, and professionalization of the rehabilitation workforce. More research on rehabilitation is needed in low- and middle-income countries, along with support for system approaches, notably on strengthening and integrating rehabilitation within the health systems. Finally, we outline a set of policy implications and recommendations, aligned to the components of the national surgical plan proposed by the Lancet Commission: infrastructure, workforce, service delivery, financing, and information management. Collaboration and sustained efforts to embed rehabilitation within national surgical plans is key to optimize health outcomes for patients with surgical conditions and ensure progress towards sustainable development goal 3: health and well-being for all.

À l'instar de la Commission Lancet sur la chirurgie mondiale, des initiatives internationales consacrées à ce sujet ont mis en évidence le besoin d'investir davantage dans le renforcement des capacités chirurgicales dans les pays à revenu faible et intermédiaire. Néanmoins, la réadaptation post-chirurgicale, connue pour améliorer les résultats fonctionnels après une intervention, reste un enjeu largement ignoré. Ces investissements accrus visant à renforcer les capacités chirurgicales doivent donc aller de pair avec une promotion des services de réadaptation. Dans le présent document, nous plaidons pour le développement d'une réadaptation post-chirurgicale dans les pays à revenu faible et intermédiaire, en identifiant les défis mais aussi les orientations politiques et les solutions possibles. Parmi elles, un meilleur leadership et une prise de conscience, favorisée par les récents efforts mondiaux qui ont entouré l'initiative Réadaptation 2030 de l'Organisation mondiale de la Santé, ainsi qu'une professionnalisation du personnel dédié à la réadaptation. D'autres recherches sur la réadaptation sont nécessaires dans les pays à revenu faible et intermédiaire, tout comme l'apport d'un soutien aux approches systémiques, en particulier pour consolider et intégrer de telles pratiques dans les systèmes de santé. Enfin, nous dégageons une série de recommandations et d'implications politiques inspirés des éléments du plan chirurgical national proposé par la Commission Lancet: infrastructures, main-d'œuvre, prestations de services, financement et gestion des informations. La collaboration et la poursuite des efforts en vue d'inclure la réadaptation dans les plans chirurgicaux nationaux jouent un rôle crucial dans l'amélioration des résultats cliniques chez les patients souffrant de complications post-opératoires. En outre, elles permettront de progresser vers le troisième objectif de développement durable: santé et bien-être pour tous à tout âge.

Las iniciativas de cirugía a nivel mundial, como la Comisión Lancet sobre Cirugía Mundial, han destacado la necesidad de aumentar la inversión para mejorar la capacidad quirúrgica en los países de ingresos bajos y medios. Sin embargo, se ha descuidado la rehabilitación relacionada con la cirugía, que se sabe que optimiza los resultados funcionales después de la intervención. Por lo tanto, el incremento de la inversión para mejorar la capacidad quirúrgica se debe complementar con la promoción de intervenciones de rehabilitación. En este artículo se defiende la necesidad de reforzar la rehabilitación relacionada con la cirugía en los países con menos recursos, y se exponen los desafíos, pero también las posibles soluciones y orientaciones políticas. Las soluciones propuestas incluyen un mayor liderazgo y concienciación, potenciados por los recientes esfuerzos mundiales en torno a la iniciativa Rehabilitación 2030 de la Organización Mundial de la Salud, y la profesionalización del personal de rehabilitación. Se necesita más investigación sobre la rehabilitación en los países de ingresos bajos y medios, junto con el apoyo a los enfoques sistémicos, en particular sobre el fortalecimiento y la integración de la rehabilitación dentro de los sistemas sanitarios. Por último, se expone un conjunto de implicaciones y recomendaciones políticas, alineadas con los componentes del plan quirúrgico nacional que propone la Comisión Lancet: infraestructura, personal, prestación de servicios, financiación y gestión de la información. La colaboración y los esfuerzos sostenidos para integrar la rehabilitación en los planes quirúrgicos nacionales son fundamentales para optimizar los resultados sanitarios de los pacientes con afecciones quirúrgicas y asegurar el progreso hacia el tercer objetivo de desarrollo sostenible: salud y bienestar para todos.

The effect of combined Action Observation Therapy with eccentric exercises in the treatment of mid-portion Achilles-tendinopathy: a feasibility pilot randomised controlled trial.

BACKGROUND: Mid-portion Achilles Tendinopathy (AT) is a common musculoskeletal condition with varying rehabilitation success rates. Despite the prevalence of this condition, a considerable proportion of individuals experience persisting pain and functional deficits. Current treatment approaches bias the biomedical model which emphasises physically treating and loading the tendon. Overall, there is a lack of consideration for the central nervous system that is commonly implicated in chronic injuries. The aim of this pilot study was to explore the feasibility of combining Action Observation Therapy (AOT), a treatment technique which targets central changes and influences motor learning, with eccentric exercises in the treatment of mid-portion AT. AOT involves the observation of movements and is commonly followed by the physical performance of these same movements. METHODOLOGY: This was a double-blinded randomised controlled pilot feasibility study. All participants underwent the 12-week Alfredson eccentric training protocol. The intervention group watched videos of the exercises prior to performing these exercises, whilst the control group watched nature videos before performing the same exercises. Study feasibility was the primary outcome measure, with the Victorian Institute of Sports Assessment- Achilles (VISA-A) selected as the primary clinical outcome measure. RESULTS: Thirty participants were recruited, reflecting a 75% eligibility rate and 100% of eligible participants enrolled in the study. The retention rate at week 12 was 80%. At week six the mean VISA-A score improved by 18.1 (95% CI 10.2-26.0) in the intervention group and 7.7 (95% CI 0.3-14.9) in the control group, and 75% and 33% of participants in the intervention and control group respectively exceeded the minimal clinically important difference (MCID). At week 12 the mean VISA-A score from baseline improved by 22.25 (95% CI 12.52-31.98) in the intervention group and 16.5-(95% CI 8.47-24.53) in the control group, equating to 75% and 58% in each group respectively exceeding the MCID. CONCLUSION: The positive feasibility outcomes and exploratory data from the clinical outcome measures suggest that a larger scaled RCT is warranted to further investigate the impact of AOT in the rehabilitation of mid-portion AT. Trial registration ISRCTN58161116, first registered on the 23/12/2020.

The effect of combined action observation therapy and eccentric exercises in the treatment of mid-portion Achilles tendinopathy: study protocol for a feasibility pilot randomised controlled trial.

BACKGROUND: Mid-portion Achilles tendinopathy (AT) is a common overuse injury which can be difficult to successfully rehabilitate. Whilst peripherally directed treatment approaches that strengthen the Achilles tendon complex can be efficacious for some individuals, others will continue to experience long-standing pain and functional deficits. Expanding our rehabilitation approach beyond the tendon mechanical properties to include techniques which target the central neurophysiological changes which can occur in chronic injuries, including mid-portion AT, may improve our rehabilitation outcomes. Action observation therapy (AOT) is one such technique which targets central changes and can enhance motor learning. To our knowledge, there is currently no available information on the combined effect of AOT and eccentric exercises in the rehabilitation of mid-portion AT, nor understanding of the feasibility of conducting randomised controlled trials that investigate this combined centrally and peripherally directed treatment approach. This protocol outlines the design of a remotely conducted parallel-group randomised controlled trial comparing the efficacy of combined AOT and eccentric loading exercises versus eccentric loading exercises alone for mid-portion AT. METHODS: Participants recruited throughout Ireland with mid-portion AT will be randomly assigned to one of the following groups: (i) The AOT group will observe videos of the eccentric exercises prior to the physical performance of the eccentric exercises. (ii) The control group will observe videos of landscapes prior to the performance of the eccentric exercises. This is a 12-week daily intervention as per the Alfredson loading protocol and outcome measures will be assessed at baseline, week 6 and week 12. Primary feasibility outcomes will include data on numbers of eligible participants, recruitment and retention rates, along with exercise compliance and acceptability of treatment. The primary clinical outcome measure will be the Victorian Institution Symptom Assessment-Achilles Questionnaire (VISA-A) assessing disability. Secondary clinical outcomes will address the remaining core domains as outlined by the International Scientific Tendinopathy Symposium consensus (ICON group) including pain, participation, functional, physical function capacity, quality of life and psychological factors. Widespread bodily pain and centralised pain features and patient satisfaction levels will also be evaluated. DISCUSSION: This study will provide scientific direction for future randomised controlled trials exploring the effect of AOT and eccentric exercises in the treatment of mid-portion AT on pain, centralised pain features, motor and non-motor functions, quality of life and patient satisfaction levels. The feasibility of the conducting a study remotely from participant screening to final follow-up assessment will also be provided. TRIAL REGISTRATION: ISRCTN58161116.

Retrospective observational study of characteristics of persons with amputations accessing International Committee of the Red Cross (ICRC) rehabilitation centres in five conflict and postconflict countries.

OBJECTIVES: Limb amputation incidence is particularly high in fragile contexts due to conflict, accidents and poorly managed diabetes. The study aim was to analyse (1) demographic and amputation characteristics of persons with any type of acquired amputation (PwA) and (2) time between amputation and first access to rehabilitation in five conflict and postconflict countries. DESIGN: A retrospective, observational study analysing differences in demographic and clinical factors and time to access rehabilitation between users with traumatic and non-traumatic amputations. SETTING: Five countries with the highest numbers of PwA in the global International Committee of the Red Cross database (Afghanistan, Cambodia, Iraq, Myanmar, Sudan). Cleaned and merged data from 2009 to 2018 were aggregated by sex; age at amputation and registration; cause, combination and anatomical level of amputation(s); living environment. PARTICIPANTS: All PwA newly attending rehabilitation. RESULTS: Data for 28 446 individuals were included (4329 (15.2%) female). Most were traumatic amputations (73.4%, 208 90); of these, 48.6% (138 01) were conflict related. Average age at traumatic amputation for men and women was 26.9 and 24.1 years, respectively; for non-traumatic amputation it was 49.1 years and 45.9 years, respectively. Sex differences in age were statistically significant for traumatic and non-traumatic causes (p<0.001, p=0.003). Delay between amputation and rehabilitation was on average 8.2 years for those with traumatic amputation, significantly higher than an average 3 years for those with non-traumatic amputation (p<0.001). CONCLUSIONS: Young age for traumatic and non-traumatic amputations indicates the devastating impact of war and fragile health systems on a society. Long delays between amputation and rehabilitation reveal the mismatch of needs and resources. For rehabilitation service providers in fragile settings, it is an enormous task to manage the diversity of PwA of various causes, age, sex and additional conditions. Improved collaboration between primary healthcare, surgical and rehabilitation services, a prioritisation of rehabilitation and increased resource provision are recommended to ensure adequate access to comprehensive rehabilitation care for PwA.

A Focus Group Study to Understand the Perspectives of Physiotherapists on Barriers and Facilitators to Advancing Rehabilitation in Low-Resource and Conflict Settings.

Physiotherapy as a health profession is continuously evolving in high-income countries (HIC). The highest burden of disease globally, however, is in low-resource and conflict contexts (LR-CC), resulting in unmet rehabilitation needs. Rehabilitation service models from HIC often face challenges when applied to the fragile health systems of LR-CC. It is important to engage rehabilitation experts living and working in LR-CC to guide service development. This study aims to understand physiotherapists' views and perspectives of current rehabilitation services, of how these services can be strengthened over the next 10 years and of the role of physiotherapy within this development. Focus group discussions (FGDs) were conducted with 31 physiotherapists from 18 LR-CC using English as a common language. Audio recordings were transcribed verbatim. Data analysis was guided by thematic analysis. Participants provided deep insights into the complexity of developing rehabilitation services within fragile health systems. Participants agreed that physiotherapy lacked recognition and resources to be utilised effectively. Interacting themes as crucial prerequisites for strengthening the sector included (1) significance of context, (2) professional identity, and (3) professionalisation supported by workforce development and advocacy. These results are an important evidence base for informing the development of rehabilitation programmes in LR-CC and for future research.

Lifestyle Interventions to Improve Glycemic Control in Adults with Type 2 Diabetes Living in Low-and-Middle Income Countries: A Systematic Review and Meta-Analysis of Randomized Controlled Trials (RCTs).

Alongside glucose lowering therapy, clinical guidelines recommend lifestyle interventions as cornerstone in the care of people living with type 2 diabetes (T2DM). There is a specific need for an up-to-date review assessing the effectiveness of lifestyle interventions for people with T2DM living in low-and-middle income countries (MICs). Four electronic databases were searched for RCTs published between 1990 and 2020. T2DM, lifestyle interventions, LMICs and their synonyms were used as search terms. Data codebooks were developed and data were extracted. Narrative synthesis and meta-analysis were conducted using random effects models to calculate mean differences (MD) and standardized mean differences (SMD) and 95% confidence intervals (CI). Of 1284 articles identified, 30 RCTs (n = 16,670 participants) met the inclusion criteria. Pooled analysis revealed significant improvement in HBA1c (MD -0.63; CI: -0.86, -0.40), FBG (SMD -0.35; CI: -0.54, -0.16) and BMI (MD -0.5; CI: -0.8, -0.2). In terms of intervention characteristics, those that included promoted self-management using multiple education components (e.g., diet, physical activity, medication adherence, smoking cessation) and were delivered by healthcare professionals in a hospital/clinic setting were deemed most effective. However, when interpreting these results, it is important to consider that most included studies were evaluated as being of low quality and there was a significant amount of intervention characteristics heterogeneity. There is a need for further well-designed studies to inform the evidence base on which lifestyle interventions are most effective for glycemic control in adults with T2DM living in LMICs.

Effect of Action Observation Therapy in the Rehabilitation of Neurologic and Musculoskeletal Conditions: A Systematic Review.

OBJECTIVE: To investigate the effect of action observation therapy (AOT) in the rehabilitation of neurologic and musculoskeletal conditions. DATA SOURCES: Searches were completed until July 2020 from the electronic databases Allied and Complementary Medicine Database (via OVID SP), Cumulative Index to Nursing and Allied Health Literature, Cochrane Library, EMBASE, MEDLINE, and the Physiotherapy Evidence Database. STUDY SELECTION: Randomized controlled trials comparing AOT with standard care were assessed. Musculoskeletal (amputee, orthopedic) and neurologic (dementia, cerebral palsy, multiple sclerosis, Parkinson disease, stroke) conditions were included. There were no age limitations. Articles had to be available in English. DATA EXTRACTION: Two reviewers independently screened titles, abstracts and full extracts of studies for eligibility and assessed the risk of bias of each study using the Cochrane Risk of Bias Tool. Data extraction included participant characteristics and intervention duration, frequency, and type. RESULTS: The effect of AOT in different outcome measures (OMs) was referenced in terms of body structures and functions, activities and participation, and environmental factors as outlined by the International Classification of Functioning, Disability, and Health (ICF). Of the 3448 articles identified, 36 articles with 1405 patients met the inclusion criteria. Seven of the 11 meta-analyses revealed a significant effect of intervention, with results presented using the mean difference and 95% CI. A best evidence synthesis was used across all OMs. Strong evidence supports the use of AOT in the rehabilitation of individuals with stroke and Parkinson disease; moderate evidence supports AOT in the rehabilitation of populations with orthopedic and multiple sclerosis diagnoses. However, moderate evidence is provided for and against the effect of AOT in persons with Parkinson disease and cerebral palsy. CONCLUSIONS: This review suggests that AOT is advantageous in the rehabilitation of certain conditions in improving ICF domains. No conclusions can be drawn regarding treatment parameters because of the heterogeneity of the intervention. AOT has been considerably less explored in musculoskeletal conditions.

Orthopaedic consultant surgeons perceptions of an advanced practice physiotherapy service in paediatrics: A qualitative study.

OBJECTIVES: The objective of this study is to determine orthopaedic consultants' perceptions of an advanced practice physiotherapy (APP) service in paediatrics. DESIGN: This is a qualitative study that use semi-structured interviews to explore consultant doctors' experiences of an APP paediatric orthopaedic service and its development. Data were transcribed verbatim and subsequently underwent thematic analysis. PARTICIPANTS: Five orthopaedic consultants in two hospital settings participated, and all of whom had experience of working with paediatric orthopaedic APPs. RESULTS: Seven themes were derived from the analysis, with all participants in the study identifying factors affecting the development of the service and demonstrating broad support for the APP role, with benefits noted as including improved efficiency of service, expansion of skill mix within the team, positive impressions of the standard of care and improved education and liaison with the families and community practitioners at large. CONCLUSIONS: This paper highlights many of the factors that should be considered when introducing an APP service in an outpatient setting. This study demonstrates consistent cross-site positive regard in the skill and competency of the APP in paediatric orthopaedics, to enhance orthopaedic services for children.

Users of rehabilitation services in 14 countries and territories affected by conflict, 1988-2018.

OBJECTIVE: To analyse the demographic and clinical characteristics of people attending physical rehabilitation centres run or supported by the International Committee of the Red Cross in countries and territories affected by conflict. METHODS: Of 150 such rehabilitation centres worldwide, 38 use an electronic patient management system. We invited all 38 centres to participate. We extracted de-identified data from 1988 to 2018 and categorized them by sex, age, country or territory and reason for using rehabilitation services. FINDINGS: Thirty-one of the 38 rehabilitation centres in 14 countries and territories participated. We included data for 287 274 individuals. Of people using rehabilitation services, 61.6% (176 949/287 274) were in Afghanistan, followed by 15.7% (44 959/287 274) in Cambodia. Seven places had over 9000 service users each (Afghanistan, Cambodia, Gaza Strip, Iraq, Myanmar, Somalia and Sudan). Overall, 72.6% (208 515/287 274) of service users were male. In eight countries, more than half of the users were of working age (18-59 years). Amputation was the most common reason for using rehabilitation services; 33.3% (95 574/287 274) of users were people with amputations, followed by 13.7% (39 446/287 274) with cerebral palsy. The male predominance was greater in the population aged 18-34 years (83.1%; 71 441/85 997) and in people with amputations (88.6%; 84 717/95 574) but was evident across all places, age groups and health conditions. CONCLUSION: The considerably lower attendance of females at the rehabilitation centres highlights the need to understand the factors that affect the accessibility and acceptability of rehabilitation for women and girls in conflict settings.

Exploring the use of ultrasound imaging by physiotherapists: An international survey.

BACKGROUND: National surveys in New Zealand, Australia and the United Kingdom suggest ultrasound imaging (USI) use by physiotherapists is increasing. However, concerns exist regarding clarity for scopes of practice, and availability and standardisation of training. OBJECTIVES: To investigate physiotherapists' understanding of scopes of practice for the use of USI; clarify the professional contexts, clinical uses and levels of training; and identify barriers preventing physiotherapists' USI use. DESIGN: A cross-sectional, observational survey. METHODS: An Internet-based survey, offered in 20 different languages, was used including items covering five domains: (1) demographic and professional characteristics; (2) knowledge of scope of practice; (3) USI use; (4) USI training content and duration; and (5) perceived barriers to physiotherapists' use of USI. RESULTS: 1307 registered physiotherapists from 49 countries responded; 30% were unsure of the scope of practice for physiotherapists' USI use. 38% of participants were users of USI, reporting varied contexts and clinical uses, reflected in the broader categories of: (i) biofeedback; (ii) diagnosis; (iii) assessment; (iv) injection guidance; (v) research; (vi) and teaching. The training users received varied, with formal training more comprehensive. 62% were non-users, the most common barrier was lack of training (76%). CONCLUSION: These findings suggest physiotherapists' USI use is increasing in various contexts; however, there is uncertainty regarding scopes of practice. There are discrepancies in training offered, with a lack of training the most common barrier to physiotherapists' use of USI. International guidelines, including a USI training framework, are needed to support the consistent and sustainable use of USI in physiotherapy.

Advanced musculoskeletal physiotherapy practice: Informing education curricula.

INTRODUCTION: Physiotherapists are operating at an advanced level of practice, usually on ad hoc basis with inhouse training, in response to the increasing burden of musculoskeletal (MSK) disorders. Discrepancies in role-specific education of advanced practice physiotherapists (APPs) creates challenges in ensuring a quality service, workforce mobility and formal recognition. This study reviewed existing MSK APP competency frameworks and education offerings, and explored physiotherapist learning needs with a view to informing international standardisation of MSK APP education curricula. METHODS: A scoping review of the literature and relevant university and regulatory websites identified APP competency frameworks and education curricula, which were verified by international experts. Content analysis, performed on the identified competencies and modules, produced a list of themes existing in MSK advanced practice internationally. A survey based on those themes identified the learning priorities of physiotherapists (n = 25) participating in an APP symposium in Ireland. RESULTS: Six APP competency frameworks and eleven curricula from the UK, Canada and Australia were identified. Themes emerging, regarding MSK APP practice internationally, included both entry-level physiotherapy (e.g., Assessment and Diagnosis) and traditionally medically-controlled tasks (e.g., Injection Therapy), as well as Research, Leadership, Service Development, Professional-related Matters and Education. Participating physiotherapists more commonly prioritised competencies which would be deemed beyond entry level physiotherapy skills (i.e., Radiology versus Manual Therapy). CONCLUSION: Despite variances in profiles of APPs both between and within countries, common themes emerged regarding their expected competencies and skills. This study provides the foundation for the adoption of internationally-recognised MSK APP competencies and education standards.

Increasing competence in wound care: A cross-sectional study to evaluate use of a virtual patient by undergraduate student nurses.

Concerns have arisen internationally over the competency of student nurses to perform wound care. A global shortage of nursing faculty and clinical practice opportunities is regarded as a contributing factor. Virtual simulation offers a possible solution. The aim of this study was to describe the development and educational evaluation of a virtual patient to supplement undergraduate learning of wound care. The National League for Nursing Jeffries model informed the design of the media. Evaluation of the virtual patient by penultimate year nursing students (n = 148) was conducted using a survey design. Findings are presented from statistical and directed content analyses. Most students rated the educational value of the virtual patient and its support of learning highly. They reported a perceived increase in confidence and ability to meet wound care competency outcomes. The virtual patient also provided students with opportunities to develop their clinical reasoning skills. This study provides evidence that virtual patient simulation is an effective pedagogy to increase clinical competence in wound care. It allows nursing students the opportunity to practice skills and utilise theory repetitively in a safe environment, unhampered by a lack of resources such as clinical placement availability and a declining faculty.

A systematic review of physical rehabilitation interventions for stroke in low and lower-middle income countries.

Purpose: Approximately 70% of strokes occur in low and middle income countries, yet the effectiveness of physical rehabilitation in these contexts remains undetermined. This systematic review identifies and summarises the current evidence supporting physical rehabilitation interventions post-stroke in low and lower-middle income countries.Methods: Five databases were comprehensively searched (April 2017) for randomised controlled trials, clinical controlled trials, and cohort studies testing rehabilitation interventions post-stroke in these countries. The Effective Public Health Practice Project Tool assessed quality of included studies.Results: Sixty-two studies (2115 participants) were included. Interventions addressed upper limb (n = 26), lower limb (n = 22), and other (n = 14) outcomes. Seven studies were rated as strong in quality, 16 moderate and 39 rated as weak. Overall, in addition to usual care, physical rehabilitation interventions improved outcomes for stroke survivors. Best evidence synthesis provides level I (b) evidence supporting constraint induced movement therapy and mirror therapy to improve upper limb functional outcomes. Level I (b) evidence supports multimodal interventions that include lower limb motor imagery to improve gait parameters. Level II (b) evidence supports sit-to-stand training to improve balance outcomes.Conclusions: Exercise-based and brain training interventions improved functional outcomes post-stroke in low and lower-middle income countries. Further high-quality studies including participation outcomes are required.Implications for RehabilitationLow-cost physical rehabilitation interventions requiring minimal resources can improve functional outcomes after stroke in low and lower-middle income countries.Exercise-based interventions can improve upper limb, lower limb, gait, and balance outcomes after stroke.Brain training paradigms such as mirror therapy and motor imagery, when included in therapy packages, can improve upper limb and gait outcomes.The proven efficacy for rehabilitation interventions in improving stroke outcomes in low and lower-middle income countries supports the need to strengthen the rehabilitation workforce in this context.