Purpose
Upper limb disability following stroke may have multiple effects on the individual. Existing assessment instruments tend to focus on impairment and function and may miss other changes that are personally important. This study aimed to identify personally-significant. impacts of upper limb disability following stroke.

Methods
Accounts by stroke survivors, in the form of web-based diaries (blogs) and stories, were sought using a blog search engine and in stroke-related web-sites. Thematic analysis using the World Health Organisation’s International Classification of Functioning Disability and Health (ICF) was used to identify personal impacts of upper limb disability following stroke.

Results
Ninety-nine sources from at least four countries were analysed. Many impacts were classifiable using the ICF, but a number of additional themes emerged, including emotional, cognitive and behavioural changes. Blogs and other web-based accounts were easily-accessible and rich sources of data, although using them raised several methodological issues, including potential sample bias.

Conclusions
A range of impacts was identified, some of which (such as use of information technology and alienation from the upper limb) are not addressed in current assessment instruments. They should be considered in post-stroke assessments. Blogs may help in the development of more comprehensive assessments.

Behaviour change interventions can be effective in helping people to lose weight, but weight is often regained. Effective interventions are required to prevent this. We conducted a systematic review and synthesis of qualitative research on people's experiences of weight loss maintenance. We searched bibliographic databases for qualitative studies about the experience of currently or previously overweight adults trying to maintain weight loss. We thematically synthesised study findings to develop a model of weight loss maintenance. Twenty six studies from five countries with 710 participants were included. The model developed through our synthesis proposes that making the behaviour changes required for weight loss maintenance generates psychological 'tension' due to the need to override existing habits, and incompatibility of the new behaviours with the fulfilment of psychological needs. Successful maintenance involves management or resolution of this tension. Management of tension can be achieved through self-regulation, renewing of motivation and managing external influences, although this can require constant effort. Resolution may be achieved through changing habits, finding non-obesogenic methods for addressing needs, and potentially through change in self-concept. Implications for the development of weight loss maintenance interventions are explored.

PURPOSE: Exercise-after-stroke programmes are increasingly being provided to encourage more physical exercise among stroke survivors, but little is known about what motivates people with stroke to participate in them. This research aimed to identify factors that motivate long-term stroke survivors to exercise, and the implications for programme design. METHODS: in two separate studies, focus groups and individual interviews were used to investigate the views of long-term stroke survivors on exercise and participating in exercise programmes. Their data were analysed thematically, and the findings of the studies were synthesised. RESULTS: Eleven stroke survivors and two partners took part in two focus groups; six other stroke survivors (one with a partner) were interviewed individually. Factors reported to influence motivation were the psychological benefits of exercise, a desire to move away from a medicalised approach to exercise, beliefs about stroke recovery, and on-going support to sustain commitment. A number of potential implications of these themes for exercise programme design were identified. CONCLUSIONS: a range of personal beliefs and attitudes and external factors may affect the motivation to exercise, and these vary between individuals. Addressing these factors in the design of exercise programmes for long-term stroke survivors may enhance their appeal and so encourage greater engagement in exercise. IMPLICATIONS FOR REHABILITATION: Exercise programmes may be more attractive to long-term stroke survivors if the psychological well-being benefits of participation are emphasised in their promotion. Some participants will be more attracted by programmes that are de-medicalised, for example, by being located away from clinical settings, and led by or involving suitably-trained non-clinicians. Programmes offered in different formats may attract stroke survivors with different beliefs about the value of exercise in stroke recovery. Programmes should provide explicit support strategies for on-going engagement in exercise.

BACKGROUND: Intervention fidelity is concerned with the extent to which interventions are implemented as intended. Consideration of fidelity is essential if the conclusions of effectiveness studies are to be credible, but little attention has been given to it in the rehabilitation literature. We describe our experiences addressing fidelity in the development of a rehabilitation clinical trial, and consider how an existing model of fidelity may be employed in rehabilitation research. METHODS: We used a model and methods drawn from the psychology literature to investigate how fidelity might be maximised during the planning and development of a stroke rehabilitation trial. We considered fidelity in intervention design, provider training, and the behaviour of providers and participants. We also evaluated methods of assessing fidelity during a trial. RESULTS: We identified strategies to help address fidelity in our trial protocol, along with their potential strengths and limitations. We incorporated these strategies into a model of fidelity that is appropriate to the concepts and language of rehabilitation. CONCLUSION: a range of strategies are appropriate to help maximise and measure fidelity in rehabilitation research. Based on our experiences, we propose a model of fidelity and provide recommendations to inform the growing literature of fidelity in this discipline.

BACKGROUND: to inform the design of a randomised controlled trial (RCT) of an exercise-based programme for long term stroke survivors, we conducted a mixed methods before-and-after case series with assessment at three time points. We evaluated Action for Rehabilitation from Neurological Injury (ARNI), a personalised, functionally-focussed programme. It was delivered through 24 hours of one-to-one training by an Exercise Professional (EP), plus at least 2 hours weekly unsupervised exercise, over 12- 14 weeks. Assessment was by patient-rated questionnaires addressing function, physical activity, confidence, fatigue and health-related quality of life; objective assessment of gait quality and speed; qualitative individual interviews conducted with participants. Data were collected at baseline, 3 months and 6 months. Fidelity and acceptability was assessed by participant interviews, audit of participant and EP records, and observation of training. FINDINGS: Four of six enrolled participants completed the exercise programme. Quantitative data demonstrated little change across the sample, but marked changes on some measures for some individuals. Qualitative interviews suggested that small benefits in physical outcomes could be of great psychological significance to participants. Participant-reported fatigue levels commonly increased, and non-completers said they found the programme too demanding. Most key components of the intervention were delivered, but there were several potentially important departures from intervention fidelity. DISCUSSION: the study provided data and experience that are helping to inform the design of an RCT of this intervention. It suggested the need for a broader recruitment strategy; indicated areas that could be explored in more depth in the qualitative component of the trial; and highlighted issues that should be addressed to enhance and evaluate fidelity, particularly in the preparation and monitoring of intervention providers. The experience illustrates the value of even small sample before-and-after studies in the development of trials of complex interventions.

BACKGROUND: Multiple guidelines are often available to inform practice in complex interventions. Guidance implementation may be facilitated if it is tailored to particular clinical issues and contexts. It should also aim to specify all elements of interventions that may mediate and modify effectiveness, including both their content and delivery. We conducted a focused synthesis of recommendations from stroke practice guidelines to produce a structured and comprehensive account to facilitate the development of community-based exercise programmes after stroke. METHODS: Published stroke clinical practice guidelines were searched for recommendations relevant to the content and delivery of community-based exercise interventions after stroke. These were synthesised using a framework based on target intervention outcomes, personal and programme proximal objectives, and recommended strategies. RESULTS: Nineteen guidelines were included in the synthesis (STRIDES; STroke Rehabilitation Intervention-Development Evidence Synthesis). Eight target outcomes, 14 proximal objectives, and 94 recommended strategies were identified. The synthesis was structured to present best practice recommendations in a format that could be used by intervention programme developers. It addresses both programme content and context, including personal factors, service standards and delivery issues. Some recommendations relating to content, and many relating to delivery and other contextual issues, were based on low level evidence or expert opinion. Where opinion varied, the synthesis indicates the range of best practice options suggested in guidelines. CONCLUSIONS: the synthesis may assist implementation of best practice by providing a structured intervention description that focuses on a particular clinical application, addresses practical issues involved in programme development and provision, and illustrates the range of best-practice options available to users where robust evidence is lacking. The synthesis approach could be applied to other areas of stroke rehabilitation or to other complex interventions.

Background and Purpose: in microcurrent therapy (MCT), low-intensity electric current is applied to promote tissue healing and relieve symptoms. MCT is used with recalcitrant skin and bone lesions, but little is known about its effects on tendinopathy, and optimal treatment parameters are uncertain. Two studies were conducted to ascertain whether varying (i) current intensity and (ii) waveform and treatment duration affect outcomes of MCT for chronic tennis elbow. Methods: Two trials compared the effects of different MCT parameters on pain and function, grip strength, and sonographically graded tendon structure and hyperaemia. Trial 1 compared monophasic MCT of intensity 50 and 500μA applied for 35h; trial 2 compared devices delivering approximately 25μA but with different waveforms and durations of 15 and 189h, respectively. Treatment was applied over 3weeks. Assessments were at baseline and 3, 6 and 15weeks. Results: for each trial, n=31. In trial 1, 50μA was more effective than 500μA, with 93% of participants 'much better' or 'fully recovered' at 15weeks, compared with 47% in the 500μA group. Tendon structural normalization was superior at 50μA, but no significant differences were found in other outcomes. In trial 2, success rates for the two groups at 15weeks were 75% and 73%, respectively, but group improvements did not differ significantly on any measure. Pooled analysis of data from both trials showed that, immediately following treatment, blood flow had fallen in the subgroup with high baseline scores and risen in the subgroup with low scores. Low baseline score correlated significantly with treatment success. Conclusion: Monophasic MCT of peak current intensity 50μA applied for tens of hours may be effective in reducing symptoms and promoting tendon normalization in chronic tennis elbow. Hyperaemia may help predict treatment outcome. A full-scale trial of the therapy is warranted. © 2011 John Wiley. &. Sons, Ltd.

OBJECTIVE: to assess the reliability and compute the minimum detectable change using sonographic scales to quantify the extent of pathology and hyperaemia in the common extensor tendon in people with tennis elbow. MATERIALS AND METHODS: the lateral elbows of 19 people with tennis elbow were assessed sonographically twice, 1-2 weeks apart. Greyscale and power Doppler images were recorded for subsequent rating of abnormalities. Tendon thickening, hypoechogenicity, fibrillar disruption and calcification were each rated on four-point scales, and scores were summed to provide an overall rating of structural abnormality; hyperaemia was scored on a five point scale. Inter-rater reliability was established using the intraclass correlation coefficient (ICC) to compare scores assigned independently to the same set of images by a radiologist and a physiotherapist with training in musculoskeletal imaging. Test-retest reliability was assessed by comparing scores assigned by the physiotherapist to images recorded at the two sessions. The minimum detectable change (MDC) was calculated from the test-retest reliability data. RESULTS: ICC values for inter-rater reliability ranged from 0.35 (95% CI: 0.05, 0.60) for fibrillar disruption to 0.77 (0.55, 0.88) for overall greyscale score, and 0.89 (0.79, 0.95) for hyperaemia. Test-retest reliability ranged from 0.70 (0.48, 0.84) for tendon thickening to 0.82 (0.66, 0.90) for overall greyscale score and 0.86 (0.73, 0.93) for calcification. The MDC for the greyscale total score was 2.0/12 and for the hyperaemia score was 1.1/5. CONCLUSION: the sonographic scoring system used in this study may be used reliably to quantify tendon abnormalities and change over time. A relatively inexperienced imager can conduct the assessment and use the rating scales reliably.

New models of interprofessional working are continuously being proposed to address the burgeoning health and social care needs of older people with complex and long-term health conditions. Evaluations of the effectiveness of these models tend to focus on process measures rather than outcomes for the older person. This discussion paper argues that the concept of frailty, and measures based on it, may provide a more user-centred tool for the evaluation of interprofessional services - a tool that cuts across unidisciplinary preoccupations and definitions of effectiveness. Numerous frailty scales have been developed for case identification and stratification of risk of adverse outcomes. We suggest that they may also be particularly suitable for evaluating the effectiveness of interprofessional working with community-dwelling older people. Several exemplars of frailty scales that might serve this purpose are identified, and their potential contributions and limitations are discussed. Further work is required to establish which is the most suitable scales for this application. The development of an appropriate frailty scale could provide an opportunity for interprofessional debate about the forms of care and treatment that should be prioritised to improve the health and well-being of this population.

The Patient-rated Tennis Elbow Evaluation (PRTEE) enables quantitative rating by the patient of pain and functional impairment associated with tennis elbow or lateral elbow tendinopathy. When used as an outcome measure in trials of therapies, a minimum clinically important difference (MCID) value is required to interpret trial outcomes. This study aimed to calculate the MCID for a sample of patients diagnosed with lateral elbow tendinopathy (LET). The PRTEE was used as an outcome measure with participants in a trial of a novel therapy for LET. It was administered at baseline and after treatment, three weeks later. Score changes were compared with patient-rated global change scores using receiver operating curve analysis. MCID values were calculated for two different criteria of clinically important difference and the effects of baseline symptom severity on the MCID were investigated. Data were available from 57 participants, with PRTEE scores in the range 13–81/100. For clinical significance defined as “a little better” the MCID for the total PRTEE score was 7/100 or 22% of baseline score. For clinical significance defined as “much better” or “completely recovered”, the MCID was 11/100 or 37% of baseline score. The MCID value was higher for a subgroup with greater baseline severity. Substantial changes in the PRTEE scores are required before they can be considered clinically significant. Clinically significant change varies according to the baseline score. The instrument may be less sensitive to change when used by people who are symptomatic in their non-dominant arm. © 2011, British Association of Hand Therapists Limited. All rights reserved.

Sonography is increasingly being used for assessment in tennis elbow research and clinical practice, but there are a lack of data regarding its validity, reliability, and responsiveness to change for this application. Studies using the modality were reviewed to establish current levels of evidence for these measurement properties. There is reasonable evidence regarding its validity for identifying tennis elbow tendinopathy, but a lack of data addressing its reliability and responsiveness. Practical issues affecting image quality are discussed, and recommendations for further investigation are suggested, to enhance the credible use of sonography with this debilitating condition.

Apomorphine hydrochloride is a dopamine agonist used in the treatment of advanced Parkinson's disease. Its administration by subcutaneous infusions is associated with the development of nodules that may interfere with absorption of the drug. This pilot study assessed the effectiveness of ultrasound (US) in the treatment of these nodules. Twelve participants were randomly assigned to receive a course of real or sham US on an area judged unsuitable for infusion. Following treatment, no significant change was observed in measures of tissue hardness and tenderness. However, 5 of 6 participants receiving real US rated the treated area suitable for infusion compared with the 1 of 6 receiving sham US. Sonographic appearance improved in both groups, but more substantially in the real US group. Power calculations suggest a total sample size of 30 would be required to establish statistical significance. A full-scale study of the effectiveness of therapeutic US in the treatment of apomorphine nodules is warranted.

Aims: Many common musculoskeletal disorders are resistant to existing management strategies, causing long-term pain and disability. While arthritic and spinal problems have been prioritized for research, several soft tissue disorders may be equally burdensome for individuals and difficult
to treat successfully. Identifying those that are least responsive to treatment may help focus the limited resources available for research and treatment provision. This study aimed to rank the most problematic disorders, and identify contributory factors, to inform the debate on research and service priorities in the management of musculoskeletal disorders.

Methods: the views of practising physiotherapists on the most problematic soft tissue disorders were sought using a postal questionnaire survey and telephone interviews. The questionnaire was sent to 193 experienced musculoskeletal physiotherapists working in National Health Service and private
clinics in south-east England.

Findings: the response rate was 48%. The top three problematic disorders were identifi ed as frozen shoulder, plantar fasciitis and tennis elbow. Subsequent interviews with 20 respondents indicated that inadequate differential diagnosis, triaging and differences in therapeutic practice may account for some of the observed variation in outcomes.

Conclusions: a greater focus on these particular disorders and issues by both clinicians and the research community is warranted.

© 2008, MA Healthcare Ltd. All rights reserved. Aims: Many common musculoskeletal disorders are resistant to existing management strategies, causing long-term pain and disability. While arthritic and spinal problems have been prioritized for research, several soft tissue disorders may be equally burdensome for individuals and diffi cult to treat successfully. Identifying those that are least responsive to treatment may help focus the limited resources available for research and treatment provision. This study aimed to rank the most problematic disorders, and identify contributory factors, to inform the debate on research and service priorities in the management of musculoskeletal disorders. Methods: the views of practising physiotherapists on the most problematic soft tissue disorders were sought using a postal questionnaire survey and telephone interviews. The questionnaire was sent to 193 experienced musculoskeletal physiotherapists working in National Health Service and private clinics in south-east England. Findings: the response rate was 48%. The top three problematic disorders were identifi ed as frozen shoulder, plantar fasciitis and tennis elbow. Subsequent interviews with 20 respondents indicated that inadequate differential diagnosis, triaging and differences in therapeutic practice may account for some of the observed variation in outcomes. Conclusions: a greater focus on these particular disorders and issues by both clinicians and the research community is warranted.

Apomorphine hydrochloride is used to treat refractory motor fluctuations in advanced Parkinson's disease. Delivery by infusion is associated with the formation of hard subcutaneous nodules, which may be painful, limit available infusion sites, and interfere with absorption of the drug. Diagnostic ultrasound was used to image affected tissue in 12 people experiencing apomorphine nodule formations. It revealed significant departures from normality in dermal and subcutaneous tissue, including a variety of nodule appearances, dermal thickening and diffuse changes consistent with inflammatory reactions. Sonographic appearances differed markedly between individuals, but no clear correlation between severity of tissue changes, patient demographics and apomorphine dose was observed. Diagnostic ultrasound may be useful as a non-invasive method of assessing subcutaneous nodule formation, to measure changes in affected tissue over time and after treatment. © British Medical Ultrasound Society 2008.

Coupling agents are required when using therapeutic ultrasound (US) to maximize acoustic contact between the transducer and the insonated tissue. US beam power is attenuated to varying extents by different couplants and this may influence treatment efficacy, since therapeutic effects are dose-dependent. It is therefore important to know how well different couplants transmit US. In this study, the transmission characteristics of a range of gel couplants were measured using a radiation force balance. Data were collected for gels commonly used by UK therapists and at the powers and frequencies advocated for low-intensity therapeutic practice. Transmissivities of standard couplants relative to degassed water varied between 95% and 108% (nominal 95% confidence intervals between 0% and 11%). The spread and ranking of transmissivities changed when the US frequency was varied. For clinical purposes, however, there was no significant difference between transmissivities of the gels under test.

Ultrasound has been used for the treatment of a variety of cutaneous wounds, particularly venous ulcers. Many of the published studies involved application of ultrasound to the surrounding tissue rather than directly over the wound. Insonating the wound itself may enhance the healing process, but the lack of data regarding the transmission characteristics of dressings has limited the use of this option. This study aimed to measure the ultrasound transmissivity of dressings commonly employed for wound management. Forty-eight different dressings and wound care products were tested in vitro using a radiation force balance. Transmissivity was found to vary significantly between dressings, from excellent to zero. These findings may be useful to clinicians in deciding whether to apply ultrasound through a particular dressing. They could also inform future studies of the efficacy of ultrasound in wound management by application directly to wounds rather than to their periphery.