Impact of an injury hospital admission on childhood academic performance: a Welsh population-based data linkage study

BACKGROUND

While injuries can impact on children's educational achievements (with threats to their development and employment prospects), these risks are poorly quantified. This population-based longitudinal study investigated the impact of an injury-related hospital admission on Welsh children's academic performance.

METHODS

The Secure Anonymised Information Linkage databank, 55 587 children residing in Wales from 2006 to 2016 who had an injury hospital admission (58.2% males; 16.8% born in most deprived Wales area; 80.1% one injury hospital admission) were linked to data from the Wales Electronic Cohort for Children. The primary outcome was the Core Subject Indicator reflecting educational achievement at key stages 2 (school years 3-6), 3 (school years 7-9) and 4 (school years 10-11). Covariates in models included demographic, birth, injury and school characteristics.

RESULTS

Educational achievement of children was negatively associated with: pedestrian injuries (adjusted risk ratio, (95% CIs)) (0.87, (0.83 to 0.92)), cyclist (0.96, (0.94 to 0.99)), high fall (0.96, (0.94 to 0.97)), fire/flames/smoke (0.85, (0.73 to 0.99)), cutting/piercing object (0.96, (0.93 to 0.99)), intentional self-harm (0.86, (0.82 to 0.91)), minor traumatic brain injury (0.92, (0.86 to 0.99)), contusion/open wound (0.93, (0.91 to 0.95)), fracture of vertebral column (0.78, (0.64 to 0.95)), fracture of femur (0.88, (0.84 to 0.93)), internal abdomen/pelvic haemorrhage (0.82, (0.69 to 0.97)), superficial injury (0.94, (0.92 to 0.97)), young maternal age (<18 years: 0.91, (0.88 to 0.94); 19-24 years: 0.94, (0.93 to 0.96)); area based socioeconomic status (0.98, (0.97 to 0.98)); moving to a more deprived area (0.95, (0.93 to 0.97)); requiring special educational needs (0.46, (0.44 to 0.47)). Positive associations were: being female (1.04, (1.03 to 1.06)); larger pupil school sizes and maternal age 30+ years.

CONCLUSION

This study highlights the importance on a child's education of preventing injuries and implementing intervention programmes that support injured children. Greater attention is needed on equity-focused educational support and social policies addressing needs of children at risk of underachievement, including those from families experiencing poverty. VIBES-JUNIOR STUDY PROTOCOL: http://dx.doi.org/10.1136/bmjopen-2018-024755.

The one-week and three-month reliability of acceleration outcomes from an insole-embedded inertial measurement unit during treadmill running

Inertial measurement units (IMUs) represent an exciting opportunity for researchers to broaden our understanding of running-related injuries, and for clinicians to expand their application of running gait analysis. The primary aim of our study was to investigate the 1-week (short-term) and 3-month (long-term) reliability of peak resultant, vertical, and anteroposterior accelerations derived from insole-embedded IMUs. The secondary aim was to assess the reliability of peak acceleration variability and left-right limb symmetry in all directions over the short and long term. A sample of healthy adult rearfoot runners (n = 23; age 41.7 ± 11.2 years) ran at a variety of speeds (2.5 m/s, 3.0 m/s, and 3.5 m/s) on a treadmill in standardised footwear with insole-embedded IMUs in each shoe. Peak accelerations exhibited good to excellent short-term reliability and moderate to excellent long-term reliability in all directions. Peak acceleration variability showed poor to good short- and long-term reliability, whereas the symmetry of peak accelerations demonstrated moderate to excellent and moderate to good short- and long-term reliability, respectively. Our results demonstrate how insole-embedded IMUs represent a viable option for clinicians to measure peak accelerations within the clinic.

Blood pressure trajectory of inpatient stroke rehabilitation patients from the Determining Optimal Post-Stroke Exercise (DOSE) trial over the first 12 months post-stroke

Background

High blood pressure (BP) is the primary risk factor for recurrent strokes. Despite established clinical guidelines, some stroke survivors exhibit uncontrolled BP over the first 12 months post-stroke. Furthermore, research on BP trajectories in stroke survivors admitted to inpatient rehabilitation hospitals is limited. Exercise is recommended to reduce BP after stroke. However, the effect of high repetition gait training at aerobic intensities (>40% heart rate reserve; HRR) during inpatient rehabilitation on BP is unclear. We aimed to determine the effect of an aerobic gait training intervention on BP trajectory over the first 12 months post-stroke.

Methods

This is a secondary analysis of the Determining Optimal Post-Stroke Exercise (DOSE) trial. Participants with stroke admitted to inpatient rehabilitation hospitals were recruited and randomized to usual care (n = 24), DOSE1 (n = 25; >2,000 steps, 40-60% HRR for >30 min/session, 20 sessions over 4 weeks), or DOSE2 (n = 25; additional DOSE1 session/day) groups. Resting BP [systolic (SBP) and diastolic (DBP)] was measured at baseline (inpatient rehabilitation admission), post-intervention (near inpatient discharge), 6- and 12-month post-stroke. Linear mixed-effects models were used to examine the effects of group and time (weeks post-stroke) on SBP, DBP and hypertension (≥140/90 mmHg; ≥130/80 mmHg, if diabetic), controlling for age, stroke type, and baseline history of hypertension.

Results

No effect of intervention group on SBP, DBP, or hypertension was observed. BP increased from baseline to 12-month post-stroke for SBP (from [mean ± standard deviation] 121.8 ± 15.0 to 131.8 ± 17.8 mmHg) and for DBP (74.4 ± 9.8 to 78.5 ± 10.1 mmHg). The proportion of hypertensive participants increased from 20.8% (n = 15/72) to 32.8% (n = 19/58). These increases in BP were statistically significant: an effect [estimation (95%CI), value of p] of time was observed on SBP [0.19 (0.12-0.26) mmHg/week, p < 0.001], DBP [0.09 (0.05-0.14) mmHg/week, p < 0.001], and hypertension [OR (95%CI): 1.03 (1.01-1.05), p = 0.010]. A baseline history of hypertension was associated with higher SBP by 13.45 (8.73-18.17) mmHg, higher DBP by 5.57 (2.02-9.12) mmHg, and 42.22 (6.60-270.08) times the odds of being hypertensive at each timepoint, compared to those without.

Conclusion

Blood pressure increased after inpatient rehabilitation over the first 12 months post-stroke, especially among those with a history of hypertension. The 4-week aerobic gait training intervention did not influence this trajectory.

TeleRehabilitation with Aims to Improve Lower extremity recovery in community-dwelling individuals who have had a stroke: protocol for a multisite, parallel group, assessor-blinded, randomised attention-controlled trial

INTRODUCTION

Telerehabilitation is an accessible service delivery model that may support innovative lower extremity rehabilitation programmes that extend the stroke recovery continuum into the community. Unfortunately, there is limited evidence on the provision of exercises for lower extremity recovery after stroke delivered using telerehabilitation. In response, we developed the TeleRehabilitation with Aims to Improve Lower extremity recovery poststroke (TRAIL) programme, a 4-week progressive exercise and self-management intervention delivered synchronously using video-conferencing technology. Our primary hypothesis is that individual within 1-year poststroke who participate in TRAIL will experience significantly greater improvements in functional mobility than individuals in an attention-controlled education programme (EDUCATION).

METHODS AND ANALYSIS

In this multisite, parallel group, assessor-blinded randomised attention-controlled trial, 96 community-living stroke survivors within 1-year poststroke will be recruited from five sites (Vancouver, Winnipeg, Toronto, London and Halifax, Canada) from the CanStroke Recovery Trials Platform which is a network of Canadian hospital sites that are affiliated with academic institutions to facilitate participant recruitment and quality trial practices. Participants will be randomised on a 1:1 basis to TRAIL or EDUCATION. Participants randomised to TRAIL will receive eight telerehabilitation sessions where they will perform exercises and receive self-management support to improve lower extremity recovery from a TRAIL physical therapist. The primary outcome will be measured using the Timed Up and Go. Secondary outcomes include lower extremity muscle strength, functional balance, motor impairment, balance self-efficacy, health-related quality of life and health service use for our economic evaluation. Measurements will be taken at baseline, immediately after the intervention, 3-month and 6-month postintervention.

ETHICS AND DISSEMINATION

Ethics approval for this research has been obtained by all participating sites. All study participants will provide their informed consent prior to enrolling them in the study. Findings from this trial will be disseminated in peer-reviewed journals and presentations at international scientific meetings.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov, NCT04908241.

Responsiveness and trajectory of changes in the rating of everyday arm-use in the community and home (REACH) scale over the first-year post-stroke

OBJECTIVE

To examine the trajectory of the Rating of Everyday Arm-use in the Community and Home (REACH) scores over the first-year post-stroke, determine if REACH scores are modified by baseline impairment level and explore the responsiveness of the REACH scale through hypothesis testing.

DESIGN

Consecutive sample longitudinal study.

SETTING

Participants were recruited from an acute stroke unit and followed up at three, six, and 12 months post-stroke.

PARTICIPANTS

Seventy-three participants with upper limb weakness (Shoulder Abduction and Finger Extension score ≤ 8).

MAIN MEASURES

The REACH scale is a six-level self-report classification scale that captures how the affected upper limb is being used in one's own environment. The Fugl-Meyer Upper Limb Assessment (FMA-UL), Stroke Upper Limb Capacity Scale (SULCS), accelerometer-based activity count ratio and Global Rating of Change Scale (GRCS) were used to capture upper limb impairment, capacity, and use.

RESULTS

The following proportions of participants improved at least one REACH level: 64% from baseline to three months, 37% from three to six months and 13% from six to 12 months post-stroke. The trajectory of REACH scores over time was associated with baseline impairment. Change in REACH had a moderate correlation to change in SULCS and the GRCS but not FMA-UL or the activity count ratio.

CONCLUSIONS

Results of hypothesis testing provide preliminary evidence of the responsiveness of the REACH scale. On average, individuals with severe impairment continued to show improvement in use over the first year, while those with mild/moderate impairment plateaued and a small proportion decreased in the early chronic phase.

Effect of Pregnancy in 42 Elite to World-Class Runners on Training and Performance Outcomes

PURPOSE

The International Olympic Committee expert group on pregnancy has identified a paucity of information regarding training and performance in truly elite athletes. Thus, the purpose of this study was to quantify elite runners' training volume throughout pregnancy and postpartum competition performance outcomes.

METHODS

Forty-two elite (>50% competed at the World Championships/Olympic) middle-/long-distance runners' training before, during, and after pregnancy (quality/quantity/type) data (retrospective questionnaire) and competition data (published online) were collected.

RESULTS

Running volume decreased significantly ( P < 0.01) from the first trimester (63 ± 34 km·wk -1 ) to the third trimester (30 ± 30 km·wk -1 ). Participants returned to activity/exercise at ~6 wk postpartum and to 80% of prepregnancy training volumes by 3 months. Participants who intended to return to equivalent performance levels postpregnancy, there was no statistical decrease in performance in the 1 to 3 yr postpregnancy compared with prepregnancy, and ~56% improved performances postpregnancy.

CONCLUSIONS

This study features the largest cohort of elite runners training and competition outcomes assessed throughout pregnancy, with training volumes being approximately two to four times greater than current guidelines. For the first time, performance was directly assessed (due to the quantifiable nature of elite running), and study participants who intended to return to high-level competition did so at a statistically similar level of performance in the 1- to 3-yr period postpregnancy. Taken together, this article provides much needed insights into current training practices and performance of elite pregnant runners, which should help to inform future training guidelines as well as sport policy and sponsor expectations around return to training timelines and performance.

Differences in Peak Impact Accelerations Among Foot Strike Patterns in Recreational Runners

Introduction

Running-related injuries (RRIs) occur from a combination of training load errors and aberrant biomechanics. Impact loading, measured by peak acceleration, is an important measure of running biomechanics that is related to RRI. Foot strike patterns may moderate the magnitude of impact load in runners. The effect of foot strike pattern on peak acceleration has been measured using tibia-mounted inertial measurement units (IMUs), but not commercially available insole-embedded IMUs. The aim of this study was to compare the peak acceleration signal associated with rearfoot (RFS), midfoot (MFS), and forefoot (FFS) strike patterns when measured with an insole-embedded IMU.

Materials and Methods

Healthy runners ran on a treadmill for 1 min at three different speeds with their habitual foot strike pattern. An insole-embedded IMU was placed inside standardized neutral cushioned shoes to measure the peak resultant, vertical, and anteroposterior accelerations at impact. The Foot strike pattern was determined by two experienced observers and evaluated using high-speed video. Linear effect mixed-effect models were used to quantify the relationship between foot strike pattern and peak resultant, vertical, and anteroposterior acceleration.

Results

A total of 81% of the 187 participants exhibited an RFS pattern. An RFS pattern was associated with a higher peak resultant (0.29 SDs; p = 0.029) and vertical (1.19 SD; p < 0.001) acceleration when compared with an FFS running pattern, when controlling for speed and limb, respectively. However, an MFS was associated with the highest peak accelerations in the resultant direction (0.91 SD vs. FFS; p = 0.002 and 0.17 SD vs. RFS; p = 0.091). An FFS pattern was associated with the lowest peak accelerations in both the resultant and vertical directions. An RFS was also associated with a significantly greater peak acceleration in the anteroposterior direction (0.28 SD; p = 0.033) than an FFS pattern, while there was no difference between MFS and FFS patterns.

Conclusion

Our findings indicate that runners should be grouped by RFS, MFS, and FFS when comparing peak acceleration, rather than the common practice of grouping MFS and FFS together as non-RFS runners. Future studies should aim to determine the risk of RRI associated with peak accelerations from an insole-embedded IMU to understand whether the small observed differences in this study are clinically meaningful.

Step Number and Aerobic Minute Exercise Prescription and Progression in Stroke: A Roadmap

Background

While higher therapeutic intensity improves motor recovery after stroke, translating findings from successful studies is challenging without clear exercise intensity targets. We show in the DOSE trial¹ more than double the steps and aerobic minutes within a session can be achieved compared with usual care and translates to improved long-term walking outcomes.

Objective

We modeled data from this successful higher intensity multi-site RCT to develop targets for prescribing and progressing exercise for varying levels of walking impairment after stroke.

Methods

In twenty-five individuals in inpatient rehabilitation, twenty sessions were monitored for a total of 500 one-hour physical therapy sessions. For the 500 sessions, step number and aerobic minute progression were modeled using linear mixed effects regression. Using formulas from the linear mixed effects regression, targets were calculated.

Results

The model for step number included session number and baseline walking speed, and for aerobic minutes, session number and age. For steps, there was an increase of 73 steps per session. With baseline walking speed, for every 0.1 m/s increase, a corresponding increase of 302 steps was predicted. For aerobic minutes, there was an increase of .56 minutes of aerobic activity (ie, 34 seconds) per session. For every year increase in age, a decrease of .39 minutes (ie, 23 seconds) was predicted.

Conclusions

Using data associated with better walking outcomes, we provide step number and aerobic minute targets that future studies can cross-validate. As walking speed and age are collected at admission, these models allow for uptake of routine measurement of therapeutic intensity.

Registration: www.clinicaltrials.gov; NCT01915368.

Predictors of health-related quality of life following injury in childhood and adolescence: a pooled analysis

BACKGROUND

Injury is a leading contributor to the global disease burden in children and places children at risk for adverse and lasting impacts on their health-related quality of life (HRQoL) and development. This study aimed to identify key predictors of HRQoL following injury in childhood and adolescence.

METHODS

Data from 2259 injury survivors (<18 years when injured) were pooled from four longitudinal cohort studies (Australia, Canada, UK, USA) from the paediatric Validating Injury Burden Estimates Study (VIBES-Junior). Outcomes were the Paediatric Quality of Life Inventory (PedsQL) total, physical, psychosocial functioning scores at 1, 3-4, 6, 12, 24 months postinjury.

RESULTS

Mean PedsQL total score increased with higher socioeconomic status and decreased with increasing age. It was lower for transport-related incidents, ≥1 comorbidities, intentional injuries, spinal cord injury, vertebral column fracture, moderate/severe traumatic brain injury and fracture of patella/tibia/fibula/ankle. Mean PedsQL physical score was lower for females, fracture of femur, fracture of pelvis and burns. Mean PedsQL psychosocial score was lower for asphyxiation/non-fatal submersion and muscle/tendon/dislocation injuries.

CONCLUSIONS

Postinjury HRQoL was associated with survivors' socioeconomic status, intent, mechanism of injury and comorbidity status. Patterns of physical and psychosocial functioning postinjury differed according to sex and nature of injury sustained. The findings improve understanding of the long-term individual and societal impacts of injury in the early part of life and guide the prioritisation of prevention efforts, inform health and social service planning to help reduce injury burden, and help guide future Global Burden of Disease estimates.

A Web-Based Risk-Reframing Intervention to Influence Early Childhood Educators' Attitudes and Supportive Behaviors Toward Outdoor Play: Protocol for the OutsidePlay Study Randomized Controlled Trial

Background

Early learning and childcare centers (ELCCs) can offer young children critical opportunities for quality outdoor play. There are multiple actual and perceived barriers to outdoor play at ELCCs, ranging from safety fears and lack of familiarity with supporting play outdoors to challenges around diverse perspectives on outdoor play among early childhood educators (ECEs), administrators, licensing officers, and parents.

Objective

Our study objective is to develop and evaluate a web-based intervention that influences ECEs’ and ELCC administrators’ perceptions and practices in support of children’s outdoor play at ELCCs.

Methods

The development of the fully automated, open-access, web-based intervention was guided by the intervention mapping process. We first completed a needs assessment through focus groups of ECEs, ELCC administrators, and licensing officers. We identified key issues, needs, and challenges; opportunities to influence behavior change; and intervention outcomes and objectives. This enabled us to develop design objectives and identify features of the OutsidePlay web-based intervention that are central to addressing the issues, needs, and challenges of ECEs and ELCC administrators. We used social cognitive theory and behavior change techniques to select methods, applications, and technology to deliver the intervention. We will use a two-parallel-group randomized controlled trial (RCT) design to evaluate the efficacy of the intervention. We will recruit 324 ECEs and ELCC administrators through a variety of web-based means, including Facebook advertisements and mass emails through our partner networks. The RCT study will be a purely web-based trial where outcomes will be self-assessed through questionnaires. The RCT participants will be randomized into the intervention group or the control group. The control group participants will read the Position Statement on Active Outdoor Play.

Results

The primary outcome is increased tolerance of risk in children’s play, as measured by the Teacher Tolerance of Risk in Play Scale. The secondary outcome is self-reported attainment of a self-developed behavior change goal. We will use mixed effects models to test the hypothesis that there will be a difference between the intervention and control groups with respect to tolerance of risk in children’s play. Differences in goal attainment will be tested using logistic regression analysis.

Conclusions

The OutsidePlay web-based intervention guides users through a personalized journey that is split into 3 chapters. An effective intervention that addresses the barriers to outdoor play in ELCC settings has the potential to improve children’s access to outdoor play and support high-quality early childhood education.

Trial Registration

ClinicalTrials.gov NCT04624932; https://clinicaltrials.gov/ct2/show/NCT04624932

International Registered Report Identifier (IRRID)

DERR1-10.2196/31041

Efficacy of an exoskeleton-based physical therapy program for non-ambulatory patients during subacute stroke rehabilitation: a randomized controlled trial

BACKGROUND

Individuals requiring greater physical assistance to practice walking complete fewer steps in physical therapy during subacute stroke rehabilitation. Powered exoskeletons have been developed to allow repetitious overground gait training for individuals with lower limb weakness. The objective of this study was to determine the efficacy of exoskeleton-based physical therapy training during subacute rehabilitation for walking recovery in non-ambulatory patients with stroke.

METHODS

An assessor-blinded randomized controlled trial was conducted at 3 inpatient rehabilitation hospitals. Patients with subacute stroke (< 3 months) who were unable to walk without substantial assistance (Functional Ambulation Category rating of 0 or 1) were randomly assigned to receive exoskeleton-based or standard physical therapy during rehabilitation, until discharge or a maximum of 8 weeks. The experimental protocol replaced 75% of standard physical therapy sessions with individualized exoskeleton-based sessions to increase standing and stepping repetition, with the possibility of weaning off the device. The primary outcome was walking ability, measured using the Functional Ambulation Category. Secondary outcomes were gait speed, distance walked on the 6-Minute Walk Test, days to achieve unassisted gait, lower extremity motor function (Fugl-Meyer Assessment), Berg Balance Scale, Patient Health Questionnaire, Montreal Cognitive Assessment, and 36-Item Short Form Survey, measured post-intervention and after 6 months.

RESULTS

Thirty-six patients with stroke (mean 39 days post-stroke) were randomized (Exoskeleton = 19, Usual Care = 17). On intention-to-treat analysis, no significant between-group differences were found in the primary or secondary outcomes at post-intervention or after 6 months. Five participants randomized to the Exoskeleton group did not receive the protocol as planned and thus exploratory as-treated and per-protocol analyses were undertaken. The as-treated analysis found that those adhering to exoskeleton-based physical therapy regained independent walking earlier (p = 0.03) and had greater gait speed (p = 0.04) and 6MWT (p = 0.03) at 6 months; however, these differences were not significant in the per-protocol analysis. No serious adverse events were reported.

CONCLUSIONS

This study found that exoskeleton-based physical therapy does not result in greater improvements in walking independence than standard care but can be safely administered at no detriment to patient outcomes. Clinical Trial Registration The Exoskeleton for post-Stroke Recovery of Ambulation (ExStRA) trial was registered at ClinicalTrials.gov (NCT02995265, first registered: December 16, 2016).

Telehealth coaching to improve self-management for secondary prevention after stroke: A randomized controlled trial of Stroke Coach

BACKGROUND

Stroke Coach is a lifestyle coaching telehealth program to improve self-management of stroke risk factors.

AIMS

To examine the efficacy of Stroke Coach on lifestyle behavior and risk factor control among community-living stroke survivors within one-year post stroke.

METHODS

Participants were randomized to Stroke Coach or an attention control Memory Training group. Lifestyle behavior was measured using the Health Promoting Lifestyle Profile II. Secondary outcomes included specific behavioral and cardiometabolic risk factors, health-related quality of life (HRQoL), cognitive status, and depressive symptoms. Measurements were taken at baseline, post-intervention (6 months), and retention (12 month). Linear mixed-effects models were used to test the study hypotheses (p < 0.05). All analyses were intention-to-treat.

RESULTS

The mean age of the Stroke Coach (n = 64) and Memory Training (n = 62) groups was 67.2 and 69.1 years, respectively. The majority of participants (n = 100) had mild stroke (modified Rankin Scale = 1 or 2), were active, with controlled blood pressure (mean = 129/79 mmHg) at baseline. At post-intervention, there were no significant differences in lifestyle (b = -2.87; 95%CI - 8.03 to 2.29; p = 0.28). Glucose control, as measured by HbA1c (b = 0.17; 95%CI 0.17 to 0.32; p = 0.03), and HRQoL, measured using SF-36 Physical Component Summary (b = -3.05; 95%CI -5.88 to -0.21; p = 0.04), were significantly improved in Stroke Coach compared to Memory Training, and the improvements were maintained at retention.

CONCLUSION

Stroke Coach did not improve lifestyle behavior; however, there were improvements to HbA1c and HRQoL among community-living stroke survivors with mild stroke-related disability. (ClinicalTrials.gov identifier: NCT02207023).

Higher Doses Improve Walking Recovery During Stroke Inpatient Rehabilitation

BACKGROUND AND PURPOSE

We investigated the effect of higher therapeutic exercise doses on walking during inpatient rehabilitation, typically commencing 1 to 4 weeks poststroke.

METHODS

This phase II, blinded-assessor, randomized controlled trial recruited from 6 Canadian inpatient rehabilitation units, between 2014 and 2018. Subjects (n=75; 25/group) were randomized into: control (usual care) physical therapy: typically, 1 hour, 5 days/week; Determining Optimal Post-Stroke Exercise (DOSE1): 1 hour, 5 days/week, more than double the intensity of Control (based on aerobic minutes and walking steps); and DOSE2: 2 hours, 5 days/week, more than quadruple the intensity of Control, each for 4 weeks duration. The primary outcome, walking endurance at completion of the 4-week intervention (post-evaluation), was compared across these groups using linear regression. Secondary outcomes at post-evaluation, and longitudinal outcomes at 6 and 12-month evaluations, were also analyzed.

RESULTS

Both DOSE1 (mean change 61 m [95% CI, 9-113], P=0.02) and DOSE2 (mean change 58 m, 6-110, P=0.03) demonstrated greater walking endurance compared with Control at the post-evaluation. Significant improvements were also observed with DOSE2 in gait speed (5-m walk), and both DOSE groups in quality of life (EQ-5D-5 L) compared with Control. Longitudinal analyses revealed that improvements in walking endurance from the DOSE intervention were retained during the 1-year follow-up period over usual care.

CONCLUSIONS

This study provides the first preliminary evidence that patients with stroke can improve their walking recovery and quality of life with higher doses of aerobic and stepping activity within a critical time period for neurological recovery. Furthermore, walking endurance benefits achieved from a 4-week intervention are retained over the first-year poststroke. Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT01915368.

Validating injury burden estimates using population birth cohorts and longitudinal cohort studies of injury outcomes: the VIBES-Junior study protocol

INTRODUCTION

Traumatic injury is a leading contributor to the global disease burden in children and adolescents, but methods used to estimate burden do not account for differences in patterns of injury and recovery between children and adults. A lack of empirical data on postinjury disability in children has limited capacity to derive valid disability weights and describe the long-term individual and societal impacts of injury in the early part of life. The aim of this study is to establish valid estimates of the burden of non-fatal injury in children and adolescents.

METHODS AND ANALYSIS

Five longitudinal studies of paediatric injury survivors <18 years at the time of injury (Australia, Canada, UK and USA) and two whole-of-population linked administrative data paediatric studies (Australia and Wales) will be analysed over a 3-year period commencing 2018. Meta-analysis of deidentified patient-level data (n≈2,600) from five injury-specific longitudinal studies (Victorian State Trauma Registry; Victorian Orthopaedic Trauma Outcomes Registry; UK Burden of Injury; British Columbia Children's Hospital Longitudinal Injury Outcomes; Children's Health After Injury) and >1 million children from two whole-of-population cohorts (South Australian Early Childhood Data Project and Wales Electronic Cohort for Children). Systematic analysis of pooled injury-specific cohort data using a variety of statistical techniques, and parallel analysis of whole-of-population cohorts, will be used to develop estimated disability weights for years lost due to disability, establish appropriate injury classifications and explore factors influencing recovery.

ETHICS AND DISSEMINATION

The project was approved by the Monash University Human Research Ethics Committee project number 12 311. Results of this study will be submitted for publication in internationally peer-reviewed journals. The findings from this project have the capacity to improve the validity of paediatric injury burden measurements in future local and global burden of disease studies.

Association between Body Composition and Sport Injury in Canadian Adolescents

Purpose: To examine the association between overweight or obesity and sport injury in a population-based sample of Canadian adolescents. Methods: Cross-sectional analyses were performed using the Canadian Community Health Survey (2009-2010), a nationally representative sample (n=12,407) of adolescents aged 12-19 years. Body composition was quantified using BMI, grouping participants into healthy weight, overweight, or obese. The outcome of interest was acute or repetitive strain injury sustained during sport in the previous year. We examined the relationship between sport injury and overweight or obesity compared with healthy weight using multivariate logistic regression, controlling for sex, ethnicity, physical activity, and socio-economic status. We also examined the interaction between physical activity and body composition in a secondary analysis with a subset of active adolescents. Results: No significant relationship was found between being overweight and sport injury (odds ratio [OR]=1.04, 95% CI: 0.92, 1.17); however, a protective effect was seen between obesity and sport injury (OR=0.67, 95% CI: 0.53, 0.84). Secondary analysis revealed that overweight youths with the highest activity level (quartile 4) did have increased odds of sport injury (OR=1.38, 95% CI: 1.04, 1.83), yet obese youths with a moderate activity level (quartile 2) were protected compared with healthy-weight youths (OR=0.46, 95% CI: 0.24, 0.91). Conclusions: Further examination of active adolescents is warranted. Studies should consider sport-specific differences and comprehensive measurement of exposure to sport.

A longitudinal study on quality of life after injury in children

Background

In high income countries, injuries account for 40 % of all child deaths, representing the leading cause of child mortality and a major source of morbidity. The need for studies across age groups, and use of health related quality of life measures that assess functional limitations in multiple health domains, with sampling at specific post-injury time points has been identified. The objective of this study was to describe the impact of childhood injury and recovery on health related quality of life (HRQoL) for the 12 months after injury.

Methods

In this prospective cohort study parents of children 0-16 years old attending British Columbia Children’s Hospital for an injury were surveyed over 12 months post-injury. Surveys assessed HRQoL at four points: baseline (pre-injury), one month, four to six months and 12 months post injury. Generalized estimating equation models identified factors associated with changes in HRQoL over time.

Results

A total of 256 baseline surveys were completed. Response rates for follow-ups at one, four and twelve months were 74 % (186), 67 % (169) and 64 % (161), respectively. The mean age of participants was 7.9 years and 30 % were admitted to the hospital. At baseline, a retrospective measure of pre-injury health, the mean HRQoL score was 90.7. Mean HRQoL ratings at one, four and 12 months post injury were 77.8, 90.3 and 91.3, respectively. Both being older and being hospitalized were associated with a steeper slope to recovery.

Conclusions

Although injuries are prevalent, the long term impacts of most childhood injuries are limited. Regardless of injury severity, most injured children recuperated quickly, and had regained total baseline status by four month post-injury. However, although hospitalization did not appear to impact long term psychosocial recovery, at four and 12 months post injury a greater proportion of hospitalized children continued to have depressed physical HRQoL scores. Both older and hospitalized children reported greater impact to HRQoL at one month post injury, and both had a steeper slope to recovery and were on par with their peers by four month.

A cross-sectional evaluation examining the use of the Achilles tendinopathy toolkit by physiotherapists in British Columbia, Canada

PURPOSE

To evaluate the awareness and use of the Achilles tendinopathy toolkit (ATT), a knowledge translation (KT) strategy supporting evidence-informed management of midportion Achilles Tendinopathy (AT), by British Columbian physiotherapists (PTs). Secondarily, to assess PTs strategies for AT management by examining the association between exploring the ATT and following best practice in clinical care as recommended by the ATT.

METHODS

Members of the Physiotherapy Association of British Columbia (BC) completed an online cross-sectional survey collecting information on demographics; awareness and exposure; perceptions, usability and applicability to clinical practice; knowledge; and attitudes. A clinical vignette assessed if respondents adhered to recommendations made by the ATT. Multi-variable logistic regression examined the association between exploring the ATT and following its recommendations.

RESULTS

Of 238 participants, 81% (n = 154) were aware of the ATT and of those 53% (n = 81) explored its contents. Time was the most frequent barrier. Bi-variable analyses showed those who explored the ATT had over double the odds of following the best practice (odds ratio = OR = 2.8; 95% confidence interval = 95% CI = 1.3-6.0). This did not remain significant in the final adjusted model (OR = 2.2; 95% CI = 0.9-5.4).

CONCLUSIONS

Evaluation of KT strategies is critical. This study revealed high awareness and moderate use of the ATT. Future work should consider the impact of toolkits on patient outcomes. Implications for Rehabilitation A toolkit is a novel knowledge translation (KT) strategy designed to provide accessibleevidence-informed resources to facilitate best practice by clinicians. The evaluation of the Achilles tendinopathy toolkit (ATT) revealed favourable findingsregarding the impact of this KT strategy on the knowledge and attitudes of British Columbia(BC) PTs and the possibility of a positive impact on best practice in clinical care. This research suggests toolkits are a feasible and meaningful KT strategy to provide clinicianswith valuable synthesized resources that have the potential to benefit patient outcomes.

Construct validity and impact of mode of administration of the PedsQL™ among a pediatric injury population

Background

The purpose of this study was to determine the construct validity of the PedsQL™ health related quality of life (HRQoL) instrument for use among injured children and to examine the impact of using different modes of administration, including paper and pencil, online and telephone.

Methods

Two hundred thirty-three participants (aged 0 – 16) were recruited from hospital wards and the emergency department of a pediatric hospital in a large urban center in British Columbia, Canada. Data used to evaluate the construct validity of the PedsQL™ were collected from participants at the time of seeking injury treatment (baseline) to capture a retrospective measure of pre injury health, and one month post injury. Data used to compare different modes of administration (n = 44) were collected at baseline. To assess construct validity repeated measures analysis of variance (rANOVA) was used to determine whether the PedsQL™ tool was able to discriminate between patients pre and post injury while investigating possible interaction by category of length of stay in hospital. The impact of different modalities of administering the PedsQL™ on item responses was investigated using Bland-Altman plots.

Results

rANOVA showed significant differences in PedsQL™ total score between baseline and one month post injury (p < .001), and differences in mean total score at one month post injury by category of injury severity (p < .001). There was also significant interaction by category of injury severity for the change in PedsQL™ total score from baseline to one month (p < .001). Pearson’s correlations were highly significant across three modalities of survey administration: paper and pencil, computer and telephone administration (range: .92 to .97, p < .001). Bland-Altman plots showed strong consistency.

Conclusion

The PedsQL™ instrument is able to discriminate between pre and post injury HRQoL, as well as HRQoL post injury for injuries of varying severity. These findings are an indication that this instrument has good construct validity for the purpose of evaluating HRQoL of injured children. Data collected via paper-pencil, online and telephone administration were highly consistent. This is important as depending on the setting, clinical or research, different modalities of completing this instrument may be more appropriate.

Knowledge, attitudes, beliefs and behaviours of older adults about pneumococcal immunization, a Public Health Agency of Canada/Canadian Institutes of Health Research Influenza Research Network (PCIRN) investigation

BACKGROUND

Fewer Canadian seniors are vaccinated against pneumococcal disease than receive the influenza vaccine annually. Improved understanding of factors influencing pneumococcal vaccination among older adults is needed to improve vaccine uptake.

METHODS

A self-administered survey measuring knowledge, attitudes, beliefs and behaviours about pneumococcal vaccination was administered to a cohort of seniors participating in a clinical trial of seasonal influenza vaccines at eight centers across Canada. Eligible participants were ambulatory adults 65 years of age or older, in good health or with stable health conditions, previously given influenza vaccine. The primary outcome was self-reported receipt of pneumococcal vaccination. Multi-variable logistic regression was used to determine factors significantly associated with pneumococcal vaccine receipt.

RESULTS

A total of 863 participants completed questionnaires (response rate 92%); 58% indicated they had received the pneumococcal vaccine. Being offered the vaccine by a health care provider had the strongest relationship with vaccine receipt (AOR 23.4 (95% CI 13.4-40.7)). Other variables that remained significantly associated with vaccine receipt in the multivariable model included having heard of the vaccine (AOR 10.1(95% CI 4.7-21.7)), and strongly agreeing that it is important for adults > 65 to be vaccinated against pneumococcus (AOR 3.3 (95% CI 1.2-9.2)). Participants who were < 70 years of age were less likely to be vaccinated.

CONCLUSIONS

These results indicate healthcare recommendation significantly influenced vaccine uptake in this population of older adults. Measures to encourage healthcare providers to offer the vaccine may help increase coverage.

Safety, immunogenicity, and tolerability of three influenza vaccines in older adults: results of a randomized, controlled comparison

To determine if newer influenza vaccines can safely improve seroprotection rates of older adults, we compared three licensed trivalent inactivated vaccines (TIVs) in a randomized, controlled trial with evaluator blinding. Participants were non-frail adults ≥ 65 y old, annually TIV-immunized. Study vaccines included intradermal (IDV), MF59-adjuvanted (ADV) and subunit (TIV) formulations of equal potency and strain composition. Blood was obtained before vaccination (V1) and 21 (V2) and 180 d (V3) afterward and tested by hemagglutination inhibition (HAI) assay. Safety diaries were completed daily by participants and specific tolerability questions were posed regarding injections and symptoms. In total, 911 participants were immunized and 887 (97.4%) completed V3. Groups had similar demographics. General symptom rates post-vaccination were similar among groups. Rates of injection site redness after IDV/ADV/TIV were 75%/13%/13% and rates of pain were 29%/38%/20%, respectively, but each vaccine was well tolerated, with symptoms causing little bother. Baseline antibody titers did not differ significantly among groups but B/Brisbane titers were too high for meaningful response assessments. At V2, seroprotection rates (HAI titer ≥ 40) were highest after ADV, the rate advantage over IDV and TIV being significant at 11.8% and 11.4% for H3N2 and 10.2% and 12.5% for H1N1, respectively. At day 180, seroprotection rates had declined ~25% and no longer differed significantly among groups. While IDV and TIV were also well tolerated, ADV induced modestly higher antibody titers in seniors to influenza A strains at 3 weeks but not 6 mo post-vaccination. Immune responses to IDV and TIV were similar in this population.

Experience with pyeloureterostomy associated with simple ligation of native ureter without ipsilateral nephrectomy in renal transplantation

Ureteroneocystostomy was used as the primary method of urinary tract reconstruction in 282 allograft renal transplants at our center since 1965. A nonrefluxing anastomosis was incorporated whenever possible. Seven patients who suffered major urological complications involving the ureteroneocystostomy required pyeloureterostomy as the method of repair using the patient's distal native ureter. No ipsilateral nephrectomy was performed and simple ligation of the native ureter with nonabsorbable suture was accomplished. Of the 7 patients 3 suffered hydronephrosis of the native kidney. None of these patients had signs or symptoms secondary to acute and chronic ureteral occlusion. Our experience suggests that intentional ligation of the native ureter during pyeloureterostomy does not result in increased morbidity to the transplant patient, and that the need for ipsilateral nephrectomy with its own added morbidity may not be necessary.