Educators' Perspectives on the Teaching and Learning of Type 2 Diabetes Content in Physiotherapy Programmes across Canada

Purpose

This qualitative descriptive study researched educators' perspectives of type 2 diabetes (T2D) Teaching and learning, in physiotherapy (PT) programmes across Canada.

Methods

Faculty members and clinical instructors from the 15 PT programmes in Canada were contacted. Online surveys collected data on the educators' professional background and perspectives on T2D in the PT curriculum. One-on-one telephone interviews were conducted and thematic analysis was used to generate themes and codes from the interview transcripts.

Results

Ten educators from 10 universities completed the survey. Seven of the 10 educators also participated in a telephone interview. Survey responses revealed that T2D content is taught predominantly through case studies and lectures. Of the 10 respondents, six reported that the curriculum does not devote adequate time to T2D content, and nine reported they "strongly agree" or "agree" that T2D is an essential component of the PT curriculum. The interviews revealed that T2D content varies across PT programmes. The educators agreed that T2D is a common condition seen in practice, there is a role for PT intervention, and T2D content is limited by classroom time.

Conclusions

Educators noted challenges integrating more T2D content in the curriculum and said that PT clinical contributions for people living with T2D are underutilized. Additional evidence-informed rationale is needed to explore optimal integration of T2D content in PT programmes.

Assessing physical function after completing a supervised education and exercise program in adults with type 2 diabetes and exploring exercise motivation at one-year follow up: A case series study

BACKGROUND

Exercise programs for adults with type 2 diabetes (T2D) improve glycemic control and physical function. However, diabetes complications, disability, and motivation pose challenges for exercise participation.

OBJECTIVE

The purpose of the study was to: 1) measure change in fasting blood glucose, blood pressure, anthropometrics (i.e. BMI and waist circumference), and physical function (i.e. endurance, agility and balance, upper and lower-body strength and flexibility) after completing an eight-week education and exercise program for adults with T2D; and 2) explore the experience of exercise continuation in people living with T2D at one-year follow-up.

METHODS

A mixed methods case series design was conducted. Participants were ≥ 18 years and had a clinical diagnosis of T2D (glycated hemoglobin (A1C) ≥ 6.5%). Participants completed two one-hour exercise sessions and one one-hour education session per week for eight weeks. Blood glucose, blood pressure, body mass index (BMI), waist circumference, and physical function were measured at baseline and after completing the program. Follow-up telephone interviews were conducted at one, six, and 12-months and thematic analysis was employed to analyze interviews.

RESULTS

Twelve participants completed the program. Clinically significant improvements were observed for waist circumference, systolic blood pressure, six-minute walk test (6MWT), timed up-and-go test (TUG), 30-second chair stand test (CST) and arm curls. Three themes emerged from the interviews that described participant reflections and experiences with a supervised education and exercise program for management of their T2D: 1) medical management; 2) lifestyle management; and 3) finding what works. Conclusion: Supervised programming improves physical function and may mitigate disability. Physiotherapists are qualified to assess and treat physical function through education and exercise.

Learnings from nursing bridging education programs: A scoping review

AIM

The aim of this scoping review is to summarize and critically evaluate research focused on nursing bridging education programs internationally. Specifically, this review addresses bridging from a: (1) Personal Support Worker (or similar) to a Registered Practical Nurse (or similar); and (2) Registered Practical Nurse (or similar) to a Registered Nurse.

BACKGROUND

Nursing bridging education programs support learners to move from one level of educational preparation or practice to another. These programs can therefore increase nursing workforce capacity. Global healthcare systems have faced nursing shortages for decades. Moreover, the presently insufficient nursing workforce is confronting an ever-increasing volume of needed healthcare that is rising with the global ageing demographic shift.

DESIGN

The Joanna Briggs Institute methods for scoping reviews, combined with Arksey and O'Malley's (2005) guidelines, were used with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR).

METHODS

MEDLINE (Ovid), CINAHL, EMBASE and SCOPUS databases were searched. Articles published in English that included Personal Support Workers, Registered Practical Nurses, Registered Nurses and/or nurses in similar categories who were studied through the process of a nursing bridging education program were included in the review. The study search was limited to papers published after 2005 (i.e., the beginning of nurse workload "overload" according to the Canadian Nurses Association). Braun and Clarke's (2006) thematic analysis was used in a content analysis of the included studies.

RESULTS

A total of 15 articles published between 2005 and 2022 were included. Four themes were generated: (1) participating in bridging education programs fuels both professional and personal development; (2) nursing bridging education programs enhance diversity in the nursing workforce; (3) student nurses do not anticipate the challenges associated with participating in a bridging program; and (4) mentor-mentee connection promotes academic learning and successful completion of nursing bridging education programs.

CONCLUSIONS

Despite experiencing challenges, participation in/completion of nursing bridging education programs leads to successful role transitioning and self-reported fulfillment of personal and professional aspirations. This review revealed the need for bridging programs to accommodate the unique needs of student nurses. Incorporation of support services, mentorship and faculty familiarity with varying nursing educational backgrounds facilitates role transitions by reducing the perceived challenges of bridging and promoting connection to foster learning. Nursing bridging education programs allow greater numbers of nurses to be trained to build workforce capacity and enable care for the world's rapidly ageing population.

The role of nurses in inpatient geriatric rehabilitation units: A scoping review

AIMS

(1) To review and synthesize research on the contributions of nurses to rehabilitation in inpatient geriatric rehabilitation units (GRUs), and (2) to compare these reported contributions to the domains of international rehabilitation nursing competency models. The roles and contributions of nurses (e.g. Registered Practical Nurses, Registered Nurses and Licensed Practical Nurses) in GRUs are non-specific, undervalued, undocumented and unrecognized as part of the formal Canadian rehabilitation process.

DESIGN

Arksey and O'Malley's methodological framework for scoping reviews and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews guidelines were used.

METHODS

Six databases were searched for relevant literature: MEDLINE, PsychINFO, CINAHL, EMBASE, SCOPUS and Nursing and Allied Health. English articles were included if they examined nursing roles or contributions to inpatient geriatric rehabilitation. Integrated synthesis was used to combine the qualitative and quantitative data, and thematic analysis was used for coding. Three sets of international competency models were amalgamated to explore how different nurse roles in geriatric rehabilitation were portrayed in the included literature.

RESULTS

Eight studies published between 1991 and 2020 were included in the review. Five main geriatric rehabilitation nursing roles were generated from synthesis of the domains of international rehabilitation nursing competency models: conserver, supporter, interpreter, coach and advocate.

CONCLUSIONS

Nurses working in inpatient geriatric rehabilitation are recognized more for their role in conserving the body than their roles in supporting, interpreting, coaching and advocacy. Interprofessional team members appear to be less sure of the nurses' role in the rehabilitation unit. Nurses themselves do not acknowledge the unique rehabilitation aspects of care for older adults. Enhancing formal education, or adding continuing education courses, to facilitate role clarity for nurses in geriatric rehabilitation could improve nurses' and interprofessional healthcare team members' understandings of the possible contributions of nurses working in rehabilitation settings.

A Survey of Canadian Physiotherapists' and Physiotherapy Students' Knowledge and Use of Executive Functioning Assessments in Clinical Practice

Purpose

This study examined what physiotherapists and physiotherapy students understand and know about executive functioning (EF), what EF outcome measures they use clinically, and whether their primary area of practice influences their assessment practices.

Method

An open online survey was distributed to registered members of the Canadian Physiotherapy Association, its various divisions, and colleges of physiotherapy within Canada that took approximately 15 minutes to complete and was available for 13 months. Pearson correlation was used to assess the relationship between subjective and objective understanding and knowledge of EF (UKEF) and a one-way multivariate analysis of variance was used to analyze differences in survey responses based on respondents' primary area of practice.

Results

A total of 335 respondents consented to participate (completion rate = 78.4%). There was a significant moderate positive correlation between subjective and objective UKEF (r = 0.43; 95% CI: 0.32, 0.54; n = 260; p < 0.001). Significant differences in survey responses were related to physiotherapists' primary areas of practice (i.e., musculoskeletal, neurological, cardiorespiratory, or multi-systems; F12,555.89 = 2.29, p = 0.008; Wilks Λ = 0.880; partial η2 = 0.042).

Conclusions

Respondents reported that they had good subjective UKEF, but this was only moderately correlated with objective UKEF.

Report on fraying resilience among the Ontario Registered Practical Nurse Workforce in long-term care homes during COVID-19

AIM

Registered Practical Nurses (RPNs) are frontline healthcare providers in Ontario long-term care (LTC) homes. Throughout COVID-19, RPNs working in LTC homes experienced prolonged lockdowns, challenging working conditions, and inadequate resource allocation. This study aimed to describe the personal and professional resilience of RPNs working in LTC during the COVID-19 pandemic.

DESIGN

An open cross-sectional online survey containing the Connor-Davidson Resilience Scale, Resilience at Work Scale®, and Resilience at Work Team Scale®.

METHODS

The survey was distributed by the RPN Association of Ontario (WeRPN) to approximately 5000 registered members working in Ontario LTC homes.

RESULTS

A total of 434 respondents participated in the survey (completion rate = 88.0%). Study respondents scored low on measures of resilience and reported extreme levels of job (54.5%) and personal (37.8%) stress. Resources to support self-care and work-life balance, build capacity for team-based care practice(s) are needed.

User experiences of older adults navigating an online database of community-based physical activity programs

Objectives

This study aimed to (1) explore older adult user experiences navigating an online health database of local physical activity programs; (2) compare navigational feedback with age-friendly website design guidelines; (3) assess online database completeness.

Methods

Focus groups, including guided tasks and a semi-structured interview script, gathered navigational user experiences of fifteen older adults. A review of the literature sought age-friendly best practice website design guidelines and a website search for local physical activity programs was completed.

Results

The design of the online database website was challenging for older adult participants to navigate and was not ‘intuitive’. Based on focus group feedback, there were multiple discrepancies between the evaluated online database and the established guidelines for designing age-friendly websites. A total of 187 physical activity programs were missing from the database.

Conclusions

Findings provide novel insight into user experiences of older adults navigating online health and physical activity program sites. Redesigning the following age-friendly website recommendations would empower older adults in the use of online databases and promote awareness of local physical activity programs. Health care providers need reliable and age-friendly online resources to link their patients with local physical activity programs to promote healthy aging.

Physiotherapists’ Perspectives on Type 2 Diabetes Management and as a Primary Condition for Referral to Physiotherapy Services: A Qualitative Descriptive Study

Purpose:

We explored the current and potential role of physiotherapists in the management of people with type 2 diabetes (T2D) and T2D as a primary condition for physiotherapy referral.

Method:

We conducted a qualitative descriptive study. Participants were physiotherapists practicing in community and outpatient settings across Canada. One-on-one telephone interviews were completed to explore provision of physiotherapy care for people with T2D, including current practices and readiness of physiotherapists to provide direct care. We employed thematic analysis for generation of themes from interviews.

Results:

We interviewed 21 participants from eight provinces and territories. Three themes were generated from the data: current approach to T2D management; challenges for physiotherapy integration; and merits of physiotherapy and needed evolution. Participants described that physiotherapists are not part of the healthcare team for T2D management. There is a gap in medical management of T2D that physiotherapy would fill, that is, education and prescription for exercise participation.

Conclusions:

Our findings support a gap in the management of T2D in Canadian healthcare, particularly in reference to physiotherapy. Further, our findings support the need for greater inclusion of physiotherapists for lifestyle counseling with an emphasis on physical activity and exercise for patients at risk of and with T2D to maximize health and improve/maintain function. Studies focusing on accessibility and funding of physiotherapy services are needed to validate these findings.

Resilience amongst Ontario registered practical nurses in long-term care homes during COVID-19: A grounded theory study

AIMS

This study aimed to understand how the personal and professional resilience of Registered Practical Nurses working in long-term care (LTC) homes in Ontario were impacted during the Coronavirus 2019 pandemic.

BACKGROUND

Registered Practical Nurses are primary regulated healthcare providers that have worked in Ontario LTC homes during the COVID-19 pandemic. As frontline workers, they have experienced increased stress secondary to lockdowns, changing Ministry of Health recommendations, social isolation and limited resources. LTC homes experienced almost a third of all COVID-19-related deaths in Ontario. Understanding registered practical nurses' (RPNs) resilience in this context is vital in developing the programs and supports necessary to help nurses become and stay resilient in LTC and across a range of settings.

METHODS

Purposive sampling was used to recruit 40 Registered Practical Nurses working in LTC homes across Ontario for interviews. Charmaz's Grounded theory guided in-depth one-on-one interviews and analyses completed between April to September 2021.

RESULTS

Registered Practical Nurse participants represented 15 (37.5%) private, and 25 (62.5%) public LTC homes across Ontario Local Health Integration Networks. Findings informed two distinct perspectives on resilience, one where nurses were able to maintain resilience and another where they were not. Sustaining and fraying resilience, presented as bimodal processes, was observed in four themes: 'Dynamic Role of the Nurse', 'Preserving Self', 'Banding Together' and 'Sense of Leadership Support'.

CONCLUSION

Resilience was largely drawn from themselves as individuals. Resources to support self-care and work-life balance are needed. Additionally, workplace supports to build capacity for team-based care practices, collegial support in problem-solving and opportunities for 'connecting' with LTC nursing colleagues would be beneficial. Our findings suggest a role for professional development resources in the workplace that could help rebuild this workforce and support RPNs in providing quality care for older adults living in LTC.

PATIENT OR PUBLIC CONTRIBUTION

Our research team included two members of the Registered Practical Nurses Association of Ontario, and these team members contributed to the discussion and design of the study methodology, recruitment, analysis and interpretation. Further, RPNs working in long-term care during the COVID-19 pandemic were the participants in this study and, therefore, contributed to the data. They did not contribute to data analysis or interpretation.

Accreditation as a driver of interprofessional education: the Canadian experience

BACKGROUND

The purpose of this study was to (1) explore evidence provided by Canadian health and social care (HASC) academic programs in meeting their profession-specific interprofessional education (IPE)-relevant accreditation standards; (2) share successes, exemplars, and challenges experienced by HASC academic programs in meeting their IPE-relevant accreditation standards; and (3) articulate the impacts of IPE-relevant accreditation standards on enabling interprofessional learning to the global HASC academic community.

METHODS

Profession-specific (bilingual, if requested) surveys were developed and emailed to the Deans/Academic Program Directors of eligible academic programs with a request to forward to the individual who oversees IPE accreditation. Responses were collated collectively and by profession. Open-ended responses associated with our first objective were deductively categorized to align with the five Accreditation of Interprofessional Health Education (AIPHE) standards domains. Responses to our additional questions associated with our second and third objectives were inductively categorized into themes.

RESULTS/DISCUSSION

Of the 270 HASC academic programs surveyed, 30% (n = 24) partially or completely responded to our questions. Of the 106 IPE-relevant standards where evidence was provided, 62% (n = 66) focused on the Educational Program, 88% of which (n = 58) were either met or partially met, and 47% (n = 31) of which focused on practice-based IPE. Respondents cited various exemplars and challenges in meeting IPE-relevant standards.

CONCLUSIONS

The overall sentiment was that IPE accreditation was a significant driver of the IPE curriculum and its continuous improvement. The array of exemplars described in this paper may be of relevance in advancing IPE implementation and accreditation across Canada and perhaps, more importantly, in countries where these processes are yet emerging.

Shoulder electromyography activity during push-up variations: a scoping review

BACKGROUND

Push-ups (PU) are a common closed chain exercise used to enhance shoulder girdle stability, with variations that alter the difficulty or target specific muscles. To appropriately select and prescribe PU exercises, an understanding of muscle activity during variations of the PU is needed. The purpose of this scoping review was to identify common PU variations and describe their muscle activation levels.

METHODS

Databases searched included PubMed, CINAHL, Scopus, and SPORTDiscus for articles published between January 2000 and November 2019.

RESULTS

Three hundred three articles were screened for eligibility with 30 articles included in the analysis. Six PU types and five muscles met the criteria for analysis. Weighted mean electromyography (EMG) amplitude was calculated for each muscle across PU types and for each PU type as a measure of global muscle activity. Triceps and pectoralis major had the highest EMG amplitude during unstable, suspension, incline with hands on a ball and the standard PU. Serratus anterior had the highest EMG amplitude during PU plus and incline PU. The greatest global EMG amplitude occurred during unstable surface PU.

DISCUSSION

These results provide clinicians with a framework for prescribing PU to target specific muscles and scale exercise difficulty to facilitate rehabilitation outcomes.

The process of commitment to exercise among stroke survivors in Canada

The objective of this research was to understand the process of commitment to exercise participation for functional recovery among community-living survivors of stroke following discharge from formal rehabilitation. Participants were recruited from a mid-sized city in south-western Ontario, Canada. Between September 2017 and March 2018, 10 individuals living in the community with the effects of stroke, who continued to engage in regular exercise post-stroke, were recruited for participation. Constructivist grounded theory methodology was employed, utilising in-depth individual interviews and theoretical sampling, whereby data collection and analysis occurred simultaneously. Analysis involved constant comparison between data and codes to reduce knowledge gaps and formulate the proposed theory. The process of commitment to exercise involved four phases. Initiation of the process followed a significant interaction with a healthcare provider who advocated for participants to learn the foundations of exercise. Through planned exercise, maintenance of a positive attitude and comparisons with their pre-stroke selves and peers, participants identified future goals and imparted the desire to get back to life before stroke. Over time individuals navigated exercise opportunities-trialling different types and environments-to learn what works. Finally, participants developed a commitment to exercise as a way of life, supported by social connections and reinforced with pride in successes-mastering self-care skills, improved mobility and meaningful function. The process of commitment to exercise among survivors of stroke required early interactions with healthcare providers to initiate exercise participation for long-term engagement, and navigation through various exercise elements fuelled by a desire to reconnect with their pre-stroke selves.

The effects of exercise interventions on physical function tests and glycemic control in adults with type 2 diabetes: A systematic review

INTRODUCTION

Regular exercise improves glycemic control and helps to mitigate the decline in strength, mobility, and balance. The 6-min walk test (6MWT), timed up-and-go test (TUG) and the sit-to-stand test (STS) are reliable measures of physical function in adults with type 2 diabetes (T2D). Outcome measures allow physiotherapists to monitor changes in physical function with exercise prescription.

METHODS

PubMed, CINAHL, EMBASE and Scopus databases and reference lists of relevant reviews were searched for randomized controlled trials (RCTs) relating to exercise and T2D published until June 2020. Studies were included when: (a) participants were adults diagnosed with T2D, (b) exercise was a main intervention and compared to controls, and (c) at least one clinical physical function measure was used to detect changes in aerobic capacity, mobility or strength.

RESULTS

Eight of 10 RCTs reported either statistically significant between-group (p < 0.05) or within-group (p < 0.05) differences in 6MWT scores. Nonsignificant between-group differences were found in two resistance training RCTs that utilized the TUG test. Three of five RCTs utilizing the STS test reported significant between groups differences (p < 0.05). Seven of 11 RCTs reported statistically significant between-group (p < 0.05) or within-group (p < 0.05) differences in glycated hemoglobin (HbA1c) levels.

CONCLUSION

Physical function measures may be useful for monitoring aerobic capacity, lower extremity strength and mobility with exercise in patients with T2D. Improvements in 6MWT scores may depend on total volume of exercise (minutes/week ∗ weeks of intervention). However, changes in HbA1c with exercise were variable and may depend on type of exercise.

The Process of Creating and Disseminating Exercise Programs by Physical Therapists for Older Adults With Chronic Back Pain

OBJECTIVE

The purpose of this study was to enhance the understanding of the process that physical therapists undertake when creating and disseminating exercise programs for older adults with chronic backpain.

METHODS

Constructivist grounded theory methodology was used as an accessible mode of researching pragmatic clinical practices. Physical therapists from outpatient, ambulatory care clinic settings participated in in-depth, individual interviews (n = 9) and in-clinic observations (n = 5). Data collection and analysis were iterative processes. Codes were generated based on recurrent themes, and constant comparative analysis was used to compare data. Analysis and data collection were concluded when theoretical sufficiency was reached.

RESULTS

Physical therapist participants described the process of creating and implementing exercise plans as involving listening to the patient's story, determining function, physical therapy care, supported integration, and, ultimately, returning back to living and life with chronic back pain. Participants worked through the 5 phases at different rates, often recurrently, when treating older adults with chronic back pain. The phases are positioned within a shared alliance between physical therapy provider and patient, with a transfer of responsibility occurring throughout treatment and follow-up sessions, progressing toward patient independence. This transfer of responsibility served as the core category for the process herein.

CONCLUSIONS

This research highlights the importance of listening to patients' stories when engaging in physical therapy care. Focusing on function, providing education and exercise as components of care, and supporting integration of exercise into everyday life are considerations for providing care for older adults with chronic back pain in physical therapist practice and, ultimately, for returning tolife.

IMPACT

With aging populations and with the increasing prevalence of chronic conditions, this research offers insight into a process for physical therapists to enact exercise engagement for improved health and quality of life for older adults with chronic backpain.

A Systematic Review of the Outcome Measures Used to Evaluate Interprofessional Learning by Health Care Professional Students During Clinical Experiences

Interprofessional education (IPE) occurs when members of more than one health or social care profession learn interactively together to improve interprofessional collaboration and health care delivery. Interprofessional experiences provide students with the skills and knowledge needed to work in a collaborative manner; however, there is no review on the outcome measures used to assess the effectiveness of IPE learning. The current systematic review examined the outcome measures used to assess interprofessional learning during student clinical experiences. An electronic search of databases retrieved trials of health professional students who completed an IPE intervention during a student clinical experience. Methodological quality of twenty-five studies meeting the inclusion criteria published between 1997 and 2018 was scored independently by two raters using the Physiotherapy Evidence Database and the Confidence in the Evidence from Reviews of Qualitative Research tool. The Interdisciplinary Education Perception Scale was used most frequently to assess interprofessional learning during a student clinical experience. This review provides a summary of outcome measures for educators to consider for evaluation of interprofessional activities during student clinical placements and serves to inform future conversations regarding the use and development of outcome measures to provide evidence for student achievement of IPE objectives and competencies.

The effects of physical exercise on executive function in community-dwelling older adults living with Alzheimer's-type dementia: A systematic review

Executive function deficit is an indicator of Alzheimer's-type dementia and manifests as disruptions of attentional control, memory, cognitive flexibility, planning, and reasoning, among other cognitive problems. Physical exercise is suggested to have a protective effect on global cognition with aging. However, whether it influences executive function in people living with Alzheimer's-type dementia specifically is unknown. The current systematic review examined the efficacy of physical exercise on executive function performance in community-dwelling older adults living with Alzheimer's-type dementia. An electronic search of databases retrieved randomized and non-randomized controlled trials of community-dwelling older adults diagnosed with Alzheimer's-type dementia who completed a physical exercise intervention and who were assessed using an executive function outcome measure. Methodological quality of six studies meeting the inclusion criteria published between 2009 and 2016 was scored independently by two raters using the Physiotherapy Evidence Database and a Cochrane informed domain-based assessment of risk of bias. Trends toward improvement in executive function scores were seen across all six studies, and significant improvement was seen in four of the eligible studies. Future studies should explore the benefits of the American College of Sports Medicine recommended 150 min of physical exercise per week with select measures of executive function.

Neuromuscular contributions to the age-related reduction in muscle power: Mechanisms and potential role of high velocity power training

Although much of the literature on neuromuscular changes with aging has focused on loss of muscle mass and isometric strength, deficits in muscle power are more pronounced with aging and may be a more sensitive measure of neuromuscular degeneration. This review aims to identify the adaptations to the neuromuscular system with aging, with specific emphasis on changes that result in decreased muscle power. We discuss how these changes in neuromuscular performance can affect mobility, and ultimately contribute to an increased risk for falls in older adults. Finally, we evaluate the literature regarding high-velocity muscle power training (PT), and its potential advantages over conventional strength training for improving functional performance and mitigating fall risk in older adults.

Association between muscle hydration measures acquired using bioelectrical impedance spectroscopy and magnetic resonance imaging in healthy and hemodialysis population

Establishing the effect of fluctuating extracellular fluid (ECF) volume on muscle strength in people with end-stage renal disease (ESRD) on hemodialysis (HD) is essential, as inadequate hydration of the skeletal muscles impacts its strength and endurance. Bioelectrical impedance spectroscopy (BIS) has been a widely used method for estimating ECF volume of a limb or calf segment. Magnetic resonance imaging (MRI)-acquired transverse relaxation times (T2) has also been used for estimating ECF volumes of individual skeletal muscles. The purpose of this study was to determine the association between T2 (gold standard) of tibialis anterior (TA), medial (MG), and lateral gastrocnemius (LG), and soleus muscles and calf BIS ECF, in healthy and in people with ESRD/HD. Calf BIS and MRI measures were collected on two occasions before and after HD session in people with ESRD/HD and on a single occasion for the healthy participants. Linear regression analysis was used to establish the association between these measures. Thirty-two healthy and 22 participants on HD were recruited. The association between T2 of TA, LG, MG, and soleus muscles and ratio of calf BIS-acquired ECF and intracellular fluids (ICF) were: TA: β = 0.30, P > 0.05; LG: β = 0.37, P = 0.035; MG: β = 0.43, P = 0.014; soleus: β = 0.60, P < 0.001. For the HD group, calf ECF was significantly associated with T2 of TA (β = 0.44, P = 0.042), and medial gastrocnemius (β = 0.47, P = 0.027) following HD only. Hence BIS-acquired measures cannot be used to measure ECF volumes of a single muscle in the ESRD/HD population; however, BIS could be utilized to estimate ratio of ECF: ICF in healthy population for the LG, MG, and soleus muscles.

Enacting Fall Prevention in Community Outreach Care

Despite increased international concern about fall prevention throughout the past 20 years, only limited attention has been paid to the experiences and perspectives of health care providers who deliver fall prevention programs. The purpose of this interpretive phenomenological study was to explore the meaning of the experience of enacting fall prevention, through individual semistructured interviews, among 6 members of an interprofessional geriatric outreach team in Ontario, Canada. Findings suggest that enacting careful practice was essential to the experience of enacting fall prevention, represented by four interrelated phenomenological themes: caring fully for older clients, carefully seeing older clients in their life contexts, enacting therapeutic relationships, and experiential learning in interprofessional teams. We discuss findings in relation to literature on emotional labor, leading to suggestions for the policy and practice of fall prevention.

"Any movement at all is exercise": a focused ethnography of rural community-dwelling older adults' perceptions and experiences of exercise as self-care

PURPOSE

To understand rural community-dwelling older adult participants' shared values, beliefs, and behaviours related to exercise as self-care.

METHODS

We conducted a constructivist-focused ethnography involving semi-structured interviews and participant observation with 17 individuals 65 years and older. Interviews were transcribed and inductively coded to develop themes related to exercise, self-care, and exercise as self-care. Field notes were triangulated with follow-up interviews and dialogue between authors to enhance interpretation.

RESULTS

Participants described exercise broadly as movement and not as a central self-care behaviour. However, awareness of the importance and health-related benefits of exercise increased after a significant personal health-related event. Participants preferred exercise that was enjoyable and previously experienced.

CONCLUSIONS

Prescribing exercise for older adults may be particularly effective if the focus is on enjoyable and previously experienced physical activity and if it incorporates interpretation of exercise guidelines and training principles in relation to chronic conditions and potential health benefits.

'Getting back to real living': A qualitative study of the process of community reintegration after stroke

OBJECTIVES

To examine the process of community reintegration over the first year following stroke, from the patient's perspective.

DESIGN

Qualitative, longitudinal, grounded theory study involving ten participants. During the first year post discharge from inpatient rehabilitation, 46 one-on-one semi-structured interviews were conducted with ten participants. Interviews were completed with participants before discharge from inpatient stroke rehabilitation and in their homes at two weeks, three months, six months and one year post discharge. Analysis was guided by grounded theory methods described by Corbin and Strauss.

SUBJECTS

Four women and six men (mean age 59.6 ± 18.0, all with left hemiparesis and without aphasia) who had sustained their first hemispheric stroke and were returning to the community following inpatient rehabilitation.

RESULTS

The process of community reintegration after stroke involved transitioning through a series of goals: gaining physical function, establishing independence, adjusting expectations and getting back to real living. The ultimate challenge for stroke survivors during this process of community reintegration was to create a balance between their expectations of themselves and their physical capacity to engage in meaningful roles.

CONCLUSIONS

Over the first year after stroke, participants reported that the process of community reintegration was marked by ongoing changes in their goals. Formal and informal caregivers need to work with stroke survivors living in the community to facilitate realistic and achievable goal setting. Tools which identify meaningful activities should also be incorporated to provide stroke survivors with the opportunity to contribute and engage with others in the community.

Pragmatism in practice: mixed methods research for physiotherapy

The purpose of this paper is to provide an argument for the place of mixed methods research across practice settings as an effective means of supporting evidence-based practice in physiotherapy. Physiotherapy practitioners use both qualitative and quantitative methods throughout the process of patient care-from history taking, assessment, and intervention to evaluation of outcomes. Research on practice paradigms demonstrates the importance of mixing qualitative and quantitative methods to achieve 'expert practice' that is concerned with optimizing outcomes and incorporating patient beliefs and values. Research paradigms that relate to this model of practice would integrate qualitative and quantitative types of knowledge and inquiry, while maintaining a prioritized focus on patient outcomes. Pragmatism is an emerging research paradigm where practical consequences and the effects of concepts and behaviors are vital components of meaning and truth. This research paradigm supports the simultaneous use of qualitative and quantitative methods of inquiry to generate evidence to support best practice. This paper demonstrates that mixed methods research with a pragmatist view provides evidence that embraces and addresses the multiple practice concerns of practitioners better than either qualitative or quantitative research approaches in isolation.

Threshold Berg balance scale scores for gait-aid use in elderly subjects: a secondary analysis

PURPOSE

To determine the threshold Berg Balance Scale (BBS) scores that discriminate among levels of gait-aid use in elderly subjects.

METHODS

A secondary analysis of data combined from two projects was performed. Both projects determined BBS performance, self-selected gait speed, and gait-aid use in samples of community-dwelling, independently ambulant individuals older than 65 years of age. Receiver operating characteristic curves were used to identify BBS scores that optimized identification of individuals with different levels of ambulation.

RESULTS

Previously determined associations between BBS score and various indicators of ambulatory ability were reproduced with the combined data set. Threshold BBS scores were identified for ability to walk without an aid (≥49/56) and ability to walk without a four-wheeled walker (≥43/56). The percent agreement values for the identified threshold scores ranged from 51% to 87%.

CONCLUSIONS

Although some threshold BBS scores could be determined, the accuracies of the scores render them of limited use for guiding gait-aid prescription in individual clients.

Clinical utility of the 2-minute walk test for older adults living in long-term care

PURPOSE

This study's purposes were to examine the measurement properties of the 2-minute walk test (2MWT), to illustrate the use of reliability coefficients in clinical practice, and to estimate sample size for a subsequent validity study.

METHOD

Sixteen residents of long-term care (LTC; mean age = 87 years) completed two 2MWTs with Rater A and two 2MWTs with Rater B on test days 1 and 2, approximately 1 week apart. On a third test day, subjects completed one trial of the Berg Balance Scale (BBS), timed up-and-go (TUG) test, and 6-minute walk test (6MWT) with Rater A. On 2 other test days, approximately 1 week apart, Rater A administered the 2MWT to five older adults living in a retirement facility. Absolute and relative reliability and concurrent and known-groups validity coefficients were calculated.

RESULTS

No main effect for rater, trial, or occasion was found. Test-retest reliability estimates of 0.94 and 0.95 were obtained. The 2MWT demonstrated concurrent validity (r > or = 0.84) with the BBS, TUG, and 6MWT. Comparison of distance walked by LTC and retirement residents showed a difference of 72.9 m (95% CI: 44.2, 101.6). The results suggest that 90% of truly stable older adults will display random fluctuations in 2MWT performance within a boundary of 15 m.

CONCLUSION

The 2MWT had sound measurement properties in this sample of LTC residents. Based on our results, 24 subjects would be required for a subsequent hypothesis-testing validity study.

"Holding me back": living with arthritis while recovering from stroke

OBJECTIVE

To describe the experience of living with arthritis while recovering from stroke.

DESIGN

Qualitative, phenomenological study. During the first three months post-stroke, 14 one-on-one semi-structured interviews were conducted. Analysis was guided by the modified van Kaam method.

SETTING

General community.

PARTICIPANTS

Three men and two women with self-reported pre-existing knee arthritis who were recovering from a first stroke.

INTERVENTION

Not applicable.

MAIN OUTCOME MEASURES

Not applicable.

RESULTS

"Holding me back" was central to the experience of living with knee arthritis while recovering from stroke, due to pain, mobility limitations, frustration, and additional coping demands. Experiencing arthritic pain occurred during daily physical activity. As a result, arthritis interfered with participants' ability to fully engage in stroke rehabilitation. The resulting mobility limitations due to arthritis were frustrating experiences that required additional coping strategies by all participants.

CONCLUSIONS

From the perspective of the participants, the slowed recovery from stroke due to arthritis illustrated the need to consider the influence of knee arthritis on stroke recovery during inpatient rehabilitation and after discharge. Stroke rehabilitation interventions that emphasize weight-bearing exercise may not be tolerated by those with arthritis. Alternate pharmacological treatments and physical rehabilitation should be considered for people with pre-existing knee arthritis post-stroke.

Utility of portable electromyography for quantifying muscle activity during daily use

BACKGROUND

Mobility has been studied using performance, questionnaire, pedometer and accelerometer measures, but these tools do not provide information about muscle activity. To better understand mechanisms associated with movement impairment as they relate to function, it is valuable to quantify muscle activity during everyday activities.

OBJECTIVE

This report presents electromyography (EMG) during daily activities from the affected and unaffected limbs of a 74-year-old man who survived a stroke 12 years ago, compared to 7 older healthy men who had not experienced a stroke.

METHODS

The biceps brachii, triceps brachii, quadriceps and hamstring muscles were recorded continuously for one 8-hour session in the unaffected limbs of the stroke survivor and control subjects. On a second day, EMG from these same muscles of the affected side was recorded for 4 h. Bursts (amplitude >2% maximum effort, duration >0.1 s) and gaps (amplitude <1% maximum effort, duration >0.1 s) of EMG were quantified for the number of times they occurred, mean event duration (seconds), mean peak amplitude (percent maximum voluntary efforts) and rate of activity (event activity/second).

RESULTS

Burst and gap patterns of the unaffected limb muscles were similar between the stroke survivor and controls. Increased numbers of bursts (approx. 40%) and gaps (approx. 44%) were seen in the subject's lower limb muscles of his affected versus unaffected side. Biceps brachii burst activity of the affected limb was increased, whereas triceps brachii burst activity was decreased. These muscle activity changes in the affected limb suggest that the triceps brachii was relatively inactive and the biceps brachii and lower limb muscles were active in an 'on' and 'off' pattern.

CONCLUSION

Muscle activity in the unaffected limb of the stroke survivor was similar compared to control subjects, but the affected limb differed from the unaffected after stroke. Portable EMG to monitor muscle activity for prolonged periods was not reported to be an impediment by the case or control subjects. Using this technology, EMG bursts and gaps can be recorded and used to describe muscle activity. Future work may consider the feasibility of this technique to monitor rehabilitation progression or long-term plasticity of muscle activity.

Reliability and Validity of Responses to Submaximal All-Extremity Semirecumbent Exercise in Older Adults

Although popular in clinical settings, little is known about the utility of all-extremity semirecumbent exercise machines for research. Twenty-one community-dwelling older adults performed two exercise trials (three 4-min stages at increasing workloads) to evaluate the reliability and validity of exercise responses to submaximal all-extremity semirecumbent exercise (BioStep). Exercise responses were measured directly (Cosmed K4b2) and indirectly through software on the BioStep. Test–retest reliability (ICC2,1) was moderate to high across all three stages for directly measured METs (.92, .87, and .88) and HR (.91, .83, and .86). Concurrent criterion validity between the K4b2and BioStep MET values was moderate to very good across the three stages on both Day 1 (r= .86, .71, and .83) and Day 2 (r= .73, .87, and .72). All-extremity semirecumbent submaximal exercise elicited reliable and valid responses in our sample of older adults and thus can be considered a viable exercise mode.

Maximal Aerobic Capacity Testing of Older Adults: A Critical Review

Most of the data that describe maximal oxygen uptake (VO(2max)) and the requirements for its attainment have been developed using young adults as subjects. Many older adults are unable to satisfactorily complete a maximal exercise effort in a standard exercise stress test. This review describes exercise tests currently available to measure VO(2max) in older adults. PubMed and CINAHL databases were searched for studies including healthy individuals older than 65 years with reproducible descriptions of the testing protocol. The research on VO(2max) testing in healthy individuals older than 65 years is limited, does not describe the protocols in detail, and/or lacks information on the psychometric properties of the exercise tests. There is a need for refinement of the few existing protocols for testing aerobic capacity in older adults, as well as the development of new protocols specifically applicable to older adults. Consensus on the criteria defining VO(2max) attainment during exercise in older adults is required, as well as agreement on the most appropriate exercise protocols and equipment, specific to older adults, to successfully fulfil these criteria.

Reliability and validity of ankle proprioceptive measures

OBJECTIVE

To determine the reliability and validity of ankle proprioceptive measures.

DESIGN

Reliability was assessed between test occasions. Construct validity was addressed by the ability of measures to differentiate among groups.

SETTING

Laboratory of an educational institution.

PARTICIPANTS

Eight healthy adults were recruited into each of 3 groups: (1) young (20-39y), (2) middle-aged (40-59y), and (3) older adults (>or=60y). Four subjects from each group (n=12) participated in retesting.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Threshold for perception of passive movement, error in active reproduction of position, error in reproduction of velocity, and error in reproduction of torque.

RESULTS

Intersession reliability was excellent (intraclass correlation coefficient [ICC] range, .79 - .95) for threshold for perception of movement, error in active reproduction, error in velocity reproduction, and error in dorsiflexion torque reproduction; intersession reliability was good for error in reproduction of plantarflexion torque (ICC=.72). Threshold for perception of movement differed between groups 1 and 3 and between groups 2 and 3 (P<.05). Error in reproduction of position was greater in group 2 than in group 1 (P<.05).

CONCLUSION

Differences in proprioception between the older and the 2 younger groups were best detected by using threshold for perception of passive movement.

Effects of isokinetic strength training on concentric and eccentric torque development in the ankle dorsiflexors of older adults

This study quantifies concentric and eccentric dorsiflexor muscle torque at various movement velocities and determines the neuromuscular effects from short-term practice of repeated maximal voluntary contractions using an isokinetic resisted exercise program in older adults. Twenty-eight subjects (76.3+/-4.6 years) trained concentric and eccentric dorsiflexion 3 days per week for 2 weeks at 30 degrees, 90 degrees, and 180 degrees/s through 40 degrees of dorsiflexion range of motion. Peak torque, rate of torque development, surface electromyography, and strength curves at each velocity were compared before and after training. Increases were found for concentric (27%) and eccentric (20%) dorsiflexor peak torque and concentric rate of torque production (20%-53%) across all movement velocities (p < .01). Training also significantly increased dorsiflexor concentric (64%) and eccentric (55%) surface electromyography; taken together, this is evidence of apparent adaptation of neural factors in older adults with short-term training. These findings support that eccentric and concentric strength training enhances the control and production of ankle muscle dorsiflexor torque in older adults, with implications for improving functional mobility of the ankle joint.

Motor skill learning of concentric and eccentric isokinetic movements in older adults

Neuromuscular adaptation at the onset of resisted exercise can be observed as increases in torque and surface electromyography. The effect of learning the motor task has been hypothesized to contribute to these early increases, especially for older people. Thus, the purpose of this study was to investigate the facilitatory effects of practice on motor performance in older adults during short-term isokinetic training of the ankle dorsiflexors (DF). Twenty-eight men and women (M = 76.3 +/- 4.6 years) volunteered for a 2-week, 3-days/week strength training program. They were tested in a sitting position on a KinCom isokinetic dynamometer at 30, 90, and 180 degrees s-1 through 40 degrees of DF movement (concentric and eccentric contractions). Criterion curves of lever arm angle patterns were cross-correlated with subject-generated angle patterns, showing significantly better correlations on posttest versus baseline. Smoothness and proficiency of muscle contraction improved with practice by fewer hesitations in movement and increased ability to change between concentric and eccentric muscle contractions. Increased agonist electromyography and torque were hypothesized to be secondary to greater neural drive and/or synchronization of motor unit firing rate and/or recruitment during maximal voluntary contraction, improved coordination, and adapted neural control of concentric and eccentric muscle contraction.

Motor unit firing rates and contractile properties in tibialis anterior of young and old men

The effects of aging on motoneuron firing rates and muscle contractile properties were studied in tibialis anterior muscle by comparing results from six young (20.8 +/- 0.8 yr) and six old men (82.0 +/- 1.7 yr). For each subject, data were collected from repeated tests over a 2-wk period. Contractile tests included maximal voluntary contraction (MVC) with twitch interpolation and stimulated twitch contractions. The old men had 26% lower MVC torque (P < 0.01) than did the young men, but percent activation was not different (99.1 and 99.3%, respectively). Twitch contraction durations were 23% longer (P < 0.01) in the old compared with the young men. During a series of repeated brief steady-state contractions at 10, 25, 50, 75, and 100% MVC, motor unit firing rates were recorded. Results from approximately 950 motor unit trains in each subject group indicated that at all relative torque levels mean firing rates were 30-35% lower (P < 0.01) in the old subjects. Comparisons between young and old subjects' mean firing rates at each of 10%, 50%, and MVC torques and their corresponding mean twitch contraction duration yielded a range of moderate-to-high correlations (r = -0.67 to -0.84). That lower firing rates were matched to longer twitch contraction durations in the muscle of old men, and relatively higher firing rates were matched with shorter contraction times from the young men, indirectly supports the neuromuscular age-related remodeling principle.

Quadriceps muscle strength, contractile properties, and motor unit firing rates in young and old men

Changes with age in the voluntary static and dynamic strength of the quadriceps muscle group have been well characterized, and the importance of the muscle group for locomotion and independent living have been highlighted in both normal human aging and in clinical studies. Surprisingly few studies of this muscle group have described age-related changes in voluntary activation ability using twitch interpolation and changes in stimulated contractile properties, and none have assessed the influence of old age on motor unit firing rates. We compared in 13 young (mean age 26 years) and 12 old (mean age 80 years) men the voluntary isometric strength, stimulated contractile properties, and average steady state motor unit firing rates in the quadriceps muscle. Maximum voluntary contraction (MVC) force and twitch tension were approximately 50% lower in the old men, but contractile speed was only approximately 10% slower than in the young men. There was no difference in the ability of either group to activate the quadriceps to a high degree (94-96%). At all isometric force levels tested (10%, 25%, 50%, 75%, and 100% MVC), there were no differences in mean motor unit firing rates. In both groups, the range of firing rates was similar and not large ( approximately 8 Hz at 10% MVC and 26 Hz at MVC). Thus, the substantial age-related weakness in this muscle does not seem to be related to changes in neural drive.

Effects of detraining on knee extensor strength and functional mobility in a group of elderly women

Long-term detraining results for individuals 75 years and older are needed. The purpose of this study was to assess long-term detraining effects on quadriceps strength and functional mobility in nursing home residents. Ten women (X = 82.8 years) who completed a strength training program were reassessed 1 year later. Clinical methods were used to remeasure dynamic and isometric quadriceps strength and functional mobility. One repetition maximum quadriceps strength declined 68.3% (p < 0.05) from trained values. Isometric strength losses were 29.8% at 90 degrees (p < 0.05), 28.7% at 60 degrees (p < 0.05), and 24.4% at 20 degrees (p < 0.05) of knee flexion 1 year postexercise. Fast-paced walking, self-selected paced walking, and timed up and go speed decreased 28.6% (p < 0.05), 19.5% (p < 0.05), and 54.1% (not significant), respectively, from posttraining. One year vs. baseline, isometric strength decreased 0-14.3%, dynamic strength decreased 48.9%, and functional mobility declined 16.5-20.7% despite an intervening training program. An increased strength loss rate beyond the age of 80 years may be a major factor influencing functional independence.

Reduced insulin binding to liver plasma membranes in inherently obese diabetic CBA/Ca mice

Insulin binding to isolated liver plasma membranes was measured in mice from C57BL and LACG strains, and in normal and obese diabetic mice from the Bristol CBA/Ca colony. A simple and rapid three-step method for the preparation and purification of liver plasma membranes, using Percoll density gradient centrifugation was used. Both high and low affinity binding was detected in membranes from all four groups of mice. The Kd values for binding were similar in all groups, but the insulin binding capacity (Bmax) at low and high affinity was significantly reduced in obese CBA mice compared to age-matched lean controls. It is proposed that insulin receptor down-regulation may account for the insulin resistance observed in spontaneously obese diabetic CBA mice.

Characterization of the spontaneous diabetes obesity syndrome in mature male CBA/Ca mice

A spontaneous maturity onset diabetes obesity syndrome occurs in a small proportion (10-20%) of male CBA/Ca mice. Inbreeding can increase the incidence to 80%. It occurs at 12-16 weeks of age, and is characterized by hyperphagia, obesity, hyperglycaemia, hypertriglyceridaemia, hyperinsulinaemia, and an impaired glucose tolerance. The mice are also resistant to exogenous insulin. Female mice remain normal except for a slight increase in serum insulin. The male obese diabetic mice have a normal life expectancy. It is proposed that CBA/Ca mice can provide examples of a useful model for investigating the aetiology of type 2 diabetes and obesity, and the effectiveness of antidiabetic and antiobesity drugs.

Relief of experimentally induced pruritus with a novel eutectic mixture of local anaesthetic agents

The effectiveness of a eutectic mixture of the local anaesthetics lignocaine and prilocaine (EMLA cream) in relieving artificially induced pruritus was examined in 20 volunteers. The study was conducted in two parts. In part one, the effect of EMLA on the threshold concentration of histamine necessary to induce pruritus was assessed by a double-blind placebo controlled method. In part two, the effect of EMLA on the perception of pruritus induced by the artificial pruritogens cowhage and papain was assessed by a single blind method. Some subjects were less sensitive to histamine after placebo cream treatment, but all subjects showed a marked reduction in sensitivity to histamine after EMLA treatment. The difference between EMLA and the placebo treatment was statistically significant. The EMLA preparation was found to be effective in alleviating pruritus induced by cowhage and papain and this effect was also statistically significant. Thus, EMLA cream was found to be effective in reducing experimentally induced pruritus and, therefore, may be useful in some clinical circumstances where persistent itch is a distressing symptom.