Implementation of the HiBalance training program for Parkinson’s disease in clinical settings: A feasibility study

BACKGROUND: Translating evidence into practice requires adaptation to facilitate the implementation of efficacious interventions. A novel highly challenging balance training program (HiBalance) was found to improve gait, balance, and physical activity in persons with Parkinson’s disease (PD) in an earlier randomized controlled trial. This study aimed to describe the adaptation process and feasibility of implementing the HiBalance program for PD within primary healthcare settings. METHOD: Feasibility was assessed in terms of study processes and scientific evaluation. Nine persons with mild–moderate PD were enrolled in this pre–post feasibility study. The dose of the original program was adapted by reducing therapist-led training sessions from three to two times weekly. Outcome measures were substituted with ones more clinically feasible. One group (n = 5) received HiBalance training three times weekly for 10 weeks while another (n = 4) trained twice weekly plus a once weekly home exercise program (HEP). Balance performance was the primary outcome, while secondary outcomes (e.g., gait speed, physical activity level, concerns of falling, and health-related quality of life) were also evaluated. RESULTS: Regarding process feasibility, attendance was high (approximately 90%) in both groups, and experiences of the group and home training were positive. Newly selected outcome measures were feasible. The scientific evaluation revealed few adverse events and no serious injuries occurred. Concerning outcomes per group, the average change in balance performance and gait speed was equal to, or exceeded, the minimally worthwhile treatment effect commonly used in PD. CONCLUSION: The findings support the feasibility, in terms of process and scientific evaluation, of the adapted HiBalance program for implementation within clinical settings. A sufficiently powered study is required to ascertain whether the newly proposed program offers similar short and long-term effects as the original program

Whole home exercise intervention for depression in older care home residents (the OPERA study) : a process evaluation

Background: The ‘Older People’s Exercise intervention in Residential and nursing Accommodation’ (OPERA) cluster randomised trial evaluated the impact of training for care home staff together with twice-weekly, physiotherapist-led exercise classes on depressive symptoms in care home residents, but found no effect. We report a process evaluation exploring potential explanations for the lack of effect. Methods: The OPERA trial included over 1,000 residents in 78 care homes in the UK. We used a mixed methods approach including quantitative data collected from all homes. In eight case study homes, we carried out repeated periods of observation and interviews with residents, care staff and managers. At the end of the intervention, we held focus groups with OPERA research staff. We reported our first findings before the trial outcome was known. Results: Homes showed large variations in activity at baseline and throughout the trial. Overall attendance rate at the group exercise sessions was low (50%). We considered two issues that might explain the negative outcome: whether the intervention changed the culture of the homes, and whether the residents engaged with the intervention. We found low levels of staff training, few home champions for the intervention and a culture that prioritised protecting residents from harm over encouraging activity. The trial team delivered 3,191 exercise groups but only 36% of participants attended at least 1 group per week and depressed residents attended significantly fewer groups than those who were not depressed. Residents were very frail and therefore most groups only included seated exercises. Conclusions: The intervention did not change the culture of the homes and, in the case study homes, activity levels did not change outside the exercise groups. Residents did not engage in the exercise groups at a sufficient level, and this was particularly true for those with depressive symptoms at baseline. The physical and mental frailty of care home residents may make it impossible to deliver a sufficiently intense exercise intervention to impact on depressive symptoms

Balance control in older adults with Parkinson’s disease : effects of medication and exercise

Aim: To investigate the effects of dopaminergic medications on turning while walking in older adults with mild to moderate Parkinson’s disease (PD). A further aim was to develop a training program targeting balance impairments related to PD, to verify the progression of this program and the specific effects on balance and gait, as well as the transfer effects on everyday living. Methods: This thesis contains an experimental and a clinical part. In the experimental part, quantitative motion analysis was used to evaluate pre- and unplanned walking turns. Nineteen individuals with PD were tested after overnight withdrawal of dopaminergic medication and approximately one hour after taking their usual dose of medication, and were compared with 17 healthy control subjects. In the clinical part, a training program with highly-challenging balance exercise and dual-tasking was developed through workshops and pilot testing. Thereafter, training progression of dynamic exercises throughout this program was evaluated with accelerometers in two training groups (n = 6 and 4). In a randomized controlled trial, 100 individuals with PD were randomized, either to a training group that received a 10-week highly-challenging balance exercise intervention with dual-tasking or to a control group (usual care). The efficacy of this intervention was evaluated before and after the intervention which included specific effects; balance, gait with and without performing a concurrent cognitive task, and transfer effects which were concerns about falling, level of physical activity and activities of daily living. Results: Dopaminergic medication had a positive increasing effect on turning distance, whereas no effects on body rotation were found. Compared with the healthy control group, individuals with PD demonstrated lower turning distance and body rotation, and turned with a narrower step width. The objective evaluation of training activity revealed that training progression was accomplished in two independent training groups. The randomized controlled trial demonstrated significant improvements in balance control and gait performance in the training group, compared with the control group. The training group also improved their performance of the cognitive task while walking; however, no group differences were found for any gait parameters during dual-tasking. Significant differences, in favor of the training group, were found for the level of physical activity and activities of daily living, while no group difference was found for concerns about falling. Conclusions: Compared with the performance of the healthy control group, dopaminergic medication does not normalize turning performance. These residual turning impairments were accompanied by difficulties alternating step width during turning, which could be important to address in the rehabilitation of individuals with PD. Highly-challenging balance exercises, including dual-task, for a 10-week period was progressive and improved balance and gait performance in older adults with PD, compared with usual care. Positive transfer effects on activities of everyday living were also revealed, indicating that appropriate training programs could promote physical activity and daily activities in individuals with PD

Comparison of embedded and added motor imagery training in patients after stroke: Study protocol of a randomised controlled pilot trial using a mixed methods approach

Copyright @ 2009 Schuster et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.Background: Two different approaches have been adopted when applying motor imagery (MI) to stroke patients. MI can be conducted either added to conventional physiotherapy or integrated within therapy sessions. The proposed study aims to compare the efficacy of embedded MI to an added MI intervention. Evidence from pilot studies reported in the literature suggests that both approaches can improve performance of a complex motor skill involving whole body movements, however, it remains to be demonstrated, which is the more effective one.Methods/Design: A single blinded, randomised controlled trial (RCT) with a pre-post intervention design will be carried out. The study design includes two experimental groups and a control group (CG). Both experimental groups (EG1, EG2) will receive physical practice of a clinical relevant motor task ('Going down, laying on the floor, and getting up again') over a two week intervention period: EG1 with embedded MI training, EG2 with MI training added after physiotherapy. The CG will receive standard physiotherapy intervention and an additional control intervention not related to MI.The primary study outcome is the time difference to perform the task from pre to post-intervention. Secondary outcomes include level of help needed, stages of motor task completion, degree of motor impairment, balance ability, fear of falling measure, motivation score, and motor imagery ability score. Four data collection points are proposed: twice during baseline phase, once following the intervention period, and once after a two week follow up. A nested qualitative part should add an important insight into patients' experience and attitudes towards MI. Semi-structured interviews of six to ten patients, who participate in the RCT, will be conducted to investigate patients' previous experience with MI and their expectations towards the MI intervention in the study. Patients will be interviewed prior and after the intervention period.Discussion: Results will determine whether embedded MI is superior to added MI. Findings of the semi-structured interviews will help to integrate patient's expectations of MI interventions in the design of research studies to improve practical applicability using MI as an adjunct therapy technique

Differences between initial and sale prices of Swedish forest properties

The Swedish market for forest properties is on fire. The prices of forestland is increasing all over the country and in year 2015 record prices occurred in some parts of Sweden. A probable explanation is that forestland generates a relatively good yield from a stable investment. In addition, the interest rate is low which is facilitates for potential investors. It is predicted that 1,5 million hectares of forestland, with a value of approximately 77 billion SEK will change owner in the next five years. The valuation of forest properties is a complex matter as they hold both monetary and non-monetary values. For example, the value depends on: standing volume, growth, geographic location, infrastructure, land consolidation, local capital density and recreational values. Previous studies have examined how both monetary and non-monetary values affect the prices of forest properties. However, there is a gap in the studies about factors affecting the price development from initial price to sale price. A possible explanation is the phenomenon underpricing which implies that brokers use an initial price below the estimated market value in order to attract many potential bidders. Hence, this phenomenon is investigated as one of the reasons for the potential differences between initial and sales prices. The aim of this paper is to examine and explain potential differences between the initial and sale prices of pure forest properties in Sweden. Pure forest properties have neither arable land nor buildings. The aim is fulfilled by finding whether differences occur and how potential dif-ferences may be explained. A mixed methods design is used containing a quantitative part in-cluding data from the SLU Market Price database during the years 2011 to 2016. The data is reduced to 214 observations that is compiled and analyzed by a regression analysis. The study also contains a qualitative part where brokers are interviewed in order to aid the explanation of the quantitative results and to include another perspective to the study. The findings display an average percentage difference between initial and sale prices in the Swedish market for pure forest properties of 8,1 percent. Neither the average percentage differences nor differences for the individual brokers indicates the use of underpricing. However, 21 percent of the properties sold in Sweden during the period have differences between initial and sale prices that may indicate underpricing. Further, 42 percent of the properties sold in Sweden have differences below 10 percent or no differences and 37 percent have differences between 10 and 25 percent. Capital density, county and the dummy variable “small property” are variables with a positive affect on the difference between initial price and sale price. Another variable affecting the difference positively is bidding neighbors. A variable that affects the difference between initial and sale price negatively is standing volume.Den svenska marknaden för skogsfastigheter glöder. Priserna på skogsmark ökar i hela landet och i vissa delar av Sverige var priserna år 2015 rekordhöga. En trolig förklaring är att skogen ger en förhållandevis bra avkastning från en stabil investering samtidigt som räntan är låg. Det förutspås att 1,5 miljoner hektar skogsmark till ett värde av ungefär 77 miljoner kronor ska byta ägare inom de kommande fem åren. Att värdera skogsfastigheter är komplext eftersom de har både monetära och icke-monetära värden. Dessa är exempelvis: virkesförråd, bonitet, geografisk position, infrastruktur, arronde-ring, kapitaltäthet på orten samt rekreationsvärden. Tidigare studier har behandlat både mone-tära och icke-monetära värdens påverkan på skogsfastigheters pris. Däremot finns det ett teo-retiskt gap i studier kring faktorer som påverkar skogsfastigheters prisutveckling från utgångspris till försäljningspris. En tänkbar orsak är exempelvis fenomenet lockprissättning som innebär att mäklaren sätter ett pris lägre än det förväntade försäljningsvärdet för att locka många potentiella köpare. Således ska detta fenomen undersökas som en av orsakerna till eventuella skillnader mellan utgångspris och försäljningspris. Syftet med denna studie är att undersöka och förklara potentiella skillnader mellan försäljningspris och utgångspris på rena skogsfastigheter i Sverige. Rena skogsfastigheter har varken åkermark eller byggnader. Syftet uppfylls genom att utreda huruvida skillnader finns och därefter förklara hur de potentiella skillnaderna kan uppstå. En mixad metod används innehållande en kvantitativ del byggd på data ifrån databasen SLU Marknadspris under åren 2011 till 2016. Denna data reduceras till 214 observationer som sammanställs och analyseras genom en regressionsanalys. Studien innehåller även en kvalitativ del där mäklare har intervjuats för att ge ett ytterligare djup och en klarhet i såväl teoretiska frågor som utfall från den kvantitativa metoden. Resultatet från denna studie visar en procentuell genomsnittlig skillnad mellan utgångspris och försäljningspris på 8,1 procent. Varken denna skillnad eller skillnaden för enskilda mäklare indikerar att lockprissättning förekommer. Däremot har 21 procent av fastigheterna sålda i Sverige under tidsperioden skillnader mellan utgångspris och försäljningspris som kan indikera lockprissättning. Vidare har 42 procent av de sålda fastigheterna skillnader under 10 procent eller inga skillnader samt 37 procent har skillnader mellan 10 och 25 procent. Kapitaltäthet, län och dummy-variabeln ”liten fastighet” har en positiv påverkan på skillnaden mellan utgångspris och försäljningspris. En annan variabel som påverkar skillnaden positivt är bjudande grannar. En variabel som har en negativ påverkan på skillnaden mellan utgångspris och försäljningspris är virkesförråd

Post-synthesis stabilization of germanosilicate zeolites ITH, IWW, and UTL by substitution of Ge for Al

M.S. thanks the Czech Science Foundation for the support of the Project 14-30898P. R.E.M. thanks the EPSRC for funding through grant EP/K025112/1.Germanosilicate zeolites often suffer from low hydrothermal stability due to the high content of Ge. Herein, we investigated the post-synthesis introduction of Al accompanied by stabilization of selected germanosilicates by degermanation/alumination treatments. The influence of chemical composition and topology of parent germanosilicate zeolites (ITH, IWW, and UTL) on the post-synthesis incorporation of Al was studied. Alumination of ITH (Si/Ge=2–13) and IWW (Si/Ge=3–7) zeolites resulted in the partial substitution of Ge for Al (up to 80 %), which was enhanced with a decrease of Ge content in the parent zeolite. In contrast, in extra-large pore zeolite UTL (Si/Ge=4–6) the hydrolysis of the interlayer Ge−O bonds dominated over substitution. The stabilization of zeolite UTL was achieved using a novel two-step degermanation/alumination procedure by the partial post-synthesis substitution of Ge for Si followed by alumination. This new method of stabilization and incorporation of strong acid sites may extend the utilization of germanosilicate zeolites, which has been until now been limited.PostprintPeer reviewe

A clinical case series investigating the effectiveness of an exercise intervention in chronic inflammatory demyelinating polyneuropathy (CIDP)

Background: Despite clinical intervention, people with chronic inflammatory demyelinating polyneuropathy (CIDP) experience difficulties in gait and balance on a daily basis. However, the effects on these variables of a tailored home based exercise programme for this population have not been investigated. This case series aims to investigate the effects of a home based tailored exercise programme on gait and balance in people with CIDP. Methods: Case series of seven people with CIDP from a neurology department of a local hospital. Participants took part in a 6 week Otago exercise programme, which include walking, strengthening and balance tasks. Participants were assessed 10 times; 3 times prior, 3 times during an exercise intervention, 3 times post intervention and once at three months follow up. The outcome measures were Berg Balance scale, 10 meter walk test, fatigue severity scale and EQ-5D-5L. Results: Participants showed an increase in walking speed and balance after the exercise intervention and most kept these improvements at 3 months follow up. Conclusion: This study shows that exercise can be beneficial for gait and balance in people with CIDP. These findings are in line with literature from related diseases such as Guillain-Barre Syndrome. However studies with a larger sample size are needed to confirm these findings in the population

Physical activity and influencing factors in people post stroke or transient ischemic attack across diverse regions in Sweden

Background and purposePhysical activity (PA) and sedentary behavior are key targets for secondary stroke prevention, yet their characteristics and contributing factors are not well understood. This study aims to explore PA and sedentary behavior in individuals' post-stroke or transient ischemic attack (TIA) and identify factors linked to low PA (≤5,000 steps/day) and prolonged sedentary time (≥8 h/day).MethodsA cross-sectional study comparing sensor-derived (activPAL) PA and sedentary time among community-dwelling individuals post stroke or TIA residing in diverse geographical regions of Sweden. Multiple logistic regression models were performed to determine potential factors associated with low PA and prolonged sedentary time.ResultsThe study included 101 participants post-stroke (n = 68) and TIA (n = 33), with a mean age of 70.5 years (65% female), mostly with no or mild disability (91%), living in metropolitan (69%) and rural (31%) areas of Sweden. Most participants (72%) had ≥ 8 h of sedentary time per day and 38% performed ≤5,000 steps per day. Using a walking aid (OR = 11.43, p = 0.002) was independently associated with low PA, whereas contextual factors; living alone (OR = 3.49, p = 0.029) and living in metropolitan areas (OR = 2.79, p = 0.036), were associated with prolonged sedentary time.Discussion and conclusionsIn this study encompassing people post stroke or TIA from diverse geographical regions across Sweden, PA was associated with mobility status whereas sedentary behavior was associated with contextual factors. The results also showed a large variation in PA highlighting the need for tailored strategies to promote PA post stroke or TIA

Recommendations for a core outcome set for measuring standing balance in adult populations: a consensus-based approach

Standing balance is imperative for mobility and avoiding falls. Use of an excessive number of standing balance measures has limited the synthesis of balance intervention data and hampered consistent clinical practice.To develop recommendations for a core outcome set (COS) of standing balance measures for research and practice among adults.A combination of scoping reviews, literature appraisal, anonymous voting and face-to-face meetings with fourteen invited experts from a range of disciplines with international recognition in balance measurement and falls prevention. Consensus was sought over three rounds using pre-established criteria.The scoping review identified 56 existing standing balance measures validated in adult populations with evidence of use in the past five years, and these were considered for inclusion in the COS.Fifteen measures were excluded after the first round of scoring and a further 36 after round two. Five measures were considered in round three. Two measures reached consensus for recommendation, and the expert panel recommended that at a minimum, either the Berg Balance Scale or Mini Balance Evaluation Systems Test be used when measuring standing balance in adult populations.Inclusion of two measures in the COS may increase the feasibility of potential uptake, but poses challenges for data synthesis. Adoption of the standing balance COS does not constitute a comprehensive balance assessment for any population, and users should include additional validated measures as appropriate.The absence of a gold standard for measuring standing balance has contributed to the proliferation of outcome measures. These recommendations represent an important first step towards greater standardization in the assessment and measurement of this critical skill and will inform clinical research and practice internationally

Structured feedback on students’ concept maps: the proverbial path to learning?

Good conceptual knowledge is an essential requirement for health professions students, in that they are required to apply concepts learned in the classroom to a variety of different contexts. However, the use of traditional methods of assessment limits the educator’s ability to correct students’ conceptual knowledge prior to altering the educational context. Concept mapping (CM) is an educational tool for evaluating conceptual knowledge, but little is known about its use in facilitating the development of richer knowledge frameworks. In addition, structured feedback has the potential to develop good conceptual knowledge. The purpose of this study was to use Kinchin’s criteria to assess the impact of structured feedback on the graphical complexity of CM’s by observing the development of richer knowledge frameworks. Fifty-eight physiotherapy students created CM’s targeting the integration of two knowledge domains within a case-based teaching paradigm. Each student received one round of structured feedback that addressed correction, reinforcement, forensic diagnosis, benchmarking, and longitudinal development on their CM’s prior to the final submission. The concept maps were categorized according to Kinchin’s criteria as either Spoke, Chain or Net representations, and then evaluated against defined traits of meaningful learning. The inter-rater reliability of categorizing CM’s was good. Pre-feedback CM’s were predominantly Chain structures (57%), with Net structures appearing least often. There was a significant reduction of the basic Spoke- structured CMs (P = 0.002) and a significant increase of Net-structured maps (P < 0.001) at the final evaluation (post-feedback). Changes in structural complexity of CMs appeared to be indicative of broader knowledge frameworks as assessed against the meaningful learning traits. Feedback on CM’s seemed to have contributed towards improving conceptual knowledge and correcting naive conceptions of related knowledge. Educators in medical education could therefore consider using CM’s to target individual student development