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Background: Motor neurone disease (MND) is a progressive neurological condition with no known cure. Supportive management and symptom control by a multidisciplinary team forms the mainstay of treatment. Caring for patients with MND throughout the COVID-19 required service providers to think of ways to adapt the service in order to meet the acute and constantly changing needs of their service users within pandemic guidelines. Aims: This paper explores innovative changes within the occupational therapy service provision during the pandemic and how it supports the multidisciplinary team (MDT) working. It also evaluates the merits and disadvantages of using virtual technology in specific areas of occupational therapy intervention. Methods: A set of prioritisation criteria was developed to understand the rationale for virtual versus face-to-face input. A reflective process has been used to identify and evaluate innovative service provision in occupational therapy in the management of motor neurone disease. Findings: Virtual consultations were an effective way of providing certain aspects of occupational therapy input. Virtual consultations were found to be less effective during moving and handling assessments, complex environmental adaptations assessment and when managing complex cognitive presentations. During the pandemic there was a rise in referrals for cognitive behavioural management, a specialist area of expertise for occupational therapy in this clinical area. A holistic approach was paramount in meeting the evolving needs of patients across functional domains. Occupational therapy complemented the caring and supportive role of nurses and other members of the MDT in the management of MND. Conclusions: Occupational therapy input can support an MDT by providing valuable assessment of functional decline, specialist equipment, supporting cognitive-behavioural performance, restoring life roles and minimising the challenges imposed by the environment. Using virtual technology discernibly can be an invaluable approach to occupational therapy practice within an MDT setting for managing a progressive neurological condition, such as MND, during a pandemic.

Introduction: This study considers the development of occupational therapy and its growth within the United Kingdom. It provides an account of the profession's past and present and suggests an opportunity for the future.\ud \ud Objective: We describe the history of occupational therapy in the United Kingdom, from the historical events that facilitated the early development of the profession up until the present time.\ud \ud Methods: This is a descriptive and historical overview of occupational therapy in the United Kingdom.\ud \ud Results: Through their influence within the social reform and arts and crafts movements, John Ruskin (1819–1900), Octavia Hill (1838–1912), and Elizabeth Casson (1881–1954) are identified as the drivers of the development of occupational therapy in the United Kingdom.\ud \ud Conclusion: We acknowledge the challenges and expectations of occupational therapy within the National Health Service and note that occupational therapy practice is greatly dependent on government funding and the policy priorities for health and education. We advocate for creativity in crafting the occupation of the occupational therapist and propose a vision for crafting creative occupation.

Purpose The purpose of this paper, practice-based mixed methods small-scale study, is to explore the design features of a “dementia friendly” acute ward environment and, staff views on the implications of daily activity engagement for patients with dementia. Design/methodology/approach Eight staff members of the multidisciplinary team who work full time on an acute “dementia friendly” ward completed semi-structured questionnaires. Thematic analysis explored responses to the open-ended questions, and a further environmental assessment tool rated features of the “dementia friendly” ward design, on promoting aspects of well-being in patients with dementia. Findings Six overarching themes were found. These included: contrasting ward colours; clear ward signage; positive staff interaction; memorabilia, and activity rooms and items, had a positive influence on patient interaction, well-being and engagement in daily activities. The audit scores were rated highly for various aspects of the ward design. These included: the ward design promoting patient interaction, well-being, mobility, orientation, continence, eating and drinking and calm and security. Research limitations/implications This practice-based small-scale study highlights the importance that a “dementia friendly” ward environment may have on patient engagement and well-being, from a daily activity perspective. Further research into the key aspects of design that enable meaningful daily activity engagement is required. Practical implications This study supports staff perceived views of the positive influence that “dementia friendly” design may have for patients with dementia. Both the physical design modifications of the ward and staff interaction were highlighted as positively influencing patient well-being, and daily activity engagement. Staff members also felt that they needed to balance the clinical ward priorities, with the contextual requirements of patients with dementia, to establish an effective “dementia friendly” ward. Originality/value The value of this research is the combined consideration of an environmental assessment tool and qualitative interviews with members of the multidisciplinary team.

This paper focuses on the occupational experiences of five men living within a forensic mental health unit over a year. This study used a descriptive qualitative case study methodology to explore the meaning and value placed on daily life (activities, occupations and routines), and how this changed over time. The men’s stories showed a complex picture of their experiences of daily life. This study demonstrated the impact of the environment on the men and the ongoing challenge of the need to balance treatment/therapy with security demands and opportunities. Three interrelated themes were identified: (1) Power and Occupation; (2) Therapy or Punishment; (3) Occupational Opportunities within Restrictions. These findings serve as a reminder to clinical teams to reassess the value of occupations attributed by their patients and the impact of the secure environment, whilst also acknowledging the potential for occupations to have a negative impact on well-being.

A dança circular, que deriva da tradição de danças folclóricas, é praticada em todo o mundo. Este artigo explora os significados que os participantes de danças circulares atribuem a ela. Foram realizadas entrevistas qualitativas com 39 participantes, focalizadores1 e coordenadores de treinamento para focalizadores de danças circulares do Reino Unido. Aplicando-se uma abordagem construtivista da teoria fundamentada em dados, 3 categorias foram desenvolvidas representando, respectivamente, as experiências dos participantes, dos focalizadores e dos coordenadores de treinamento de dança circular. Este artigo aborda, especificamente, a primeira categoria, denominada “Não posso imaginar minha vida sem [as danças circulares]”, relacionada à experiência de 22 dançarinos. De uma perspectiva ocupacional, o estudo revela como os participantes tomam consciência de uma percepção de significado e da satisfação através do envolvimento na dança circular e da potencial contribuição desta ocupação para o bem-estar das pessoas.

Background/Aims: This study considers the feasibility of using Therapy Outcome Measure (TOMs) in a community rehabilitation therapy team working with patients over 65 years of age. Methods: An action research approach was used. Data collection and analysis included completion of the outcome measure scores over a 22-week period through semi-structured individual interviews with the therapy team participants, group reflections and the researcher's reflections. Results: Sixty-seven patients were considered in this study, with 26 patient scores included. Nineteen (73%) of those scored for admission and discharge demonstrated sensitivity, with a difference of one score or more. However, the study participants agreed that the TOMs scales and descriptors did not best describe their patient group. They acknowledged that the study had included a small sample size. Conclusions: TOMs was agreed to be an ‘OK fit’ for community rehabilitation patients rather than a ‘best fit’. It should be used as part of a variety of outcome measures to evidence the multidimensional aspects of this speciality, where patients have complex needs and therefore require more complex interventions. This study also highlights the need for further research with a larger sample size.

Occupational science is of importance to multiple disciplines due to its potential to contribute to understandings of complex social issues. “Occupation”, as a key concept of occupational science, is recognised as being highly complex, making it challenging for students to develop a comprehensive understanding of the concept. Terminology of occupational science literature has been noted at times as using the terms occupation, purposeful activity and activity interchangeably, which further adds to the challenge of teaching the concept. This paper explores evolving definitions of occupation, challenges this evolution has created within education, and the potential use of occupation as a threshold concept. Consideration of a selection of pedagogic methods used in teaching the concept of occupation is briefly explored. The paper concludes with identification of a newly developed occupation-focused teaching tool as a proposed alternative approach to teaching the concept of occupation. The teaching tool was originally developed to teach occupation as a discrete concept, rather than the therapeutic use of occupation as taught in occupational therapy education. The tool is an analogy for occupation, and has utility in supporting the transformation of students’ understanding of the concept of occupation, commensurate to understandings of occupational science.

I am delighted to present the Dr Elizabeth Casson Memorial Lecture at the 41st conference of the newly ‘Royal’ College of Occupational Therapists (RCOT), here at the ICC in Birmingham. Indeed I am especially delighted to be delivering the lecture in Birmingham, as this feels like coming home – I was born and bought up nine miles down the road, in Solihull. I would like to thank my nominees and the RCOT council for giving me this opportunity to present the prestigious Dr Elizabeth Casson Memorial Lecture. No Casson Memorial Lecture should start without a reminder to its namesake, and to the importance of Elizabeth Casson’s work to the profession of occupational therapy in the United Kingdom. She opened the first school of occupational therapy in the United Kingdom (UK) at Dorset House, Clifton, Bristol in 1930. We continue to owe her a lot. While writing and researching this lecture I was struck by the opening sentence of Dr Casson’s paper, published in 1941, in which she details 40 cases treated at the clinic attached to the school: Rehabilitation needs serious attention at present (Casson 1941). I will come back to this important statement later on. But, before I start out, I am going to give you the take home message of my lecture first (e.g. my last slide first): Publish. Publish. Publish.

This article is written in response to the linked editorial by Dr Geraghty about the adaptive Pacing, graded Activity and Cognitive behaviour therapy; a randomised Evaluation (PACE) trial, which we led, implemented and published. The PACE trial compared four treatments for people diagnosed with chronic fatigue syndrome. All participants in the trial received specialist medical care. The trial found that adding cognitive behaviour therapy or graded exercise therapy to specialist medical care was as safe as, and more effective than, adding adaptive pacing therapy or specialist medical care alone. Dr Geraghty has challenged these findings. In this article, we suggest that Dr Geraghty’s views are based on misunderstandings and misrepresentations of the PACE trial; these are corrected.

“Occupational engagement” is a term often used within occupational science and occupational therapy literature. However, it has yet to be clearly and consistently described resulting in a lack of clarity in the use and definition of this term. This paper is derived from a larger piece of research, which used social constructionism to explore occupational engagement for five men living in a secure mental health unit from an occupational science perspective (Morris et al, 2016). This research required the development of a clear description of ‘occupational engagement’. Following an exploration and critical review of the literature, the process of developing a new description of ‘occupational engagement’ is outlined. Occupational engagement cannot be considered in isolation, so within this paper it is positioned within a descriptive framework of values and consequences. The development of the framework returned to the etymology of relevant terms, considering both the value of consequences of occupational experiences. This is the first published holistic description of this term as the framework fully acknowledges the negative as well as positive dimensions of occupation. The paper concludes with the implications of how this new framework could be useful to occupational science.

Background: To establish whether the current training of student sonographers in both academic and clinical settings is sufficient for educating about the dangers of work-related musculoskeletal disorders (WRMSDs). Methods: A dual method of data collection was undertaken. Initially, a focus group was set up, involving a small group of practicing sonographers from a hospital in the United Kingdom, with the results of that survey being used to design a postal survey questionnaire. The questionnaire focused on ergonomics, scanning technique, training in physical techniques, personal general health, risk, stress, and task management. It was sent to seven participating universities across the United Kingdom. Approvals were obtained from the local ethics committees, the hospital Trust, and the academic institution. Results: The focus group highlighted several areas in which improvements could be made in educating sonographers on the reduction of WRMSDs. The questionnaire results indicated that students are being taught about certain aspects of WRMSD prevention by both their university and clinical mentors. Respondents received training on the prevention of WRMSDs: 97% in the university setting and 81% from clinical mentors. Conclusions: Improvements need to be made in terms of educating students to perform muscle-strengthening exercises during the workday; to have a system of reporting injury; to consider personal health, well-being, and stress management in the workplace; and to evaluate the ergonomics of computer workstations.

Introduction: The aims of this exploratory mixed methods study were to explore practice placement educators' perceptions and expectations of pre-registration master's level students on placement and to compare the findings of educators who had previous experience of master's level students with those who had none. Method: Twenty-six educators completed questionnaires and four took part in semi-structured interviews; forty placement reports were reviewed. Findings: The findings show that many educators have higher expectations of master's level students than they do of undergraduate students, due to perceptions of maturity and previous education, life, and work experience. These expectations were contradicted, however, by concerns that master's level students achieve less academic and clinical competence in the shorter time frame for study. Staff with no prior experience at this level lacked confidence in their own abilities to meet the challenge of supporting a master's level student, while staff experienced at this level found many benefits for their own learning as well as for their clinical team. Conclusion: Further education, support, and collaboration with the university could enhance the placement experience for both educators and students and may result in the acquisition of more placement offers. The findings will be used to inform future educator training days as well as widen dissemination of information to all practice placement educators. Further collaboration and effective communication between the university and the educators may promote self-confidence in staff, enhance confidence in student abilities, as well as ensuring that assessment is provided at an appropriate level.

Chronic Fatigue Syndrome, also known as Myalgic Encephalomyelitis (CFS/ME), has a significant impact upon daily functioning. Most recommended treatments aim to alter activity patterns based upon assumptions of activity avoidance. However, as there is limited research on the experience of activity and occupational beliefs in people with CFS/ME, this study took a qualitative approach to understand the meaning of activity in people with this disabling condition.This study applied a social constructivist grounded theory methodology. Semi-structured interviews took place with 14 participants attending a Specialist CFS/ME Service in England.The emergent themes described a premorbid state of constant action with difficulty stopping an activity once it had commenced. When this pattern was interrupted by illness, participants attempted to maintain their previous level of occupational engagement. Negative associations and emotions were described in response to the concept of doing nothing or limited activity. A recurring cycle was reported of increasing activity levels when symptoms improved, followed by post exertional symptoms.Consequently, participants' beliefs about concepts of both activity and inactivity need to be considered within the application of rehabilitation programmes for CFS/ME that aim to modify activity related behaviours.Chronic fatigue syndrome/myalgic encephalomyelitis (CFS/ME) is commonly treated in the UK using activity modification. In this small qualitative study, patients expressed negative feelings and beliefs towards the concept of doing nothing and therefore sought to push their activity levels when this was available, leading to recurring cycles of symptoms and activity. Rehabilitation programmes need to consider how people with CFS/ME engaged with activity and inactivity before the condition and how this may impact upon engagement with activity-based rehabilitation programmes.

PurposeThe purpose of this study is to analyse the effect on clinical practice of auditing doctors, advanced nurse practitioners and pharmacist consultations within an out of hours primary care organisation and the resultant effects this may have on clinical practice and the quality of care provision.Design/methodology/approachThe study utilises a multi method time series case study approach using the results from the Royal College of General Practitioners (RCGP) audit tool analysis, alongside focus group analysis and participant observation.FindingsThe results demonstrate that there is a clear link between implementation of a clinical audit strategy within a wider clinical governance framework and improved standards of all clinician's work. This study also demonstrates how the analysis can inform a definition of quality.Research limitations/implicationsThe definition of quality is limited and is one of the limitations of the study since it is related to out of hours primary care only.Practical implicationsResults may be extrapolated to other care providers both out of hours and in traditional GP practices.Originality/valueThis case study demonstrates how the time series analysis of audit results can assist in assuring commissioners of health services of the quality of the services they appoint.

Chronic fatigue syndrome/myalgic encephalomyelitis (CFS/ME) is a disabling condition that disrupts the normal rhythms and activity patterns of daily life. Although temporal dimensions such as time use, tempo and temporality have an important relationship to occupation there has been limited study of these factors within CFS/ME. This qualitative study explored how people with CFS/ME perceived the relationship between time and occupation through the experience of their illness. A social constructivist approach to grounded theory involving in-depth interviews with 14 participants, recruited through a specialist service in the UK, revealed emerging concepts of accelerating time before illness, with a focus on imminent tasks. During illness actions slowed, but contrasted with the experience for some participants of time disappearing. As participants adjusted to the condition there was a greater focus on being present and consciously slow, as a sense of control within time emerged. These findings suggest that further consideration is given to the broader aspects of time and rhythm within occupational science, evolving from the current clock time perspective to incorporate event time and resynchronisation of occupational balance.

BACKGROUND: Trial findings show cognitive behaviour therapy (CBT) and graded exercise therapy (GET) can be effective treatments for chronic fatigue syndrome, but patients' organisations have reported that these treatments can be harmful and favour pacing and specialist health care. We aimed to assess effectiveness and safety of all four treatments. METHODS: In our parallel-group randomised trial, patients meeting Oxford criteria for chronic fatigue syndrome were recruited from six secondary-care clinics in the UK and randomly allocated by computer-generated sequence to receive specialist medical care (SMC) alone or with adaptive pacing therapy (APT), CBT, or GET. Primary outcomes were fatigue (measured by Chalder fatigue questionnaire score) and physical function (measured by short form-36 subscale score) up to 52 weeks after randomisation, and safety was assessed primarily by recording all serious adverse events, including serious adverse reactions to trial treatments. Primary outcomes were rated by participants, who were necessarily unmasked to treatment assignment; the statistician was masked to treatment assignment for the analysis of primary outcomes. We used longitudinal regression models to compare SMC alone with other treatments, APT with CBT, and APT with GET. The final analysis included all participants for whom we had data for primary outcomes. This trial is registered at http://isrctn.org, number ISRCTN54285094. FINDINGS: We recruited 641 eligible patients, of whom 160 were assigned to the APT group, 161 to the CBT group, 160 to the GET group, and 160 to the SMC-alone group. Compared with SMC alone, mean fatigue scores at 52 weeks were 3·4 (95% CI 1·8 to 5·0) points lower for CBT (p = 0·0001) and 3·2 (1·7 to 4·8) points lower for GET (p = 0·0003), but did not differ for APT (0·7 [-0·9 to 2·3] points lower; p = 0·38). Compared with SMC alone, mean physical function scores were 7·1 (2·0 to 12·1) points higher for CBT (p = 0·0068) and 9·4 (4·4 to 14·4) points higher for GET (p = 0·0005), but did not differ for APT (3·4 [-1·6 to 8·4] points lower; p=0·18). Compared with APT, CBT and GET were associated with less fatigue (CBT p = 0·0027; GET p = 0·0059) and better physical function (CBT p=0·0002; GET p

Purpose In recent years, the use of numeric paging in many medical centers has been largely replaced by 1-way alphanumeric paging. There is currently no research studying the potential for alphanumeric paging to lead to problems in communication. The purpose of this article is to determine whether the use of alphanumeric pagers may lead to potential problems in patient care and/or communication. Methods Alphanumeric pages sent to residents on 3 surgical services at the Medical College of Virginia Hospital were collected over a 3-month period. The pages were classified according to reason for the page, amount of information provided, and follow-up required. Results A total of 52,384 alphanumeric pages were sent to residents on the surgical services over a 3-month period. There were 1037 pages (2.0% of total) that contained patient laboratory results. 11,844 pages (22.6% of total) contained a callback number with no sender information and 6198 (11.8% of total) contained a callback number and sender information. Trauma pages totaled 10,312 (19.7% of total). There were 2636 pages (5.0% of total) that contained identifying information, potentially violating HIPAA regulations. Conclusions The authors have observed a significant number of occurrences in which alphanumeric pages lack sufficient information, do not indicate the urgency of the page, and still require immediate callback by residents. This potentially interrupts patient care and educational activities.

Substantial changes have been made in recent years to the process of obtaining ethical and research governance approval for research projects in the NHS. The advent of the Integrated Research Application System (IRAS) has streamlined the process, providing a single point of entry. Ethical approval gained in one part of the country is now valid throughout the UK. The previous process of gaining research governance approval in NHS Trusts was maligned and it has been overhauled with the introduction of the National Institute of Health Research (NIHR) Coordinated System for gaining NHS Permission. In addition to updating the reader about the new processes around gaining ethical and Trust approval for research within an NHS setting, essential research project documentation needed for submission are discussed. The aspects of a proposal that Ethics Committees and Trust RD small scale unfunded studies and student projects are potentially at risk of being marginalised in the quest for a streamlined ethics and NHS Trust research governance approval process. However, researchers’ familiarity with the approval system should minimise rejection rates and delays.

Introduction: Time has a reciprocal relationship with occupation: each helps to define and give meaning to the other. This paper explores how this interconnection has been embraced within occupational therapy. Method: Literature from a variety of disciplines was critically reviewed, in order to discern how occupational therapy has engaged with the temporal dimensions of occupation since its inception and the relevance of time to current practice. Findings and discussion: Although theoretical discussions demonstrate the importance of aspects of time within occupation, there has been only limited translation of these into occupational therapy practice. Aspects of time use, tempo and temporality are discussed in relation to their application to clinical practice. As the pace of life increases and humanity's relationship with time changes, this presents the profession with both challenges and opportunities. Conclusion: Time is a vital aspect of occupation. Occupational therapists need to return to core values of time awareness, rhythm and balance, because the profession once again needs to find time.

This study was set within the UK inter-professional multi-centre randomized controlled PACE Trial of manual-based therapy (BMC Neurology, 2007, 7: 6). The aim of supervision within ‘the trial’ was to maintain specificity of manual-based therapy, sustain retention of therapists, manage quality control and assurance of the therapy, monitor competence in delivering therapy and enhance professional development. The rationale for the study was that the approach to supervision within the trial appeared to be different from the previous experience of supervision for many of the therapists, especially occupational therapists and physiotherapists. A self-report questionnaire utilizing survey methodology identified differences in therapists’ previous clinical supervision and current supervision experience within the trial. All respondents ( n = 14) indicated that they liked and preferred supervision that was agenda structured, one to one and regular (at least once a month), interspersed with group (team supervision), peer support meetings, review of taped therapy sessions by supervisor and/or peer for feedback and competency rating. In the main this combination of supervision methods had not been previously experienced. This has implications for practice and future therapy research that both therapists and managers will need to consider. In particular the implementation of group supervision and review of audio taped therapy sessions for analysis, review and feedback in practice to enhance learning and client care.

The aim of this study was to investigate the experiences of physiotherapists engaged in clinical supervision. It aimed to indicate whether physiotherapists understood the purpose of clinical supervision and whether the term affected their understanding and use of the process. The study is set in a physiotherapy department in an acute District General Hospital. Sixteen potential participants were contacted, eight qualified physiotherapists consented to take part. The study adopted a qualitative approach using semi-structured audio-taped interviews which were transcribed prior to content analysis. A key finding was that the physiotherapists did not have a clear understanding of the purpose of clinical supervision in relation to other support available, for example annual appraisal and rotational reviews. Tensions arose for those who associated clinical supervision with line management and appraisal. Clinical supervision was most effective for physiotherapists who had selected their own supervisor, who were clear about its purpose and who were able to make the link between clinical supervision, continuing professional development and reflective practice. The study concludes that the purpose of clinical supervision in relation to other support needs to be clarified to help physiotherapists use the process more effectively and that clinical supervisors should receive support and training in this important role. Clinical supervision is used for different purposes at different stages of a career and can enhance the development of confident practitioners. The term ‘clinical supervision’ is inappropriate for physiotherapists due to its lack of clarity. ‘Peer Support and Development’ is an example of an alternative title that may better describe the purpose of the activity.

The introduction of a new development review process, the Knowledge and Skills Framework (KSF), has placed a greater demand on occupational therapists within the health service to be more accountable for practice. It has been proposed that the KSF may provide a useful structure for supervision in order to ensure continual development. Therefore, this literature review looked at the appropriateness of addressing both clinical and managerial issues within the supervisory process.The results indicate that despite many professions being unsure of how best to deliver supervision, there is a common understanding that a structure combining clinical and managerial supervision, such as the KSF, may be useful. It is, however, recommended that the roles of appraiser and supervisor remain separate, because many researchers found conflict within this duality of role as having an impact upon the effectiveness of supervision. It is also recommended that further research be undertaken in order to evaluate formally the effectiveness of integrating the KSF into supervision.

The recovery of individuals with very severe chronic fatigue syndrome/ myalgic encephalomyelitis (CFS/ME) is possible with successful multidisciplinary management. This case vignette aims to highlight the beneficial outcome of using occupational therapy lifestyle management and the Canadian Occupational Performance Measure to identify perceived problems in occupational performance and indicate change. The current management strategies in CFS/ME are discussed briefly and the challenges of the management of severe CFS/ME are described, indicating a need for a supportive team and specialist inpatient services. In 2003, the Department of Health released funds in England to develop more widely accessible CFS/ME services. This case study illustrates a positive outcome for one individual with severe CFS/ME, following admission to a specialist inpatient facility. It is hoped that it may aid other therapists working with and developing services for people with severe presentations of CFS/ME.

This work was commissioned by a charity, the Physical Disability and Sensory Impairment Forum, owing to local parental concerns relating to the assessment for and provision of mobility equipment. The project was set up as a preliminary investigation to consider those concerns. A literature review was carried out in order to establish current practice in the National Health Service wheelchair service in England, the role of the wheelchair in children's mobility, the wheelchair and seating needs of children and the met and unmet need. A questionnaire was distributed to children and their parents to gain their views. The response rate was disappointingly poor and, therefore, the results are not presented. However, the full report is available from the author.

Introduction It is important for healthcare professionals to understand the reality of living with diabetes in order to better engage and enable people to self-manage. The purpose of this research was thus a preliminary exploration of the lived experience of diabetes. Method This qualitative study involved seven people with a diagnosis of type 1, type 2 or pre-diabetes. Data was collected via semi-structured interviews and analysed using a phenomenological approach including the use of metaphor. Findings were shared with participants using a felted metaphor of charting a course of health and wellbeing through a choppy sea. Findings: Themes explored within the elements of the metaphor included the boat (self-identity, control, balance, compliance and empowerment, emotions), the sea (physical and social environment, lifestyle, life events), the course (information gathering, change, self-action) and the boatyard (relationships with healthcare providers). Conclusion For those with type 1, type 2 and pre-diabetes, the elements of charting a course of health and wellbeing through a choppy sea are very much focused on the person in their own context, impacted by their environment, life stage, occupations and attitudes to diabetes self-management, all of which fall within the remit of occupational therapy.

It has been stated that, although most chronic fatigue syndrome (CFS) patients can be treated in primary care and that cognitive behaviour therapy and prescribed, graded aerobic exercise appear to be promising in outpatient management, a minority of patients will require inpatient care (Royal Colleges of Physicians, General Practitioners and Psychiatrists 1996). To date, little has been written on the need for and impact of an inpatient approach for patients with CFS. This study builds on previous work to show how patients with complex CFS responded to a specifically designed occupational therapy inpatient programme, using the principles of cognitive behaviour therapy and graded activity. A quasi-experimental study was carried out using current inpatients with those on the waiting list as a comparison. At 6 months following discharge, a significant difference between the groups in terms of symptoms and level of ability was not demonstrated. However, a significant effect was shown in patients' perceived health, length of time tired and management of the illness. Thirty-one (72%) of the inpatient group, compared with 10 (53%) of the comparison group, stated that they felt better than the previous year. Thirty-one (72%) of the inpatient group, compared with 7 (37%) of the comparison group, indicated better management of their illness. These findings give some evidence of the need for an inpatient CFS management programme for specific patients with complex CFS.

Time and occupation are intrinsically linked, as time defines occupation and occupation gives meaning to time. This article examines the dynamic relationship between time and occupation. Occupational concepts such as engagement, presence and balance are explored in the context of this relationship. A framework is proposed for synthesising existing occupational concepts and temporal perspectives. Within the framework we conceptualise the action of synchronisation as the harmonious co-ordination of time and occupation that enhances well-being. The proposed model integrates the additional dimensions of time, namely tempo and temporality, and reintroduces the importance of rhythm, physiological cycles and human consciousness within the experience of time. The relevance of synchronisation to the human experience of occupation and the essence of doing, being and becoming are discussed.

Background: Chronic fatigue syndrome/myalgic encephalomyelitis (CFS/ME), in its most severe clinical presentation, can result in patients becoming housebound and bedbound so unable to access most available specialist services. This presents particular clinical risks and treatment needs for which the National Institute for Health and Care Excellence (NICE) advises specialist medical care and monitoring. The extent of National Health Service (NHS) specialist provision in England for severe CFS/ME is currently unknown. Objectives: To establish the current NHS provision for patients with severe CFS/ME in England. Setting: and participants All 49 English NHS specialist CFS/ME adult services in England, in 2013. Method: Cross-sectional survey by email questionnaire. Primary outcome measures: Adherence to NICE guidelines for severe CFS/ME. Results: All 49 services replied (100%). 33% (16/49) of specialist CFS/ME services provided no service for housebound patients. 55% (27/49) services did treat patients with severe CFS/ME and their interventions followed the NICE guidelines. The remaining services (12%, 6/49) offered occasional or minimal support where funding allowed. There was one NHS unit providing specialist inpatient CFS/ME provision in England. Conclusions: Study findings highlight substantial variation in access to specialist care for patients with severe presentation of CFS/ME. Where treatment was provided, this appeared to comply with NICE recommendations for this patient group.

The Chronic Fatigue Syndrome (CFS) Service within the Essex Neuroscience's Centre has been developing since 1990. The service was established as a comprehensive diagnostic and management service in July 1994. From May 1990 to March 1998, 318 patients with CFS were admitted into the programme and since November 1994, 1189 patients seen as outpatients. A previous survey indicated a positive perceived change in level of ability following the inpatient programme for all levels of CFS from mild to very severe. Of those admitted since 1990, 14% (43/318) were severely affected (extremely restricted mobility) and 9% (29/318) very severely affected (totally bedbound). Most studies on CFS do not include the more severe expressions of the disease; therefore, this descriptive paper aims to show the perceived outcome of these more severely affected patients following the inpatient programme. In particular, the eventual diagnosis, the specific approach to treatment and management and grading of patients will be described and the potential influence of the programme presented. The patients not diagnosed with CFS on discharge appeared to do least well at follow up.

The cause of Chronic Fatigue Syndrome (CFS) is as yet undetermined; therefore, precise definitions for diagnosis and research have been developed. The most accepted diagnostic criteria are detailed below. It has been suggested that there are 150 000 cases of CFS in the UK, with a 2:1 predominance of females to males, and that prognosis without treatment is poor. The patterns of illness seen in CFS are identified and the development of an occupational therapy programme for the management of CFS is described.

This paper describes chronic fatigue syndrome (CFS) and methods of management in a National Health Service Neurological Sciences Facility. A retrospective postal survey was carried out to determine the perceived level of ability of CFS inpatients 6 months following discharge from an inpatient programme of CFS treatment and management. One hundred and ninety-nine patients were admitted into the CFS inpatient programme, aged 16–68 years and with a mean age of 39 years. A specifically designed self-report questionnaire was used to ascertain duration of fatigue, change in work pattern and current level of ability (6 months following the inpatient programme). One hundred and nine patients fulfilled the Centre for Disease Control 1994 criteria for CFS. At 6 months post-discharge, 89 (82%) patients had a perceived increase in level of ability compared with prior to their admission to hospital. The duration of symptoms appeared to affect outcome. A further controlled trial using published rating scales is currently under way to substantiate the findings.

Background: The delivery of services to those who are house bound or those that are unable to access transport, especially within a rural locality were identified as issues by the North Cumbria Chronic Fatigue Syndrome (CFS/ME) team. Technology that would enable the team to work with clients in their own home; without the resource implications of providing a domiciliary-based service was explored. The rationale was to provide a service to clients that have difficulty accessing clinics, particularly the severely affected and to create a more inclusive ‘closer to home’ service provision. The investigation was divided into four phases:\ud • Systematic review of the literature\ud • Scoping exercise via a questionnaire to all current clients\ud • Feasibility and acceptability pilot with 5 clients\ud • Development of larger cohort observational study\ud \ud Results: Phases 1–3 are complete. The review identified that in-home desktop video-conferencing is likely to be well received by patients and to be equivalent to in-person therapy in terms of clinical outcomes. Cost effectiveness of systems was shown to be reliant on initial outlay and amount of usage, and that such services could result in significant savings in time and money for patients [1]. The scoping exercise identified that there was a need for tele-rehabilitation to address the difficulties this population face in travelling to appointments, and that it was feasible as most people already had access to computers with broadband internet connection. The pilot study showed that PC-based video-conferencing in a real-life situation, linking people’s homes to a clinical base, is technically feasible and resulted in positive feedback from clients and the therapist. Technology functioned effectively, facilitating satisfactory interactions between clients and therapist. Technical problems were judged by clients and therapist not to interfere with the interaction. An implementation guide including tips for best practice and troubleshooting has been produced. This project to date has had an impact on the service and the patients. The interventions delivered by video-conferencing have resulted in high satisfaction levels for patients and have produced similar clinical outcomes to in-person delivery. This mode of delivery is being used for both consultant review sessions and patient to therapist interactions. The use of video-conferencing is now embedded into the service and offered to patients when travel or level of disability could affect attendance due to difficulties with transport or level of symptoms.\ud \ud Conclusions: It is feasible to use video-conferencing as a means of delivering interventions for people with chronic fatigue in rural communities. Further investigation is required to understand the differences between clinic-based and video-conferencing interventions over time.

The combined approach of graded activity and cognitive behaviour therapy in the treatment and management of chronic fatigue syndrome within an inpatient NHS neurology ward is discussed. A retrospective medical audit of 28 patients indicated that 57% had an increased activity level six months following discharge. Controlled clinical studies are required to examine the benefit and effect of the combined treatment approach discussed.

We conducted a systematic review of literature relating to videoconferencing in therapeutic interventions for chronic conditions. Two hundred articles were reviewed in detail, 35 of which were relevant to the study. Of these, eight were randomized controlled trials (RCTs) and the remainder were service evaluations, pilot studies and case studies. Two major themes emerged, relating specifically to videoconferencing: clinical outcomes and patient satisfaction. There were 14 studies which measured clinical outcomes of interventions for chronic conditions delivered by videoconferencing. A range of evidence, including four RCTs of high quality, indicates that interventions for a variety of conditions, including psychological and physical, delivered by videoconferencing produce similar outcomes to treatment delivered in-person. Evidence suggests that levels of patient satisfaction with telerehabilitation are high and that the formation of a good therapeutic alliance is possible. Several papers reported that clinical staff showed lower levels of satisfaction in using telerehabilitation than patients. It is feasible to use videoconferencing as a means of delivering therapeutic interventions for people with chronic conditions in rural communities.

This preliminary study explores the everyday needs and requirements of patients with motor neurone disease (MND) and indicates similarities and differences between the patient's viewpoint, that of their main carer and that of their occupational therapist (OT). The study highlights differences between the three subject groups. The MND subjects' views centred on physical needs, the carers on the emotional and psychological impact of MND and caring, while that of the OTs focused on the co-ordination of physical and psychological aspects of MND, both for patient and carer. The primary need agreed upon by all subject groups was the essential role of the carer in the management of MND.

The Model for End Stage Liver Disease (MELD) score is a mortality predictor in patients awaiting liver transplantation. We evaluated the MELD score's ability to predict morbidity for patients with cirrhosis undergoing laparoscopic cholecystectomy. From March 1991 to February 2004, data of all patients undergoing laparoscopic cholecystectomy were prospectively collected. Data of patients with liver cirrhosis were reviewed. The MELD and Child scores were correlated with outcome variables. Of 7859 patients undergoing laparoscopic cholecystectomy, 99 patients (1.3%) exhibited liver cirrhosis, 44 women and 55 men. The mean age was 55 years (range, 28 to 92 years). The mortality rate was 6.3 per cent, morbidity rate 18 per cent, and conversion rate 11 per cent. Laboratory values on 55 patients were available to calculate MELD scores. The mean MELD score was 11 (range, 6 to 23). There was no significant variation in MELD scores with gender ( P = 0.61) or cirrhosis etiology, alcoholic and nonalcoholic ( P = 0.52). MELD and Child's score correlated well ( P < 0.001); however, the risk of complication was not related to the MELD ( P = 0.94) or Child-Pugh-Turcotte score ( P = 0.26). Morbidity for patients with liver cirrhosis undergoing laparoscopic cholecystectomy remains high. The MELD score is useful for transplant risk stratification for but requires further investigation regarding morbidity prediction for laparoscopic cholecystectomy.

Wilson disease is an inherited autosomal recessive disorder of hepatic copper metabolism leading to copper accumulation in hepatocytes and in extrahepatic organs such as the brain and the cornea. Originally Wilson disease was described as a neurodegerative disorder associated with cirrhosis of the liver. Later, Wilson disease was observed in children and adolescents presenting with acute or chronic liver disease without any neurologic symptoms. While diagnosis of neurologic Wilson disease is straightforward, it may be quite difficult in non-neurologic cases. Up to now, no single diagnostic test can exclude or confirm Wilson disease with 100% certainty. In 1993, the gene responsible for Wilson disease was cloned and localized on chromosome 13q14.3 (MIM277900) (1, 2). The Wilson disease gene ATP7B encodes a P-type ATPase. More than 200 disease causing mutations of this gene have been described so far (3). Most of these mutations occur in single families, only a few are more frequent (like H1069Q, 3400delC and 2299insC in Caucasian (4-6) or R778L in Japanese (7), Chinese and Korean patients). Studies of phenotype-genotype relations are hampered by the lack of standard diagnostic criteria and phenotypic classifications. To overcome this problem, a working party discussed these problems in depth at the 8th International Meeting on Wilson disease and Menkes disease in Leipzig/Germany (April 16-18, 2001). After the meeting, a preliminary draft of a consensus report was mailed to all active participants and their comments were incorporated in the final text.

It is an honour to act as guest editors for this special issue of the British Journal of Occupational Therapy (BJOT), containing current research and concerns about occupational performance from Australia, Chile, Ireland, the United Kingdom, the United States, and Japan. Occupational performance, the ‘doing of meaningful activities, tasks, and roles through complex interaction between the person and the environment’ (Baum et al 2011), is important for occupational therapists. It describes our unique role and people’s ability to engage in meaningful activities, tasks, and roles that support both their participation in daily life and their sense of wellbeing (Christiansen and Baum 2005).

What does good dental nurse training look like? asks Diane Cox, a dental nurse and tutor from Absolute Dental in Devon.

Following concern about how to support pupils with Chronic Fatigue Syndrome (CFS), the first author (an educational psychologist) attended a two-day course run by Havering Hospitals Trust Chronic Fatigue Syndrome Diagnostic and Management Service. This article seeks to describe the approach used, and investigate the ways in which EPs can work with pupils, while supporting and liaising with the medical team.

Three members of a family with normal parents had a common constellation of findings that included absent corpus callosum and recurrent bacterial infections. The older male and female siblings both died from infection at an early age. The patient’s CBC was significant for elevated numbers of monocytes that were large and vacuolated. Her T- and B-cell function was normal. These preliminary findings suggested a defect in innate immunity. Evaluation of the patient’s peripheral blood monocytes by flow cytometry showed normal size and maturity. Phagocytosis and activation of peripheral blood derived macrophages by cytokines were also similar to controls. In contrast, the patient’s cultured macrophages were significantly more spread than those from normal individuals and contained a disordered actin cytoskeleton when cultured on fibronectin. The ability of the macrophage to transmigrate across an endothelial cell barrier was impaired. However examination by time-lapse videomicroscopy showed that the mutant macrophages had increased protrusional activity and movement. This is the first report describing a genetic macrophage motility disorder that results in an increased susceptibility to infection.

A research project was carried out at St George's Hospital to look at the role and effectiveness of occupational therapy with cardiothoracic patients. It was found that, once the service was in operation, a high demand existed and appropriate referrals were seen. The results indicate that treatment was effective.

Objectives To describe the development, delivery and quality control of three manual-based therapies as given in an inter-professional multi-centre randomized controlled trial of therapies for chronic fatigue syndrome (CFS). Methods Experienced therapy leaders were recruited. These therapy leaders then developed the treatments and therapy manuals, piloted them, and planned training and supervision. Appropriately-qualified therapists were recruited to deliver each therapy and trained in the specific therapy philosophy, model and delivery. Training and supervision was face-to-face and by telephone, and included reviewing audio recordings of therapy sessions. Results At the end of the trial, the therapists delivering all three trial therapies were similarly highly rated as adhering well to their manuals and scored similarly and highly on therapeutic alliance with patients and therapy differentiation. Conclusions High-quality delivery of therapy can be achieved if there is an experienced therapy lead, if therapy manuals have been piloted, and if therapists are well trained and supervised, including the review of recorded treatment sessions. Routine clinical practice could benefit from the implementation of these procedures.