Search

Exercise is important for people with Parkinson's (PwP), with high-intensity interval training (HIIT) proposed as a feasible and effective exercise modality. However, no literature synthesis for PwP has been undertaken.To evaluate the feasibility, safety, physiological and clinical effects of HIIT for PwP.Systematic searches of Medline, Embase, CINAHL, Web of Science, and Google Scholar were undertaken. Studies that included ≥ 2 weeks of HIIT for PwP and reported sufficient detail for full quality assessment were eligible. Quality was assessed with the TESTEX scale or the Downs and Black tool according to study design. Feasibility and safety data, physiological and clinical outcomes were extracted. Meta-analyses explored the pooled effects of HIIT on VOEleven articles were identified (seven controlled/comparator studies and four single group) including 117 HIIT participants predominantly of mild-to-moderate disease severity. HIIT programmes were professionally supervised and between 6 weeks and 24 months. Overall, study quality was deemed to be moderate to good. Following screening, nine studies reported 90-100% programme completion; however, only one was 12 weeks in duration. Adverse events were uncommon. HIIT improved VOUp to 12 weeks of supervised HIIT appears to be feasible and safe for some people with mild-to-moderate disease severity. HIIT improves cardiorespiratory fitness and may increase BDNF and improve motor symptoms in PwP. Future studies should explore safe ways to facilitate access and long-term adherence.

High-intensity interval training (HIIT) is useful and feasible for some people with Parkinson’s (PwP), although long-term adherence may be problematic. If practical, undertaking HIIT in the home setting could be a way to encourage continued participation. However, no home-based HIIT programme has been developed for this population. Therefore, the objectives of this study were to co-create a feasible, accessible, and safe home-based HIIT programme for PwP, including intervention components and logic model. This supports the longer term aim to assess the practicality and utility of home-based HIIT for PwP. The study included three stages. Firstly, an initial HIIT programme and logic model proposal was developed based on existing evidence. This was refined through an iterative, co-creative process of focus groups, exercise testing and interviews involving end-users and relevant stakeholders. Finally, a draft intervention was produced with further co-creator input. During the iterative process, five focus groups, 10 exercise testing sessions and 10 post exercise interviews were undertaken, involving academic researchers, 6 PwP, one family member and two clinicians. These co-creators developed HIIT-Home4Parkinson’s (HH4P), a 12-week thrice weekly home-based HIIT programme for PwP based on adaptability, individualisation, and remote support. Despite methodological limitations within the development process, the co-created HH4P programme could be feasible, safe, and useful for PwP. A feasibility study should now be undertaken to address remaining uncertainties prior to a full trial.

Telerehabilitation has increasingly been used since the COVID-19 pandemic but with limited guidance available on undertaking physical assessments using remote methods. We aimed to provide such guidance by developing a Telerehab Toolkit, an online information and training resource for practitioners, patients, and carers on telerehabilitation for people with physical disabilities and movement impairment.Development and evaluation of the toolkit were informed by the Knowledge to Action framework and took place iteratively in two phases-knowledge creation and action. Information was collated from various sources including literature review, online survey, service evaluation, and focus group discussions. The toolkit has been evaluated using think-aloud interviews, e-mail and social media feedback from users, and analytics data on user engagement with the website.The Telerehab Toolkit focuses on remote physical assessments, and contains information on technology, digital skills, remote assessment tools, information governance, and safety for telerehabilitation. Resources include top tips from practitioners and patients, how-to guides, checklists, videos, and links to evidence.The Telerehab Toolkit has been well-received by practitioners, healthcare students, patients, and carers, is being disseminated widely, and is freely available (www.plymouth.ac.uk/research/telerehab). IMPLICATIONS FOR REHABILITATIONTelerehabilitation has been increasingly used since the COVID-19 pandemic, but with limited guidance and training for practitioners on undertaking safe and effective remote physical assessments.The Telerehab Toolkit has been developed iteratively using the Knowledge to Action framework; it is a free online resource for practitioners and patients with specific guidance on telerehabilitation for physical disabilities and movement impairment.It is anticipated that the resource will help to improve the knowledge, skills, and confidence of the current and future rehabilitation workforce.

Rationale, Aims and Objectives: Telerehabilitation was used to ensure continued provision of care during the COVID-19 pandemic, but there was a lack of guidance on how to use it safely and effectively for people with physical disabilities and movement impairment. In this service evaluation, we aimed to collate information on practitioner and patient experiences, challenges and facilitators, and examples of best practice to inform the development of an online toolkit and training package. Methods: Guided discussions were carried out with 44 practitioners, 7 patients and 2 carers from five health and social care organisations in South West England, and analysed thematically.Results: Practitioners and patients had positive experiences of telerehabilitation and were optimistic about its future use. Recognized benefits for people with physical disabilities included greater flexibility, reduced travel and fatigue, having appointments in a familiar environment and ease of involving family members. Challenges encountered were: technological (usability issues, access to technology and digital skills); difficulties seeing or hearing patients; the lack of ‘hands-on’ care; and safety concerns. Facilitators were supported by colleagues or digital champions, and family members or carers who could assist patients during their appointments. Key themes in best practice were: person-centred and tailored care; clear and open communication and observation and preparation and planning. Practitioners shared tips for remote physical assessments; for example, making use of patient-reported outcomes, and asking patients to wear bright and contrasting coloured clothing to make it easier to see movement. Conclusion: Telerehabilitation holds promise in health and social care, but it is necessary to share good practice to ensure it is safe, effective and accessible. We collated information and recommendations that informed the content of the Telerehab Toolkit (https://www.plymouth.ac.uk/research/telerehab), a practical resource for practitioners, patients and carers, with a focus on remote assessment and management of physical disabilities and movement impairment.

Falls are highly prevalent in people with multiple sclerosis (MS) and result in a range of negative consequences, such as injury, activity curtailment, reduced quality of life, and increased need for care and time off work. This narrative review aims to summarize key literature and to discuss future work needed in the area of fall prevention for people with MS. The incidence of falls in people with MS is estimated to be more than 50%, similar to that in adults older than 80 years. The consequences of falls are considerable because rate of injury is high, and fear of falling and low self-efficacy are significant problems that lead to activity curtailment. A wide range of physiological, personal, and environmental factors have been highlighted as potential risk factors and predictors of falls. Falls are individual and multifactorial, and, hence, approaches to interventions will likely need to adopt a multifactorial approach. However, the literature to date has largely focused on exercise-based interventions, with newer, more comprehensive interventions that use both education and exercise showing promising results. Several gaps in knowledge of falls in MS remain, in particular the lack of standardized definitions and outcome measures, to enable data pooling and comparison. Moving forward, the involvement of people with MS in the design and evaluation of programs is essential, as are approaches to intervention development that consider implementation from the outset.

OBJECTIVE The objective of this review was to summarize the best available evidence regarding the effectiveness of non-pharmacological interventions to treat orthostatic hypotension (OH) in elderly people and people with a neurological condition. INTRODUCTION Orthostatic hypotension is common in elderly people and people with a neurological condition and can interfere with or limit rehabilitation. Non-pharmacological interventions to treat OH could allow for longer and earlier mobilization, which is recommended in national clinical guidelines for rehabilitation in the acute or sub-acute phase following stroke or other neurological conditions. INCLUSION CRITERIA The review considered people aged 50 years and older, and people aged 18 years and elderly people with a neurological condition. Non-pharmacological interventions to treat OH included compression garments, neuromuscular stimulation, physical counter-maneuvers, aerobic or resistance exercises, sleeping with head tilted up, increasing fluid and salt intake, and timing and size of meals. The comparator was usual care, no intervention, pharmacological interventions, or other non-pharmacological interventions. Outcome measures included systolic blood pressure, diastolic blood pressure, heart rate, cerebral blood flow, observed/perceived symptoms, duration of standing or sitting in minutes, tolerance of therapy, functional ability, and adverse events/effects. METHODS Databases for published and unpublished studies available in English up to April 2018 with no lower date limit were searched. Critical appraisal was conducted using standardized instruments from JBI. Data were extracted using standardized tools designed for quantitative studies. Where appropriate, studies were included in a meta-analysis; otherwise, data were presented in a narrative form due to heterogeneity. RESULTS Forty-three studies - a combination of randomized controlled trials (n = 13), quasi-experimental studies (n = 28), a case control study (n = 1), and a case report (n = 1) - with 1069 participants were included. Meta-analyses of three interventions (resistance exercise, electrical stimulation, and lower limb compression bandaging) showed no significant effect of these interventions. Results from individual studies indicated physical maneuvers such as leg crossing, leg muscle pumping/contractions, and bending forward improved orthostatic hypotension. Abdominal compression improved OH. Sleeping with head up in combination with pharmacological treatment was more effective than sleeping with head up alone. Eating smaller, more frequent meals was effective. Drinking 480 mL of water increased blood pressure. CONCLUSIONS The review found mixed results for the effectiveness of non-pharmacological interventions to treat OH in people aged 50 years and older, and people with a neurological condition. There are several non-pharmacological interventions that may be effective in treating OH, but not all have resulted in clinically meaningful changes in outcome. Some may not be suitable for people with moderate to severe disability; therefore, it is important for clinicians to consider the patient's abilities and impairments when considering which non-pharmacological interventions to implement.

UNSTRUCTURED These are authors' responses to peer review of ms#30516.

ObjectiveTo identify the available guidance and training to implement telerehabilitation movement assessments for people (adults and children) with a physical disability, including those recovering from COVID-19.DesignRapid scoping review.Included sources and articlesPubMed, CINAHL, PsychInfo, Cochrane, Embase, Web of Science, PEDro, UK Health Forum, WHO, National Archives and NHS England were searched using the participant–concept–context framework from 2015 to August 2020. Primary studies that recruited individuals with physical disabilities and guidance documents aimed at providers to implement movement-related telerehabilitation were included.Results23 articles (11 primary research studies, 3 systematic reviews and 9 guidance documents) were included out of 7857 that were identified from the literature search. Two main issues were found: (1) telerehabilitation guidance (from both research studies and guidance documents) was not specific to movement-related assessment and (2) most primary research studies provided neither guidance nor training of movement-specific assessment to practitioners. Of the COVID-19 related guidance, two articles reported COVID-19 management that only referred to identifying COVID-19 status without references to specific movement-related guidance.ConclusionsTelerehabilitation guidance and training have existed pre-COVID-19, yet the lack of specific movement-related information and provider support is surprising. This gap must be addressed to optimise effective implementation of remote assessments for those with physical disabilities.Review registrationOpen Science Framework: osf.io/vm6sp.

UNSTRUCTURED These are author responses to peer review.

Purpose: To gain insight into the experiences of, and potential solutions to, social isolation amongst severely impaired people with multiple sclerosis.Methods: A phenomenological research approach...

BACKGROUND Telerehabilitation is a feasible and potentially effective alternative to face-to-face rehabilitation. However, specific guidance, training, and support for practitioners who undertake remote assessments in people with physical disabilities and movement impairment are limited. OBJECTIVE The aims of this survey of United Kingdom–based health and social care practitioners were to explore experiences, assess training needs, and collate ideas on best practices in telerehabilitation for physical disabilities and movement impairment. The aim will be to use the findings to inform a practical tool kit and training package for telerehabilitation use. METHODS UK rehabilitation practitioners were invited to complete an online questionnaire from November to December 2020. Opportunity and snowball sampling were used to recruit participants from professional and educational networks, special interest groups, and via social media. Closed questionnaire items were analyzed using descriptive statistics. Qualitative inductive analysis using NVivo was used for open responses. RESULTS There were 247 respondents, of which 177 (72%) were physiotherapists and occupational therapists. Most (n=207, 84%) had used video-based consultations (typically supported by telephone and email), and the use of this method had increased in frequency since the COVID-19 pandemic. Practitioners perceived telerehabilitation positively overall and recognized benefits for patients including a reduced infection risk, convenience and flexibility, and reduced travel and fatigue. Common obstacles were technology related (eg, internet connection), practical (eg, difficulty positioning the camera), patient related (eg, health status), practitioner related (eg, lack of technical skills), and organizational (eg, lack of access to technology). Support from family members or carers was a major facilitator for successful remote consultations. Of the 207 respondents who had used video-based consultations, 103 (50%) had assessed physical impairments using this method, 107 (52%) had assessed physical function, and 121 (59%) had used patient-reported outcome measures. Although practitioners generally felt confident in delivering video-based consultations, they felt less proficient in undertaking remote physical assessments, expressing concerns about validity, reliability, and safety. Only 46 of the 247 (19%) respondents had received any training in telerehabilitation or video consultations, and some felt they were “feeling their way in the dark.” Practitioners desired training and guidance on physical assessment tools suitable for remote use, when to use video-based consultations or alternative methods, governance issues, digital platforms, and signposting to digital skills training for themselves and their patients. CONCLUSIONS In response to the COVID-19 pandemic, practitioners rapidly adopted telerehabilitation for people with physical disabilities and movement impairment. However, there are technical, practical, and organizational obstacles to overcome, and a clear need for improved guidance and training in remote physical assessments. The findings of this survey will inform the development of a tool kit of resources and a training package for the current and future workforce in telerehabilitation.

BACKGROUND Understanding and assessing patients’ body movements is essential for physical rehabilitation but is challenging in video consultations, as clinicians are frequently unable to see the whole patient or observe the patient as they perform specific movements. OBJECTIVE The objective of this exploratory study was to assess the use of readily available technologies that would enable remote assessment of patient movement as part of a video consultation. METHODS We reviewed the literature and available technologies and chose four technologies (Kubi and Pivo desktop robots, Facebook Portal TV, wide-angle webcam), in addition to help from a friend or a simple mobile phone holder, to assist video consultations. We used 5 standard assessments (sit-to-stand, timed “Up & Go,” Berg Balance Test, ankle range of motion, shoulder range of motion) as the “challenge” for the technology. We developed an evaluation framework of 6 items: efficacy, cost, delivery, patient setup, clinician training and guidance, and safety. The coauthors, including 10 physiotherapists, then took the roles of clinician and patient to explore 7 combinations of 5 technologies. Subsequently, we applied our findings to hypothetical patients based on the researchers’ family members and clinical experience. RESULTS Kubi, which allowed the clinician to remotely control the patient’s device, was useful for repositioning the tablet camera to gain a better view of the patient’s body parts but not for tracking movement. Facebook Portal TV was useful, but only for upper body movement, as it functions based on face tracking. Both Pivo, with automated full body tracking using a mobile phone, and the wide-angle webcam for a laptop or desktop computer show promise. Simple solutions such as having a friend operate a mobile phone and use of a mobile phone holder also have potential. The setup of these technologies will require better instructions than are currently available from suppliers, and successful use will depend on the technology readiness of patients and, to some degree, of clinicians. CONCLUSIONS Technologies that may enable clinicians to assess movement remotely as part of video consultations depend on the interplay of technology readiness, the patient’s clinical conditions, and social support. The most promising off-the-shelf approaches seem to be use of wide-angle webcams, Pivo, help from a friend, or a simple mobile phone holder. Collaborative work between patients and clinicians is needed to develop and trial technological solutions to support video consultations assessing movement.

Background Balance, mobility impairments and falls are problematic for people with multiple sclerosis (MS). The “Balance Right in MS (BRiMS)” intervention, a 13-week home and group-based exercise and education programme, aims to improve balance and minimise falls. This study aimed to evaluate the feasibility of undertaking a multi-centre randomised controlled trial and to collect the necessary data to design a definitive trial. Methods This randomised controlled feasibility study recruited from four United Kingdom NHS clinical neurology services. Patients ≥ 18 years with secondary progressive MS (Expanded Disability Status Scale 4 to 7) reporting more than two falls in the preceding 6 months were recruited. Participants were block-randomised to either a manualised 13-week education and exercise programme (BRiMS) plus usual care, or usual care alone. Feasibility assessment evaluated recruitment and retention rates, adherence to group assignment and data completeness. Proposed outcomes for the definitive trial (including impact of MS, mobility, quality of life and falls) and economic data were collected at baseline, 13 and 27 weeks, and participants completed daily paper falls diaries. Results Fifty-six participants (mean age 59.7 years, 66% female, median EDSS 6.0) were recruited in 5 months; 30 randomised to the intervention group. Ten (18%) participants withdrew, 7 from the intervention group. Two additional participants were lost to follow up at the final assessment point. Completion rates were > 98% for all outcomes apart from the falls diary (return rate 62%). After adjusting for baseline score, mean intervention—usual care between-group differences for the potential primary outcomes at week 27 were MS Walking Scale-12v2: − 7.7 (95% confidence interval [CI] − 17.2 to 1.8) and MS Impact Scale-29v2: physical 0.6 (CI − 7.8 to 9), psychological − 0.4 (CI − 9.9 to 9). In total, 715 falls were reported, rate ratio (intervention:usual care) for falls 0.81 (0.41 to 2.26) and injurious falls 0.44 (0.41 to 2.23). Conclusions Procedures were practical, and retention, programme engagement and outcome completion rates satisfied a priori progression criteria. Challenges were experienced in completion and return of daily falls diaries. Refinement of methods for reporting falls is therefore required, but we consider a full trial to be feasible. Trial registration ISRCTN13587999 Date of registration: 29 September 2016

The genetic engineering method CRISPR has been touted as an efficient, inexpensive, easily used, and targeted genetic modification technology that is widely suggested as having the potential to solve many of the problems facing agriculture now and in the future. Like all new technologies, however, it is not without challenges. One of the most difficult challenges to anticipate and detect is gene targets that are inaccessible due to the chromatin state at their specific location. There is currently no way to predict this during the process of designing a sgRNA target, and the only way to detect this issue before spending time and resources on full transformations is to test the cleavage ability of the sgRNA in vivo. In wheat, this is possible using protoplast isolation and PEG transformation with Cas9 ribonucleoprotein complexes. Therefore, we have developed a streamlined protocol for testing the accessibility of sgRNA targets in wheat. The first steps involve digesting wheat leaf tissue in an enzymatic solution and then isolating viable protoplasts using filters and a sucrose gradient. The protoplasts are then transformed using Cas9 ribonucleoprotein complexes via PEG-mediated transformation. DNA is isolated from the CRISPR-Cas-edited protoplasts and PCR is performed to amplify the gene target region. The PCR product is then used to assess the editing efficiency of the chosen sgRNA using Sanger sequencing. This simplified protocol for the isolation and transformation of wheat protoplast cells using Cas9 ribonucleoprotein complexes streamlines CRISPR transformation projects by allowing for a fast and easy test of sgRNA accessibility in vivo.

Background Telerehabilitation is a feasible and potentially effective alternative to face-to-face rehabilitation. However, specific guidance, training, and support for practitioners who undertake remote assessments in people with physical disabilities and movement impairment are limited. Objective The aims of this survey of United Kingdom–based health and social care practitioners were to explore experiences, assess training needs, and collate ideas on best practices in telerehabilitation for physical disabilities and movement impairment. The aim will be to use the findings to inform a practical tool kit and training package for telerehabilitation use. Methods UK rehabilitation practitioners were invited to complete an online questionnaire from November to December 2020. Opportunity and snowball sampling were used to recruit participants from professional and educational networks, special interest groups, and via social media. Closed questionnaire items were analyzed using descriptive statistics. Qualitative inductive analysis using NVivo was used for open responses. Results There were 247 respondents, of which 177 (72%) were physiotherapists and occupational therapists. Most (n=207, 84%) had used video-based consultations (typically supported by telephone and email), and the use of this method had increased in frequency since the COVID-19 pandemic. Practitioners perceived telerehabilitation positively overall and recognized benefits for patients including a reduced infection risk, convenience and flexibility, and reduced travel and fatigue. Common obstacles were technology related (eg, internet connection), practical (eg, difficulty positioning the camera), patient related (eg, health status), practitioner related (eg, lack of technical skills), and organizational (eg, lack of access to technology). Support from family members or carers was a major facilitator for successful remote consultations. Of the 207 respondents who had used video-based consultations, 103 (50%) had assessed physical impairments using this method, 107 (52%) had assessed physical function, and 121 (59%) had used patient-reported outcome measures. Although practitioners generally felt confident in delivering video-based consultations, they felt less proficient in undertaking remote physical assessments, expressing concerns about validity, reliability, and safety. Only 46 of the 247 (19%) respondents had received any training in telerehabilitation or video consultations, and some felt they were “feeling their way in the dark.” Practitioners desired training and guidance on physical assessment tools suitable for remote use, when to use video-based consultations or alternative methods, governance issues, digital platforms, and signposting to digital skills training for themselves and their patients. Conclusions In response to the COVID-19 pandemic, practitioners rapidly adopted telerehabilitation for people with physical disabilities and movement impairment. However, there are technical, practical, and organizational obstacles to overcome, and a clear need for improved guidance and training in remote physical assessments. The findings of this survey will inform the development of a tool kit of resources and a training package for the current and future workforce in telerehabilitation.

Purpose: To explore the perceptions and experiences of people with stroke living in the community with regard to the perceived causes, impact and solutions to minimise falls.Methods: A qualitative research approach underpinned by a constructivist paradigm utilising a phenomenological methodology. Twelve people with stroke participated in focus groups; the data were analysed using thematic analysis.Results: Three themes and one foundation theme were identified. (1) Trips and triggers: falls were perceived to be linked to external triggers, one of which was walking aids. (2) Blame and burden: self-blame and worry about being a burden may be associated with underreporting of falls. (3) Restrict and reduce: people with stroke restrict activity and reduce participation to manage falls. The underpinning theme of self-efficacy highlights the apparent diminished falls self-efficacy, and the perception amongst the participants that falls are inevitable.Conclusions: This study highlights the perceived negative consequences of falls amongst people with stroke, and the potential contribution of falls to the reduced levels of physical activity often seen following a stroke. Our findings emphasise the need to address falls and balance related self-efficacy alongside strategies to promote safe mobility. A paradigm shift may be needed to highlight potentially modifiable intrinsic risk factors and emphasise the relevance and value of proactive fall prevention to people with stroke.Implications for rehabilitationPeople with stroke may not report falls or may minimise their significance, using alternative terms such as trips and stumbles. Rehabilitation staff need to approach falls in a way that emphasises the positive value of reporting and addressing falls management proactively.People with stroke may focus on extrinsic rather than intrinsic factors, so it is important to identify and highlight potentially modifiable intrinsic falls risks during assessment and treatment.Falls are associated with the use of mobility aids, and people frequently report using multiple aids obtained from a range of sources. Our study findings suggest that assessment and education about the appropriate use of mobility aids should be integral to stroke-specific falls interventions.Falls are often associated with activity reduction and avoidance, which could contribute to reduced participation and increased secondary issues. Approaches to encourage physical activity after stroke need to include recognition of falls risk and methods to optimise safe mobility.The relationship between self-efficacy and people's attitudes and responses to falling is an important consideration. It is likely that that self-efficacy strategies could positively contribute to the effectiveness of stroke falls management interventions.

Background Supporting people with multiple sclerosis (MS) to achieve and maintain recommended levels of physical activity is important but challenging. Web-based interventions are increasingly being used to deliver targeted exercise programs and promote physical activity. Purpose The purpose of this study was to systematically review current evidence regarding the effectiveness and user experience of web-based interventions in increasing physical activity in people with MS. Data Sources MEDLINE, EMBASE, CINAHL, AMED, PEDro, PsychInfo, Web of Sciences, The Cochrane Library, and gray literature were searched from 1990 to September 2016. Study Selection English language articles reporting the use of web-based interventions to increase physical activity in adults with MS were included. Eligible quantitative studies were of any design and reported a measure of physical activity. Qualitative studies exploring users’ experiences in any context were included. Of the 881 articles identified, 9 met the inclusion criteria. Data Extraction Two reviewers independently assessed methodological quality and extracted data using standardized critical appraisal and data extraction tools from the Joanna Briggs Institute Meta Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI). Data Synthesis Meta-analysis of self-reported physical activity questionnaire data from 4 studies demonstrated a standardized mean difference of 0.67 (95% CI = 0.43–0.92), indicating a positive effect in favor of the web-based interventions. Narrative review of accelerometry data from 3 studies indicated increases in objectively measured physical activity. No qualitative studies met the inclusion criteria. Limitations In the 9 included articles, only 2 different interventions (used with people who were ambulant) were reported. Conclusions Web-based interventions had a short-term positive effect on self-reported physical activity in people who had MS and were ambulant. Evidence is not currently available to support or refute their use in the long-term or with people who are not ambulant.

Background Understanding and assessing patients’ body movements is essential for physical rehabilitation but is challenging in video consultations, as clinicians are frequently unable to see the whole patient or observe the patient as they perform specific movements. Objective The objective of this exploratory study was to assess the use of readily available technologies that would enable remote assessment of patient movement as part of a video consultation. Methods We reviewed the literature and available technologies and chose four technologies (Kubi and Pivo desktop robots, Facebook Portal TV, wide-angle webcam), in addition to help from a friend or a simple mobile phone holder, to assist video consultations. We used 5 standard assessments (sit-to-stand, timed “Up & Go,” Berg Balance Test, ankle range of motion, shoulder range of motion) as the “challenge” for the technology. We developed an evaluation framework of 6 items: efficacy, cost, delivery, patient setup, clinician training and guidance, and safety. The coauthors, including 10 physiotherapists, then took the roles of clinician and patient to explore 7 combinations of 5 technologies. Subsequently, we applied our findings to hypothetical patients based on the researchers’ family members and clinical experience. Results Kubi, which allowed the clinician to remotely control the patient’s device, was useful for repositioning the tablet camera to gain a better view of the patient’s body parts but not for tracking movement. Facebook Portal TV was useful, but only for upper body movement, as it functions based on face tracking. Both Pivo, with automated full body tracking using a mobile phone, and the wide-angle webcam for a laptop or desktop computer show promise. Simple solutions such as having a friend operate a mobile phone and use of a mobile phone holder also have potential. The setup of these technologies will require better instructions than are currently available from suppliers, and successful use will depend on the technology readiness of patients and, to some degree, of clinicians. Conclusions Technologies that may enable clinicians to assess movement remotely as part of video consultations depend on the interplay of technology readiness, the patient’s clinical conditions, and social support. The most promising off-the-shelf approaches seem to be use of wide-angle webcams, Pivo, help from a friend, or a simple mobile phone holder. Collaborative work between patients and clinicians is needed to develop and trial technological solutions to support video consultations assessing movement.

This review aims to explore the experiences of people with Parkinson's disease (pwPD) participation in physical activity and their views of interventions designed to engage and sustain engagement. Synthesis of the best available evidence will be used to determine any gaps in the research literature and make recommendations on approaches to increase and maintain engagement in physical activity in pwPD living in a community setting. The specific objectives are to.

The objective of the review was to synthesize the best available qualitative evidence on the experiences and preferences of people with Parkinson's disease for physical activity, their perceived motivators and barriers to engagement, as well as their views on support mechanisms and behavior change interventions designed to sustain participation.National and international guidelines recommend regular physical activity to improve health and wellbeing and to prevent disease. Research on Parkinson's disease indicates that physical activity programs can be beneficial in addressing both physical symptoms and overall wellbeing. However, despite recommendations, sustained engagement in regular physical activity among people with Parkinson's disease is limited. To promote physical activity it is important to understand their perspectives on this topic.This review considered studies that included a qualitative evaluation of the experiences and views of people with Parkinson's disease regarding physical activity and interventions designed to sustain participation.The databases MEDLINE, Embase, CINAHL, AMED, Scopus and Web of Science, and unpublished studies in sources of grey literature (Google, OpenGrey, MedNar, Conference Paper Index, PQDT) were searched. Language limiters were restricted to English and dates ranged from the inception of the database to June 30, 2017. Two reviewers assessed studies that met the inclusion criteria independently, using the criteria of the Joanna Briggs Institute (JBI) Critical Appraisal Checklist for Qualitative Research. One reviewer completed data extraction using the standardized qualitative data extraction tool. This was checked for accuracy by a second reviewer. The qualitative research findings were pooled using JBI methodology. The JBI process of meta-aggregation was used to identify categories and synthesized findings.Nineteen studies were included in this review following assessment of the methodological quality of each study. Two studies were excluded after the methodological review as the findings were not supported by illustrations of the participant voice. Subsequently, 105 findings were extracted and aggregated into 20 categories and eight synthesized findings. Methodological quality was variable and overall confidence in the findings was determined to be low.This review revealed that people with Parkinson's disease viewed physical activity as an enjoyable and positive experience, which aided with control of their symptoms and enhanced their wellbeing and quality of life. Aligned with evidence from older adults and those with long-term conditions, this review identified disease presentation, intrapersonal characteristics, program design, external support and the social and physical environment as contributory factors which influenced the ability of people with Parkinson's disease to sustain engagement in physical activity. The unique contribution and weighting of these factors will affect an individual's participation in physical activity. This review provides important insights into the challenges of undertaking physical activity while living with a progressive and fluctuating disease. These qualitative findings give healthcare providers an insight into the views and experiences of people with Parkinson's disease and are useful, alongside quantitative evidence of effectiveness, for the design of physical activity programs that are meaningful for this population. However, a limitation of this review is that it does not address the views and experiences of people with Parkinson's disease who are inactive.

Objectives To evaluate the effectiveness of interventions in reducing falls and/or improving balance as a falls risk in multiple sclerosis (MS). Data Sources Computer-based and manual searches included the following medical subject heading keywords: "Multiple Sclerosis AND accidental falls" OR "Multiple Sclerosis AND postural balance" OR "Multiple Sclerosis AND exercise" OR "Multiple Sclerosis AND physical/physio therapy" NOT animals. All literature published to November 2014 with available full-text details were included. Study Selection Studies were reviewed against the PICO (participants, interventions, comparisons, outcomes) selection criteria: P, adults with MS; I, falls management/balance rehabilitation interventions; C, randomized/quasi-randomized studies comparing intervention with usual care or placebo control; O, falls outcomes and measures of balance. Fifteen articles of the original 529 search results were included. Data Extraction Two reviewers independently extracted data and assessed methodological quality using the Cochrane Risk of Bias tool. Data Synthesis Random-effects meta-analysis indicated a small decrease in falls risk (risk ratio, .74), although the 95% confidence interval (CI) crossed 1 (95% CI, .12–4.38). The pooled standardized mean difference (SMD) for balance outcomes was .55 (95% CI, .35–.74). SMD varied significantly between exercise subgroupings; gait, balance, and functional training interventions yielded the greatest pooled effect size (ES) (SMD=.82; 95% CI, 0.55–1.10). There was a moderate positive correlation between program volume (min/wk) and ES (Cohen's d ) ( r =.70, P =.009), and a moderate negative correlation between program duration in weeks and ES ( r =−.62, P =.03). Variations in interventions and outcomes and methodological limitations mean that results must be viewed with caution. Conclusions This review suggests that balance may improve through exercise interventions, but that the magnitude of the improvements achieved in existing programs may not be sufficient to impact falls outcomes. Supporting participants to achieve an appropriate intensity of practice of highly challenging balance activities appears to be critical to maximizing effectiveness.

Objective: This study evaluated the relationship between physiological and perceived fall risk in people with multiple sclerosis (MS). Design: Secondary analysis of data from prospective cohort studies undertaken in Australia, the United Kingdom, and the United States. Setting: Community. Participants: Ambulatory people with MS (N=416) (age 51.5±12.0 years; 73% female; 62% relapsing-remitting MS; 13.7±9.9 years disease duration). Interventions: Not applicable. Main Outcome Measures: All participants completed measures of physiological (Physiological Profile Assessment [PPA]) and perceived (Falls Efficacy Scale-international [FESi]) fall risk and prospectively recorded falls for 3 months. Results: 155 (37%) of the participants were recurrent fallers (≥2 falls). Mean PPA and FESi scores were high (PPA 2.14±1.87, FESi 34.27±11.18). The PPA and the FESi independently predicted faller classification in logistic regression, which indicated that the odds of being classified as a recurrent faller significantly increased with increasing scores (PPA odds ratio [OR] 1.30 [95% CI 1.17-1.46], FESi OR 1.05 [95% CI 1.03-1.07]). Classification and regression tree analysis divided the sample into four groups based on cutoff values for the PPA: (1) low physiological/low perceived risk (PPA 27.5), (3) high physiological/low perceived risk (PPA >2.83, FESi 35.5). Over 50% of participants had a disparity between perceived and physiological fall risk; most were in group 2. It is possible that physiological risk factors not detected by the PPA may also be influential. Conclusions: This study highlights the importance of considering both physiological and perceived fall risk in MS and the need for further research to explore the complex interrelationships of perceptual and physiological risk factors in this population. This study also supports the importance of developing behavioral and physical interventions that can be tailored to the individual’s needs.

To utilise stakeholder input to inform the structure, format and approach of a multiple sclerosis (MS) balance, safe mobility and falls management programme.Using a three-round nominal group technique, participants individually rated their agreement with 20 trigger statements, followed by a facilitated group discussion and re-rating. Three mixed groups included service users (n = 15) and providers (n = 19). Quantitative analysis determined agreement, whilst qualitative responses were analysed thematically.Median scores for each of the 20 trigger statements did not change significantly over sequential rounds, however, deviations around the medians indicated more agreement amongst participants over time. Key recommendations were: Aims and approach: The programme should be tailored to the needs of people with MS. Falls and participation-based outcomes are equally important. Structure and format: The programme should balance expected burden and anticipated benefit, moving away from models requiring weekly attendance and promoting and supporting self-efficacy. Optimising engagement: Support to maintain engagement and intensity of practice over the long term is essential. Sustainability: Adequate funding is necessary. Staff should have MS specific knowledge and experience.Participants collaboratively identified critical components of a MS balance, safe mobility and falls management programme. They also highlighted the importance of a collaborative, user-centred, MS-specific approach. Implications for Rehabilitation People with multiple sclerosis need condition-specific interventions focussed on maximising balance and safe mobility and reducing falls. Programme design should support self-efficacy and flexible engagement. Adequate support and funding are seen as essential by both service users and providers.

This study is funded by the NIHR Health Technology Assessment Programme (14/176/12), United Kingdom. Background: Impaired mobility is a cardinal feature of multiple sclerosis (MS) and is rated by people with MS as their highest priority. By the secondary progressive phase, balance, mobility and physical activity levels are significantly compromised; an estimated 70% of people with secondary progressive MS fall regularly. Our ongoing research has systematically developed ‘Balance Right in MS’ (BRiMS), an innovative, manualised 13-week guided self-management programme tailored to the needs of people with MS, designed to improve safe mobility and minimise falls. Our eventual aim is to assess the clinical and cost effectiveness of BRiMS in people with secondary progressive MS by undertaking an appropriately statistically powered, multi-centre, assessor-blinded definitive, randomised controlled trial. This feasibility study will assess the acceptability of the intervention and test the achievability of running such a definitive trial. Methods/design: This is a pragmatic multi-centre feasibility randomised controlled trial with blinded outcome assessment. Sixty ambulant people with secondary progressive MS who self-report two or more falls in the previous 6 months will be randomly allocated (1:1) to either the BRiMS programme plus usual care or to usual care alone. All participants will be assessed at baseline and followed up at 15 weeks and 27 weeks post-randomisation. The outcomes of this feasibility trial include: • Feasibility outcomes, including trial recruitment, retention and completion • Assessment of the proposed outcome measures for the anticipated definitive trial (including measures of walking, quality of life, falls, balance and activity level) • Measures of adherence to the BRiMS programme • Data to inform the economic evaluation in a future trial • Process evaluation (assessment of treatment fidelity and qualitative evaluation of participant and treating therapist experience) Discussion: The BRiMS intervention aims to address a key concern for MS service users and providers. However, there are several uncertainties which need to be addressed prior to progressing to a full-scale trial, including acceptability of the BRiMS intervention and practicality of the trial procedures. This feasibility trial will provide important insights to resolve these uncertainties and will enable a protocol to be finalised for use in the definitive trial. Publisher PDF

The aim of this article is to provide recommendations on behalf of the International MS Falls Prevention Research Network (IMSFPRN) for the primary outcome measure for multiple sclerosis (MS) falls-prevention interventions. The article will consider the definition of a fall, methods of measuring falls, and the elements of falls that should be recorded, as well as how these elements should be presented and analyzed. While this information can be used to inform the content of falls-prevention programs, the primary aim of the article is to make recommendations on how the outcome of these programs should be captured.

Background Falls are a significant issue in people with multiple sclerosis (MS), with research demonstrating fall rates of more than 50%. Purpose The purpose of this study was to evaluate the risk factors associated with falling in people with MS. Data Sources Mixed search methods were used, including computer-based and manual searches. Additionally, hand searches of reference lists and conference abstracts were performed. All literature published from the source's earliest date to January 2012 was included; only full-text English-language sources (or those where a translation was available) were included. Study Selection Eligibility criteria specified articles evaluating any aspect of fall risk in adults with a confirmed MS diagnosis, where the incidence of falling as determined by prospective or retrospective participant report was included. Data Extraction Data were extracted independently by 2 reviewers using a written protocol and standardized extraction documentation. Detailed assessment of each article was independently undertaken by both reviewers, including assessment of study quality using an adaptation of the Newcastle Ottawa Scale plus extraction of key data (participant characteristics, fall incidence, and outcomes). Data Synthesis The final review comprised 8 articles with a total of 1,929 participants; 1,037 (53.75%) were classified as fallers. Eighteen different risk factors were assessed within the included studies. Meta-analysis demonstrated an increase in fall risk associated with impairments of balance and cognition, progressive MS, and use of a mobility aid. Narrative review of the qualitative articles and those factors where meta-analysis was not possible also was undertaken. Limitations Variation in assessment, analysis, and reporting methods allowed meta-analysis for only 4 factors. Conclusion There is limited evidence of the factors associated with fall risk in people with MS. Further methodologically robust studies are needed.

International audience; Generating a contiguous, ordered reference sequence of a complex genome such as hexaploid wheat (2n = 6x = 42; approximately 17 GB) is a challenging task due to its large, highly repetitive, and allopolyploid genome. In wheat, ordering of whole-genome or hierarchical shotgun sequencing contigs is primarily based on recombination and comparative genomics-based approaches. However, comparative genomics approaches are limited to syntenic inference and recombination is suppressed within the pericentromeric regions of wheat chromosomes, thus, precise ordering of physical maps and sequenced contigs across the whole-genome using these approaches is nearly impossible. We developed a whole-genome radiation hybrid (WGRH) resource and tested it by genotyping a set of 115 randomly selected lines on a high-density single nucleotide polymorphism (SNP) array. At the whole-genome level, 26 299 SNP markers were mapped on the RH panel and provided an average mapping resolution of approximately 248 Kb/cR1500 with a total map length of 6866 cR1500 . The 7296 unique mapping bins provided a five- to eight-fold higher resolution than genetic maps used in similar studies. Most strikingly, the RH map had uniform bin resolution across the entire chromosome(s), including pericentromeric regions. Our research provides a valuable and low-cost resource for anchoring and ordering sequenced BAC and next generation sequencing (NGS) contigs. The WGRH developed for reference wheat line Chinese Spring (CS-WGRH), will be useful for anchoring and ordering sequenced BAC and NGS based contigs for assembling a high-quality, reference sequence of hexaploid wheat. Additionally, this study provides an excellent model for developing similar resources for other polyploid species.

The aim of this article is to provide recommendations on behalf of the International MS Falls Prevention Research Network (IMSFPRN) for the primary outcome measure for multiple sclerosis (MS) falls-prevention interventions. The article will consider the definition of a fall, methods of measuring falls, and the elements of falls that should be recorded, as well as how these elements should be presented and analyzed. While this information can be used to inform the content of falls-prevention programs, the primary aim of the article is to make recommendations on how the outcome of these programs should be captured.

Evidence suggests that choice of setting may be important in influencing the outcomes of rehabilitation programs, as well as optimizing participant satisfaction and adherence. This article aims to examine the factors that may inform the choice of setting for a falls-prevention program tailored to the needs of people with multiple sclerosis, including the influence of setting on program effectiveness, participant engage ment, cost, and sustainability. Any new program should ensure that the choice of setting is informed by the intended program outcomes as well as an awareness of the opportunities and challenges presented by each type of setting. Evaluations of falls programs for older people suggest that immediate outcomes are similar regardless of setting; however, long-term outcomes may differ by setting, possibly owing to differential effects on adherence. Programs based away from home may offer benefits in terms of maintaining motivation, providing peer-support opportunities, and allowing regular access to facilitator input, while home-based programs offer unique opportunities for context-based practice and the integration of fallsprevention activities into real life. Additionally, home-based programs may address some of the long-term feasibility issues associated with programs away from home. A “mixed” program incorporating elements of home- and community-based activity may be the most sustainable and effective choice to achieve both longand short-term goals within a falls-prevention program. However, currently there are significant gaps in knowledge relating to comparative program outcomes, cost, and long-term sustainability. Int J MS Care. 2014;16:186–191.

Objective To evaluate falls rate and the characteristics of falls (including fall-related injuries) in a multiple sclerosis (MS) cohort. Design As part of a study evaluating falls risk, a cohort of 150 participants prospectively recorded actual and near fall events using a daily diary over 3 months, as well as the circumstances of each fall including related injuries. Setting Community setting. Participants A population-based sample of people (N=150) with a confirmed diagnosis of MS (Expanded Disability Status Scale, 3.5–6.5) was recruited via a patient-centered longitudinal study database of disease course in people with MS. Interventions Not applicable. Main Outcome Measures Rate of actual and near falls, circumstances and consequences of falls (including rates and type of injury plus follow-up care). Results The response rate for the falls diary was 92.7%. A total of 672 actual falls and 3785 near falls were recorded, with a moderate correlation between the numbers of actual and near falls per person (ρ=.474; 95% confidence interval, .34–.59). Men recorded significantly more falls than women. Falls were associated with a range of activities, although 27.6% occurred during general mobility activities such as walking, turning, and moving between positions. Injuries occurred in 11.1% of falls, with 6 individuals requiring medical attention. Conclusions People with MS experience high numbers of falls, with associated injuries. Falls occur during a wide range of activities, reflecting their potential impact on daily life. Evaluating the characteristics of individuals who experience frequent near falls but few actual falls may be valuable for research and clinical practice.

Background:People with multiple sclerosis (MS) experience frequent falls, which are associated with impairments and limitations to activities and participations.Objective:The objective of this paper is to evaluate falls risk factors using robust clinical measures.Methods:A total of 150 individuals (confirmed MS diagnosis, Expanded Disability Status Scale (EDSS) 3.5–6.5) were recruited, with 148 participants included in the final analysis. Demographic data were collected and performance assessed in eight predictor measures (Physiological Profile Assessment (PPA), Brief Ataxia Rating scale, Ashworth scale (Ashworth), Modified Falls Efficacy scale, Symbol Digit Modalities Test, dual-task interference, lying/standing blood pressure, static/dynamic visual acuity). Participants prospectively recorded falls over three months using a daily diary. People were classified as “fallers” based on reports of ≥ two falls.Results:A total of 104 participants recorded 672 falls; 78 (52.7%) reported ≥ two falls. Continence issues, previous falls history and use of prescribed medications were each associated with increased risk of being a “faller”. Ashworth and PPA risk score contributed significantly to a logistic regression model predicting faller/non-faller classification. The reduced model (Ashworth, PPA, EDSS) showed fair-to-good predictive ability (ROC c-statistic 0.73, sensitivity 70%, specificity 69%).Conclusion:This study confirms the high prevalence of falls in ambulant people with MS. Important potentially modifiable risk factors are identified, suggesting aspects to target in falls interventions.

Introduction The Physiological Profile Assessment (PPA) is used in research and clinical practice for assessing fall risk. We compared PPA test performance between people with multiple sclerosis (MS) and healthy controls, determined the fall-risk profile for people with MS and developed a reference database for people with MS. Methods For this study, 416 ambulant people with MS (51.5 ± 12.0 years) and 352 controls (52.8 ± 12.2 years) underwent the PPA (tests of contrast sensitivity, proprioception, quadriceps strength, reaction time and sway) with composite fall-risk scores computed from these measures. MS participants were followed prospectively for falls for 3 months. Results The MS participants performed significantly worse than controls in each PPA test. The average composite fall-risk score was also significantly elevated, indicating a “marked” fall risk when compared with controls. In total, 155 MS participants (37.3%) reported 2 + falls in the follow-up period. Frequent fallers performed significantly worse than non-frequent fallers in the contrast sensitivity, reaction time and sway tests and had higher PPA composite scores. Conclusions In line with poor PPA test performances, falls incidence in people with MS was high. This study provides comprehensive reference data for the PPA measures for people with MS that could be used to inform future research and clinical practice.

Background Problem Based Learning (PBL) has been integrated into a range of health education curricula; however there is limited research evaluating the application of skills developed through PBL in clinical practice. Aim This study aimed to provide evidence of how skills gained through PBL are applied in practice by student physiotherapists, from the perspective of their placement supervisors. Method A qualitative one-to-one semi-structured interview methodology was used, purposively recruiting a sample of 10 qualified physiotherapists with experience of placement supervision of students studying on a PBL physiotherapy undergraduate degree. Results The supervisors felt that PBL offered positive benefits for both student education and clinical practice. There was evidence of the application of skills and attributes associated with PBL, including positive learning behaviours and a high level of motivation and self-direction. Supervisors felt that proactive students were able to apply transferable skills inherent in the PBL approach to clinical practice, including a holistic, problem-solving approach and effective team-working but that there was considerable variation between students. Conclusions There is evidence of variable application of skills associated with PBL in clinical practice in this study group. Further research would be useful to explore the factors that enable students to successfully apply the attributes developed using a PBL approach into practice.

Objective To provide an insight into individual physiotherapists’ experiences of Continuing Professional Development (CPD), and to gain an understanding of the challenges of undertaking CPD in a geographically dispersed primary healthcare setting. Design A qualitative phenomenological methodology using a one-to-one semi-structured interview technique to achieve an in-depth exploration of this complex area of study. Data analysis was conducted by data transcription, immersion, coding and generation of themes using a pragmatic five-step process. Participants Eleven participants were identified from a study population of physiotherapists working in two local primary care trusts following the principle of maximum variation sampling. Results Four main themes emerged: CPD processes; motivation for undertaking CPD; enabling CPD; and outcomes of CPD. Participants felt that CPD should include a range of activities and learning behaviours. However, there was a preference for active learning styles and formal course-based learning. Engagement in reflective practice and portfolio keeping was generally poor, with participants identifying lack of skills in these areas. Factors motivating CPD engagement included a strong sense of professional obligation and wishing to provide the best possible service to patients. There was frustration over the impact of external issues including political and organisational change on CPD, and anxiety over forthcoming regulatory changes affecting physiotherapy. The study also identified issues around CPD planning and needs identification. There was evidence of change in individuals’ practice and internal perceptions as outcomes of CPD, although issues around the application and maintenance of change were identified. Conclusions There is evidence that CPD has an effect on clinical practice in this small group of physiotherapists working in community National Health Service settings. Significantly, undertaking CPD improves confidence as well as competence, enabling individuals to form effective therapeutic relationships with patients and other members of their teams.

Physical mapping and genome sequencing are underway for the ≈17 Gb wheat genome. Physical mapping methods independent of meiotic recombination, such as radiation hybrid (RH) mapping, will aid precise anchoring of BAC contigs in the large regions of suppressed recombination in Triticeae genomes. Reports of endosperm development following pollination with irradiated pollen at dosages that cause embryo abortion prompted us to investigate endosperm as a potential source of RH mapping germplasm. Here, we report a novel approach to construct RH based physical maps of all seven D-genome chromosomes of the hexaploid wheat 'Chinese Spring', simultaneously. An 81-member subset of endosperm samples derived from 20-Gy irradiated pollen was genotyped for deletions, and 737 markers were mapped on seven D-genome chromosomes. Analysis of well-defined regions of six chromosomes suggested a map resolution of ∼830 kb could be achieved; this estimate was validated with assays of markers from a sequenced contig. We estimate that the panel contains ∼6,000 deletion bins for D-genome chromosomes and will require ∼18,000 markers for high resolution mapping. Map-based deletion estimates revealed a majority of 1-20 Mb interstitial deletions suggesting mutagenic repair of double-strand breaks in pollen provides a useful resource for RH mapping and map based cloning studies.