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Background: Urinary incontinence affects around half of stroke survivors in the acute phase, and it often presents as a new problem after stroke or, if pre-existing, worsens significantly, adding to the disability and helplessness caused by neurological deficits. New management programmes after stroke are needed to address urinary incontinence early and effectively. Objective: The Identifying Continence OptioNs after Stroke (ICONS)-II trial aimed to evaluate the clinical effectiveness and cost-effectiveness of a systematic voiding programme for urinary incontinence after stroke in hospital. Design: This was a pragmatic, multicentre, individual-patient-randomised (1 : 1), parallel-group trial with an internal pilot. Setting: Eighteen NHS stroke services with stroke units took part. Participants: Participants were adult men and women with acute stroke and urinary incontinence, including those with cognitive impairment. Intervention: Participants were randomised to the intervention, a systematic voiding programme, or to usual care. The systematic voiding programme comprised assessment, behavioural interventions (bladder training or prompted voiding) and review. The assessment included evaluation of the need for and possible removal of an indwelling urinary catheter. The intervention began within 24 hours of recruitment and continued until discharge from the stroke unit. Main outcome measures: The primary outcome measure was severity of urinary incontinence (measured using the International Consultation on Incontinence Questionnaire) at 3 months post randomisation. Secondary outcome measures were taken at 3 and 6 months after randomisation and on discharge from the stroke unit. They included severity of urinary incontinence (at discharge and at 6 months), urinary symptoms, number of urinary tract infections, number of days indwelling urinary catheter was in situ, functional independence, quality of life, falls, mortality rate and costs. The trial statistician remained b

Background: Thickened fluids are a recognised intervention strategy in use for people with dysphagia. However, their bacterial profile has not previously been examined. Aims: To identify bacteria and changes in bacterial profiles in a range of water sources and thickener preparations over a 5-day period. Methods: Nine experiments were performed using a range of preparations of water (sterile, drinking, non-drinking tap water) and a thickening agent (sterile sachet and a used tin). Findings: No bacteria were grown on serial subcultures of sterile water, both with and without thickener. Drinking, tap and thickened water left at room temperature for 24 hours may become contaminated with environmental organisms. Conclusions: The growth of bacteria in preparations of thickening agent appears to be dependent upon water quality, while the proliferation of bacteria is dependent upon the length of time the preparation is allowed to stand at room temperature.

Background: Despite being used satisfactorily by millions of people worldwide for a range of conditions, and the homeopathy community’s efforts to integrate homeopathy into NHS services, homeopathy provision has been declining. Aim: A pragmatic investigation of the integration of homeopathy in the UK NHS. Method: A nationwide postal survey among 144 members of the Faculty of Homeopathy mapped demographic data and integration of homeopathy services in the NHS, building on a Canadian integration model proposed by Boon in 2004. To enable a comprehensive understanding, 10 semi-structured interviews explored homeopaths' strategies to integrate homeopathy successfully into NHS services. Results: A sample of 72 respondents revealed that 27 were actively offering homeopathy treatment in their NHS service. According to the continuum proposed by Boon, UK services integrating homeopathy treatment are characterised as collaborative and multidisciplinary. Seven profiles of homeopathic providers in the NHS could be distinguished. In the interviews, several suggestions were put forward to restore the badly damaged image of homeopathy. The interviewees disagreed about whether integration was the preferred strategy to reach this goal, or even whether integration was desirable at all, but the accreditation of homeopathy within the healthcare system was deemed vital for the survival of homeopathy, even for the success of private practices. A lack of resources and the dwindling numbers of newly trained homeopathy practitioners were mentioned as a matter of concern. A major frustration was the negation of existing evidence for homeopathy, leaving homeopaths questioning what kind of evidence – from fundamental research or from outcome studies – would be the best way forward. Conclusion: Despite positive results regarding the integration of homeopathic services in the NHS, the information disclosed in the interviews revealed a concern about the survival of homeopathy.

Background: Developing a clinical academic role in Nursing, Midwifery and the Allied Health Professions (NMAHP) is challenging due to lack of a national career pathway, recognition and understanding of the role. Aims: This evaluation explored perspectives of aspiring or active clinical academics and health care managers in NMAHP about the benefits, barriers and enablers of engagement in these career pathways. Methods: Eight workshops were facilitated across England (four each for managers and prospective clinical academics); 162 participants shared their experiences and perceptions of clinical academic research activities. Findings: Three major themes were identified related to the perceived benefits, barriers and enablers of engagement in these career pathways: Building health research capacity; Building individuals’ health research capability; and Improving patient care. Conclusion: This report demonstrates factors that are valued and perceived to be working well by practitioners and their clinical service managers, and highlights key priorities for further strategic support.

This chapter examines the causes and contributing factors of bladder and bowel problems in stroke, and discusses assessment and management protocols. The prevalence of urinary incontinence (UI) after stroke is high, with studies suggesting around half of people admitted to hospital experience UI, and a third a loss of bowel control. Although UI is common after stroke, it is always important to exclude transient causes early on in the assessment process. Urinary tract infection (UTI) is a frequent cause of UI, and urine should be tested for leucocytes and nitrites within 24 hours of admission. All patients admitted to hospital with stroke should have a nursing assessment, including urine testing, within 24 hours of admission to identify UI and detect UTI or other abnormality. Healthcare professionals can do much to help improve and manage bladder and bowel problems, starting with having a good understanding of key issues and completing an early assessment of problems.

Lois Thomas, Christine Roffe, Joanne Booth, Christopher Chapple, Caroline Watkins, Brenda Roe, Christopher Sutton, Bruce Hollingsworth, Céu Mateus, David Britt, Cliff Panton and Kina Bennett; for the MRC Continence Programme and R&D Stroke and Incontinence Study

Aims and objectives To explore the views and experiences of stroke survivors and carers about a systematic voiding programme for post-stroke incontinence. Background Urinary incontinence after stroke is common and associated with poorer functional outcome. Structured assessment and management are potentially effective interventions but it is important that there is a good understanding of stroke survivors’ and carers’ views of their acceptability and implementation. Design Qualitative study within a feasibility trial. Methods 16 participants (12 stroke survivors, 4 carers) were interviewed using a structured schedule shortly before discharge from one of six inpatient stroke units across six hospitals. Interviews were audiorecorded, transcribed verbatim, and thematic analysis was conducted. Findings Participants included seven male and five female stroke survivors (mean age 76 years), and four female carers (two wives, two daughters). Themes relating to the preliminary (assessment) phase of the programme were: physical impact, psychological impact, beliefs about incontinence, and the assessment process itself. Main themes relating to the implementation of the programme included: Timed voiding decisions, adapting the programme or the timed voiding schedule, and urinary incontinence management techniques. Participants felt that the programme helped them to re-establish a regular pattern of micturition and to regain autonomy. Conclusions The effectiveness of a systematic voiding programme may partly lie in its educational component, challenging patients’ and carers’ assumptions that post-stroke incontinence is inevitable. Individual adaptation of the programme, and the ability to incorporate it alongside other aspects of care, are likely to be key factors influencing implementation. Relevance to clinical practice Urinary incontinence is common after stroke. In order to maximise benefits from a systematic voiding programme, nurses should support stroke survivors to overt

Aim: To evaluate factors influencing uptake and delivery of behavioural interventions for urinary incontinence from the perspective of clients and clinical staff. Background: Behavioural interventions are recommended as first-line therapy for the management of urinary incontinence. Barriers to and enablers of uptake and delivery of behavioural interventions have not been reviewed. Design: Systematic narrative review. Data sources: MEDLINE, EMBASE, CINAHL, PsychInfo, AMED (inception to May 2013); Proceedings of the International Continence Society (ICS) (2006-13). Review methods: ENTREQ reporting guidelines were followed. Studies where data were collected from clients or staff about their experiences or perceptions of behavioural interventions were included. Two reviewers independently screened records on title and abstract. Full-text papers were obtained for records identified as potentially relevant by either reviewer. Two reviewers independently filtered all full-text papers for inclusion, extracted findings and critically appraised studies. Results: Seven studies involving 200 participants identified clients’ views. Findings identified from at least one study of moderate quality included increased fear of accidents and convenience of treatment. Factors enabling participation included realistic goals and gaining control. Six studies involving 427 participants identified staff views. Findings identified from at least one study of moderate quality included staff education and perceptions of treatment effectiveness. Enabling factors included teamwork and experience of success. Conclusion: There is little detailed exploration of clients’ experiences of, and responses to, behavioural interventions. Evidence for staff relates predominantly to prompted voiding in long-term residential care. Studies of the uptake and delivery of other behavioural interventions in other settings are warranted.

Background Repetitive task training (RTT) involves the active practice of task-specific motor activities and is a component of current therapy approaches in stroke rehabilitation. Objectives Primary objective: To determine if RTT improves upper limb function/reach and lower limb function/balance in adults after stroke. Secondary objectives: 1) To determine the effect of RTT on secondary outcome measures including activities of daily living, global motor function, quality of life/health status and adverse events. 2) To determine the factors that could influence primary and secondary outcome measures, including the effect of 'dose' of task practice; type of task (whole therapy, mixed or single task); timing of the intervention and type of intervention. Search methods We searched the Cochrane Stroke Group Trials Register (4 March 2016); the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library 2016, Issue 5: 1 October 2006 to 24 June 2016); MEDLINE (1 October 2006 to 8 March 2016); Embase (1 October 2006 to 8 March 2016); CINAHL (2006 to 23 June 2016); AMED (2006 to 21 June 2016) and SPORTSDiscus (2006 to 21 June 2016). Selection criteria Randomised/quasi-randomised trials in adults after stroke, where the intervention was an active motor sequence performed repetitively within a single training session, aimed towards a clear functional goal. Data collection and analysis Two review authors independently screened abstracts, extracted data and appraised trials. We determined the quality of evidence within each study and outcome group using the Cochrane 'Risk of bias' tool and GRADE (Grades of Recommendation, Assessment, Development and Evaluation) criteria. We did not assess follow-up outcome data using GRADE. We contacted trial authors for additional information. Main results We included 33 trials with 36 intervention-control pairs and 1853 participants. The risk of bias present in many studies was unclear due to poor reporting; the evidence has

We explored health professionals’ views of implementing a systematic voiding program (SVP) in a multi-site qualitative process evaluation in stroke services recruited to the intervention arms of a cluster randomized controlled feasibility trial during 2011-13. We conducted semistructured group or individual interviews with 38 purposively selected nursing, managerial and care staff involved in delivering the SVP. Content analysis of transcripts used normalization process theory as a pre-specified organization-level exploratory framework. Barriers to implementing the SVP included perceived lack of suitability for some patient groups; patient fear of extending hospital stay; and difficulties with SVP enactment, scheduling, timing, recording, and monitoring. Enablers included the guidance provided by the SVP; patient and relative involvement; extra staff; improved nursing skill and confidence; and experience of success. Three potential mechanisms of consistency, visibility, and individualization linked the SVP process with improvements in outcome, and should be emphasized in SVP implementation.

In common with many cluster-randomised trials, it was difficult to determine the appropriate sample size for the planned trial of the effectiveness of a systematic voiding programme for post-stroke incontinence due to the lack of a robust estimate of the intra-cluster correlation coefficient (ICC). One approach to overcome this problem is a method of combining ICC values in the Bayesian framework (Turner et al. 2005). We adopted this approach and used Bayesian hierarchical modelling to estimate the ICC.

Primary objective The primary objective is to assess the effectiveness of interv entions to improve patient identification, access to and utilis ation of genetic and genomic counselling services when compared to: i) No intervention; ii) Usual or current practice; and iii) Other active intervention. Secondary objective The secondary objective is to explore the resource use and costs associated with interventions aimed at improving patient identification, access to and utilisation of genetic and genomic counselling services from studies meeting the eligibility criteria. We will report on factors that may explain variation in the eff ectiveness of interventions aimed at improving patient iden tification, access to and utilisation of genetic and genomic counselling services from studies meeting the eligibility criteria. Another secondary objective is to explore how interventions w hich target improved patient identification, access to and utili sation of genetic and genomic counselling services affect the subsequent appropriate use of health services for the prevention or early detection of disease. It is also possible that the genetic counselling interaction itself will contribute to the possible use of preventative services.

Background The implementation of strategies to monitor and enhance treatment fidelity is of paramount importance in trials of complex interventions. A recent framework published by the National Institutes of Health Behavior Change Consortium recommends addressing five areas of treatment fidelity, one of which is delivery of treatment. This study aimed to explore fidelity to treatment delivery of the ICONS intervention (a systematic voiding programme [SVP]). This included exploring the feasibility of a method to assess fidelity to treatment delivery and collecting preliminary evidence of the level of fidelity to SVP delivery in order to inform strategies for improving fidelity in a future trial. Methods Delivery of treatment was recorded by nurses through completion of daily clinical logs, which included: a voiding interval, proposed voiding times and actual voiding times. The a priori method for assessment of fidelity – comparing actual voiding times with proposed voiding times – was trialled on a small amount of data. Due to errors in documentation of the voiding intervals and proposed voiding times it was not possible to assess fidelity directly as planned. A new method was devised, which included identification of ‘key quality indicators’. Results This new approach to assessing fidelity used key quality indicators based upon presence of the data needed to make the comparison between proposed and actual voiding times. The proportion of clinical logs with correct documentation of voiding intervals and proposed voiding times was less than 40 %. For clinical logs with correct documentation, an actual voiding time within 30 min of the proposed voiding time was identified on approximately 55 % of occasions. Conclusions Lessons learnt from this study have implications for the future ICONS definitive trial and for other trials of complex interventions. Implementation of a complex intervention may often deviate from what is intended. While careful consideration should be

Background: Urinary incontinence (UI) following acute stroke is common, affecting between 40% and 60% of people in hospital, but is often poorly managed. Aim: To develop, implement and evaluate the preliminary effectiveness and potential cost-effectiveness of a systematic voiding programme (SVP), with or without supported implementation, for the management of UI after stroke in secondary care. Design: Structured in line with the Medical Research Council framework for the evaluation of complex interventions, the programme comprised two phases: Phase I, evidence synthesis of combined approaches to manage UI post stroke, case study of the introduction of the SVP in one stroke service; Phase II, cluster randomised controlled exploratory trial incorporating a process evaluation and testing of health economic data collection methods. Setting: One English stroke service (case study) and 12 stroke services in England and Wales (randomised trial). Participants: Case study, 43 patients; randomised trial, 413 patients admitted to hospital with stroke and UI. Interventions: A SVP comprising assessment, individualised conservative interventions and weekly review. In the supported implementation trial arm, facilitation was used as an implementation strategy to support and enable people to change their practice. Main outcome measures: Participant incontinence (presence/absence) at 12 weeks post stroke. Secondary outcomes were quality of life, frequency and severity of incontinence, urinary symptoms, activities of daily living and death, at discharge, 6, 12 and 52 weeks post stroke. Results: There was no suggestion of a beneficial effect on outcome at 12 weeks post stroke [intervention vs. usual care: odds ratio (OR) 1.02, 95% confidence interval (CI) 0.54 to 1.93; supported implementation vs. usual care: OR 1.06, 95% CI 0.54 to 2.09]. There was weak evidence of better outcomes on the Incontinence Impact Questionnaire in supported implementation (OR 1.22, 95% CI 0.72 to 2.08) but t

Background Urinary incontinence (UI) affects half of patients hospitalised after stroke and is often poorly managed. Cochrane systematic reviews have shown some positive impact of conservative interventions (such as bladder training) in reducing UI, but their effectiveness has not been demonstrated with stroke patients. Methods We conducted a cluster randomised controlled feasibility trial of a systematic voiding programme (SVP) for the management of UI after stroke. Stroke services were randomised to receive SVP (n = 4), SVP plus supported implementation (SVP+, n = 4), or usual care (UC, n = 4). Feasibility outcomes were participant recruitment and retention. The main effectiveness outcome was presence or absence of UI at six and 12 weeks post-stroke. Additional effectiveness outcomes included were the effect of the intervention on different types of UI, continence status at discharge, UI severity, functional ability, quality of life, and death. Results It was possible to recruit patients (413; 164 SVP, 125 SVP+, and 124 UC) and participant retention was acceptable (85% and 88% at six and 12 weeks, respectively). There was no suggestion of a beneficial effect on the main outcome at six (SVP versus UC: odds ratio (OR) 0.94, 95% CI: 0.46 to 1.94; SVP+ versus UC: OR: 0.62, 95% CI: 0.28 to 1.37) or 12 weeks (SVP versus UC: OR: 1.02, 95% CI: 0.54 to 1.93; SVP+ versus UC: OR: 1.06, 95% CI: 0.54 to 2.09). No secondary outcomes showed a strong suggestion of clinically meaningful improvement in SVP and/or SVP+ arms relative to UC at six or 12 weeks. However, at 12 weeks both intervention arms had higher estimated odds of continence than UC for patients with urge incontinence. Conclusions The trial has met feasibility outcomes of participant recruitment and retention. It was not powered to demonstrate effectiveness, but there is some evidence of a potential reduction in the odds of specific types of incontinence. A full trial should now be considered.

BACKGROUND: Urinary incontinence (UI) affects between 40 and 60% of people in hospital after stroke, but is often poorly managed in stroke units. OBJECTIVES: To inform an exploratory trial by three methods: identifying the organisational context for embedding the SVP; exploring health professionals' views around embedding the SVP and measuring presence/absence of UI and frequency of UI episodes at baseline and six weeks post-stroke. DESIGN: A mixed methods single case study included analysis of organisational context using interviews with clinical leaders analysed with soft systems methodology, a process evaluation using interviews with staff delivering the intervention and analysed with Normalisation Process Theory, and outcome evaluation using data from patients receiving the SVP and analysed using descriptive statistics. SETTING: An 18 bed acute stroke unit in a large Foundation Trust (a 'not for profit' privately controlled entity not accountable to the UK Department of Health) serving a population of 370,000. PARTICIPANTS: Health professionals and clinical leaders with a role in either delivering the SVP or linking with it in any capacity were recruited following informed consent. Patients were recruited meeting the following inclusion criteria: aged 18 or over with a diagnosis of stroke; urinary incontinence (UI) as defined by the International Continence Society; conscious; medically stable as judged by the clinical team and with incontinence classified as stress, urge, mixed or 'functional'. All patients admitted to the unit during the intervention period were screened for eligibility; informed consent to collect baseline and outcome data was sought from all eligible patients. RESULTS: Organisational context: 18 health professionals took part in four group interviews. Findings suggest an environment not conducive to therapeutic continence management and a focus on containment of UI. Embedding the SVP into practice: 21 nursing staff took part in six group int

Background Assessing fidelity to complex healthcare interventions in clinical trials is a challenging area. ‘ICONS' is a cluster randomised controlled feasibility trial of a systematic voiding programme (SVP), incorporating bladder training and prompted voiding, to promote post-stroke continence. Here we describe feasibility of one aspect of fidelity assessment: the day-to-day implementation of the SVP through analysis of clinical logs. Methods Nurses completed clinical logs daily, which included documenting: the toileting interval, proposed toileting times and times toileted. Clinical logs were sampled across trial sites. The original intention was to assess fidelity by exploring the degree of concordance between proposed times and times toileted. Initial analysis revealed the unfeasibility of this method due to documentation errors in toileting intervals and proposed times. Consequently, the planned method was changed to identification of key ‘quality indicators' (QIs) for documentation of practice. Results The need to revise the method of measurement demonstrates the difficulty in assessing fidelity. Assessment of clinical logs revealed low levels of adherence to key quality indicators. However, it is unclear whether this indicates poor fidelity or an imprecise method of fidelity assessment. Conclusion This study highlights challenges of assessing fidelity to complex interventions. Lessons learned will inform the measurement of fidelity in a future trial. Researchers should be aware that the practical implementation of complex healthcare interventions may not be exactly as intended. For ICONS, clinical logs constituted a proxy measure of day-to-day fidelity to the intervention: identification of alternative methods could be considered.

BACKGROUND: The World Health Organisation reports that cancer mortality rates in developing African countries are rising because late diagnosis limits treatment options. In the UK there is evidence of inequalities in the delivery of cancer services to black and minority ethnic groups contributing to deaths from late diagnoses. UK studies of the African population are limited and focus on the African Caribbean community. Hence, UK cancer prevention strategies may not account for the African population’s cultural beliefs or attitudes towards cancer; this may affect awareness of the signs and symptoms. AIM: To identify evidence-based information about African immigrants’ views regarding cancer. METHODS: Six databases were searched: Academic Search Complete, AMED, CINAHL, MEDLINE, PsycInfo, and Soc Index. The literature search was extended to include grey literature and a search of reference lists of relevant studies. Publications not written in English were excluded. RESULTS: Six qualitative, nine quantitative, and one mixed method study were identified; all except two were conducted in the USA. The majority indicated that African people had low levels of knowledge about cancer risk factors, signs and symptoms. Misconceptions, cultural and religious belief and fear appear to influence African people’s views towards cancer; this may affects their behaviour in terms of seeking treatment. CONCLUSION: This review demonstrates a need for UK based studies to determine the relevance of review findings towards, and fill the gaps in knowledge about, the growing UK based African population.

Background: The implementation of research in practice is influenced not only by individual clinicians, but the organisational context in which they operate. Strategies aimed at increasing research use therefore need to incorporate a wider range of factors, rather than solely focusing on achieving change in individual practitioners. Content: This article presents findings relating to the identification of organisational factors facilitating research-based practice in allied health profession (AHP) departments. Fifty eight AHP clinicians and operational managers from nine teams participated in the study, representing four National Health Service organisations. Participants completed the benchmarking survey tool in their teams and were asked to provide examples of elements within their organisation which facilitated research-based practice in relation to 17 benchmarks of departmental context. Conclusions: The AHPs in this study provided a rich variety of indicators facilitating research-based practice in their organisations. There was some evidence of strategies in place to facilitate this at an organisational level but little evidence of collaboration across professional boundaries.

Repetitive task training resulted in modest improvement across a range of lower limb outcome measures, but not upper limb outcome measures. Training may be sufficient to have a small impact on activities of daily living. Interventions involving elements of repetition and task training are diverse and difficult to classify: the results presented are specific to trials where both elements are clearly present in the intervention, without major confounding by other potential mechanisms of action.

Background: Given the current emphasis on networks as vehicles for innovation and change in health service delivery, the ability to conceptualise and measure organisational enablers for the social construction of knowledge merits attention. This study aimed to develop a composite tool to measure the organisational context for evidence-based practice (EBP) in healthcare. Methods: A structured search of the major healthcare and management databases for measurement tools from four domains: research utilisation (RU), research activity (RA), knowledge management (KM), and organisational learning (OL). Included studies were reports of the development or use of measurement tools that included organisational factors. Tools were appraised for face and content validity, plus development and testing methods. Measurement tool items were extracted, merged across the four domains, and categorised within a constructed framework describing the absorptive and receptive capacities of organisations. Results: Thirty measurement tools were identified and appraised. Eighteen tools from the four domains were selected for item extraction and analysis. The constructed framework consists of seven categories relating to three core organisational attributes of vision, leadership, and a learning culture, and four stages of knowledge need, acquisition of new knowledge, knowledge sharing, and knowledge use. Measurement tools from RA or RU domains had more items relating to the categories of leadership, and acquisition of new knowledge; while tools from KM or learning organisation domains had more items relating to vision, learning culture, knowledge need, and knowledge sharing. There was equal emphasis on knowledge use in the different domains. Conclusion: If the translation of evidence into knowledge is viewed as socially mediated, tools to measure the organisational context of EBP in healthcare could be enhanced by consideration of related concepts from the organisational and management science

Background: The active practice of task-specific motor activities is a component of current approaches to stroke rehabilitation. Objectives: To determine if repetitive task training after stroke improves global, upper or lower limb function, and if treatment effects are dependent on the amount, type or timing of practice. Search strategy: We searched the Cochrane Stroke Trials Register (October 2006), The Cochrane Library, MEDLINE, EMBASE, CINAHL, AMED, SportDiscus, Science Citation Index, Index to Theses, ZETOC, PEDro, and OT Seeker (to September 2006), and OT search (to March 2006). We also searched for unpublished/non-English language trials, conference proceedings, combed reference lists, requested information on bulletin boards, and contacted trial authors. Selection criteria: Randomised/quasi-randomised trials in adults after stroke, where the intervention was an active motor sequence performed repetitively within a single training session, aimed towards a clear functional goal, and where the amount of practice could be quantified. Data collection and analysis: Two authors independently screened abstracts, extracted data and appraised trials. Assessment of methodological quality was undertaken for allocation concealment, blinding, loss to follow up and equivalence of treatment. We contacted trial authors for additional information. Main results: Fourteen trials with 17 intervention-control pairs and 659 participants were included. Primary outcomes: results were statistically significant for walking distance (mean difference (MD) 54.6, 95% CI 17.5 to 91.7); walking speed (standardised mean difference (SMD) 0.29, 95% CI 0.04 to 0.53); sit-to-stand (standard effect estimate 0.35, 95% CI 0.13 to 0.56); and of borderline statistical significance for functional ambulation (SMD 0.25, 95% CI 0.00 to 0.51), and global motor function (SMD 0.32, 95% CI -0.01 to 0.66). There were no statistically significant differences for hand/arm function, or sitting balance/reach. Sec