Frequency of dressing changes for central venous access devices on catheter-related infections

Background People admitted to intensive care units and those with chronic health care problems often require long-term vascular access. Central venous access devices (CVADs) are used for administering intravenous medications and blood sampling. CVADs are covered with a dressing and secured with an adhesive or adhesive tape to protect them from infection and reduce movement. Dressings are changed when they become soiled with blood or start to come away from the skin. Repeated removal and application of dressings can cause damage to the skin. The skin is an important barrier that protects the body against infection. Less frequent dressing changes may reduce skin damage, but it is unclear whether this practice affects the frequency of catheter-related infections. Objectives To assess the effect of the frequency of CVAD dressing changes on the incidence of catheter-related infections and other outcomes including pain and skin damage. Search methods In June 2015 we searched: The Cochrane Wounds Specialised Register; The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library); Ovid MEDLINE; Ovid MEDLINE (In-Process & Other Non-Indexed Citations); Ovid EMBASE and EBSCO CINAHL. We also searched clinical trials registries for registered trials. There were no restrictions with respect to language, date of publication or study setting. Selection criteria All randomised controlled trials (RCTs) evaluating the effect of the frequency of CVAD dressing changes on the incidence of catheter-related infections on all patients in any healthcare setting. Data collection and analysis We used standard Cochrane review methodology. Two review authors independently assessed studies for inclusion, performed risk of bias assessment and data extraction. We undertook meta-analysis where appropriate or otherwise synthesised data descriptively when heterogeneous. Main results We included five RCTs (2277 participants) that compared different frequencies of CVAD dressing changes. The studies were all conducted in Europe and published between 1995 and 2009. Participants were recruited from the intensive care and cancer care departments of one children's and four adult hospitals. The studies used a variety of transparent dressings and compared a longer interval between dressing changes (5 to15 days; intervention) with a shorter interval between changes (2 to 5 days; control). In each study participants were followed up until the CVAD was removed or until discharge from ICU or hospital. - Confirmed catheter-related bloodstream infection (CRBSI) One trial randomised 995 people receiving central venous catheters to a longer or shorter interval between dressing changes and measured CRBSI. It is unclear whether there is a difference in the risk of CRBSI between people having long or short intervals between dressing changes (RR 1.42, 95% confidence interval (CI) 0.40 to 4.98) (low quality evidence). - Suspected catheter-related bloodstream infection Two trials randomised a total of 151 participants to longer or shorter dressing intervals and measured suspected CRBSI. It is unclear whether there is a difference in the risk of suspected CRBSI between people having long or short intervals between dressing changes (RR 0.70, 95% CI 0.23 to 2.10) (low quality evidence). - All cause mortality Three trials randomised a total of 896 participants to longer or shorter dressing intervals and measured all cause mortality. It is unclear whether there is a difference in the risk of death from any cause between people having long or short intervals between dressing changes (RR 1.06, 95% CI 0.90 to 1.25) (low quality evidence). - Catheter-site infection Two trials randomised a total of 371 participants to longer or shorter dressing intervals and measured catheter-site infection. It is unclear whether there is a difference in risk of catheter-site infection between people having long or short intervals between dressing changes (RR 1.07, 95% CI 0.71 to 1.63) (low quality evidence). - Skin damage One small trial (112 children) and three trials (1475 adults) measured skin damage. There was very low quality evidence for the effect of long intervals between dressing changes on skin damage compared with short intervals (children: RR of scoring ≥ 2 on the skin damage scale 0.33, 95% CI 0.16 to 0.68; data for adults not pooled). - Pain Two studies involving 193 participants measured pain. It is unclear if there is a difference between long and short interval dressing changes on pain during dressing removal (RR 0.80, 95% CI 0.46 to 1.38) (low quality evidence). Authors' conclusions The best available evidence is currently inconclusive regarding whether longer intervals between CVAD dressing changes are associated with more or less catheter-related infection, mortality or pain than shorter intervals.

Information preferences for the evaluation of coastal development impacts on ecosystem services: A multi-criteria assessment in the Australian context

Ecosystem based management requires the integration of various types of assessment indicators. Understanding stakeholders' information preferences is important, in selecting those indicators that best support management and policy. Both the preferences of decision-makers and the general public may matter, in democratic participatory management institutions. This paper presents a multi-criteria analysis aimed at quantifying the relative importance to these groups of economic, ecological and socio-economic indicators usually considered when managing ecosystem services in a coastal development context. The Analytic Hierarchy Process (AHP) is applied within two nationwide surveys in Australia, and preferences of both the general public and decision-makers for these indicators are elicited and compared. Results show that, on average across both groups, the priority in assessing a generic coastal development project is for the ecological assessment of its impacts on marine biodiversity. Ecological assessment indicators are globally preferred to both economic and socio-economic indicators regardless of the nature of the impacts studied. These results are observed for a significantly larger proportion of decision-maker than general public respondents, questioning the extent to which the general public's preferences are well reflected in decision-making processes.

Evaluating the effects of international exposure from networks ties and mimetic pressure on clustered SMEs in Brazil

Research on the internationalisation of small and medium-sized enterprises (SMEs) has received increasing attention in recent years due to the important role they play in today’s economic environment. Internationalisation prompting, or awareness, is an already recognised phase of the innovation-related stages model (I-model). This phase of awareness is closely related to the international exposure that a firm may experience during the occasion when it realises its competitors are already internationalising. Although the literature has discussed the various forms in which international exposure may happen, there has been limited attention given to the extent of its effect on the internationalisation of clustered SMEs that behave according to the I-Model. This study will assess the applicability of the I-Model in a dynamic, competitive and co-operative setting of an industrial cluster. It also evaluates the impact (if any) of international exposure derived from networks and the mimetic pressure that these firms may experience due to their embeddedness in an industrial cluster. Results from this study will indicate the effectiveness of the improved adapted model that will provide a richer insight for both academic researchers and policy makers.

Use and usability of custom-made orthopedic shoes

The goal of this study was to investigate the use of custom-made orthopedic shoes (OS) and the association between the use of OS and the most relevant aspects of their usability. Over a 6-month period, patients meeting the inclusion criteria were recruited by 12 orthopedic shoe companies scattered throughout the Netherlands and asked to complete a questionnaire composed of a pre- and post-OS section. Patients with different pathologies were included in the study (n = 339; response 67%). Mean age of the patients was 63 +/- 15 years, and 38% were male. Three months after delivery, 81% of the patients used their OS frequently (4-7 days/week), 13% occasionally (1-3 days/week), and 6% did not use their OS. Associations were found between use and all measured aspects of usability (p-values varied from <0.001 to 0.028). Patients who used their OS more often had a more positive opinion regarding all the aspects of usability. We conclude that all aspects of the usability of OS are relevant in relation to their use and should be taken into account when prescribing and evaluating OS.

Evaluating the specificity of community injury hospitalization data over time

This study identified the areas of poor specificity in national injury hospitalization data and the areas of improvement and deterioration in specificity over time. A descriptive analysis of ten years of national hospital discharge data for Australia from July 2002-June 2012 was performed. Proportions and percentage change of defined/undefined codes over time was examined. At the intent block level, accidents and assault were the most poorly defined with over 11% undefined in each block. The mechanism blocks for accidents showed a significant deterioration in specificity over time with up to 20% more undefined codes in some mechanisms. Place and activity were poorly defined at the broad block level (43% and 72% undefined respectively). Private hospitals and hospitals in very remote locations recorded the highest proportion of undefined codes. Those aged over 60 years and females had the higher proportion of undefined code usage. This study has identified significant, and worsening, deficiencies in the specificity of coded injury data in several areas. Focal attention is needed to improve the quality of injury data, especially on those identified in this study, to provide the evidence base needed to address the significant burden of injury in the Australian community.

Carbon sequestration: Evaluating the impact on rural land and valuation approach

This thesis uses semi-structured interviews and documentary analysis to explore the impact of carbon sequestration rights on rural land in Queensland and to determine whether current rural valuation knowledge and practice is equipped to deal with these rights. The carbon right in Queensland is complex and subject to significant individual variation. The nature and form of this right will determine whether it has a positive or negative impact on Queensland rural land. Significant gaps in the knowledge of industry stakeholders, including rural valuers, concerning carbon rights were found, and recommendations for valuation practice were made.

A multi-criteria approach for hospital capacity analysis

Hospitals are critical elements of health care systems and analysing their capacity to do work is a very important topic. To perform a system wide analysis of public hospital resources and capacity, a multi-objective optimization (MOO) approach has been proposed. This approach identifies the theoretical capacity of the entire hospital and facilitates a sensitivity analysis, for example of the patient case mix. It is necessary because the competition for hospital resources, for example between different entities, is highly influential on what work can be done. The MOO approach has been extensively tested on a real life case study and significant worth is shown. In this MOO approach, the epsilon constraint method has been utilized. However, for solving real life applications, with a large number of competing objectives, it was necessary to devise new and improved algorithms. In addition, to identify the best solution, a separable programming approach was developed. Multiple optimal solutions are also obtained via the iterative refinement and re-solution of the model.

Exploring the role of lean thinking in sustainable business practice

A large and growing body of literature has explored corporate environmental sustainability initiatives and their impacts locally, regionally and internationally. While the initiatives provide examples of environmental stewardship and cleaner production, a large proportion of the organisations considered in this literature have ‘sustainable practice’, ‘environmental stewardship’ or similar goals as add-ons to their core business strategy. Furthermore, there is limited evidence of organizations embracing and internalising sustainability principles throughout their activities, products or services. Many challenges and barriers impede outcomes as whole system design or holistic approach to address environmental issues, with some evidence to suggest that targeted initiatives could be useful in making progress. ‘Lean management’ and other lean thinking strategies are often put forward as part of such targeted approaches. Within this context, the authors have drawn on current literature to undertake a review of lean thinking practices and how these influence sustainable business practice, considering the balance of environmental and economic aspects of triple bottom line in sustainability. The review methodology comprised firstly identifying theoretical constructs to be studied, developing criteria for categorising the literature, evaluating the findings within each category and considering the implications of the findings for areas for future research. The evaluation revealed two main areas of consideration: - a) lean manufacturing tools and environmental performance, and; - b) integrated lean and green models and approaches. However the review highlighted the ad hoc use of lean thinking within corporate sustainability initiatives, and established a knowledge gap in the form of a system for being able to consider different categories of environmental impacts in different industries and choose best lean tools or models for a particular problem in a way to ensure holistic exploration. The findings included a specific typology of lean tools for different environmental impacts, drawing from multiple case studies. Within this research context, this paper presents the findings of the review; namely the emerging consensus on the relationships between lean thinking and sustainable business practice. The paper begins with an overview of the current literature regarding lean thinking and its documented role in sustainable business practice. The paper then includes an analysis of lean and green paradigms in different industries; and describes the typology of lean tools used to reduce specific environmental impacts and, integrated lean and green models and approaches. The paper intends to encourage industrial practitioners to consider the merits and potential risks with using specific lean tools to reduce context-specific environmental impacts. It also aims to highlight the potential for further investigation with regard to comparing different industries and conceptualising a generalizable system for ensuring lean thinking initiatives build towards sustainable business practice.

Evaluating viewpoint entropy for ribbon representation of protein structure

While many measures of viewpoint goodness have been proposed in computer graphics, none have been evaluated for ribbon representations of protein secondary structure. To fill this gap, we conducted a user study on Amazon’s Mechanical Turk platform, collecting human viewpoint preferences from 65 participants for 4 representative su- perfamilies of protein domains. In particular, we evaluated viewpoint entropy, which was previously shown to be a good predictor for human viewpoint preference of other, mostly non-abstract objects. In a second study, we asked 7 molecular biology experts to find the best viewpoint of the same protein domains and compared their choices with viewpoint entropy. Our results show that viewpoint entropy overall is a significant predictor of human viewpoint preference for ribbon representations of protein secondary structure. However, the accuracy is highly dependent on the complexity of the structure: while most participants agree on good viewpoints for small, non-globular structures with few secondary structure elements, viewpoint preference varies considerably for complex structures. Finally, experts tend to choose viewpoints of both low and high viewpoint entropy to emphasize different aspects of the respective structure.

The tired foot. The effects of physical activity, energy expenditure and sleep on the diabetic foot population

Background The most common pathway to development of diabetes foot ulcers is repetitive daily activity stress on the plantar surface of the neuropathic foot. Studies suggest an association between different diabetic foot complications and physical activity. However, to the best of the authors knowledge the steps/day and sleep patterns of people with diabetic foot ulcers has yet to be investigated. This observational study aims to investigate the physical activity and sleep patterns of three groups of adults with type 2 diabetes and different foot complications Methods Participants with type 2 diabetes were recruited into three groups: 1. those with no reported foot complications (DNIL), 2. those with diagnosis of neuropathy (DPN) and 3. those with a neuropathic ulcer (DFU). Exclusion criteria included peripheral arterial disease and mobility aid use. Participants wore a SenseWear Pro 3 Armband continuously for 7 days and completed an Epworth Sleepiness Scale. The Armband is a validated automated measure of activity (walking steps, average Metabolic Equivalent Task (MET), physical activity (>3 METs) duration), energy expenditure(kJ) (total and physical activity (>3 METs)) and sleep (duration). Data on age, sex, BMI, diabetes duration and HbA1c were also collected. Results Sixty-Six (14 DNIL, 22 DPN and 30 DFU's participants were recruited; 71% males, mean age 61(±12) years, diabetes duration 13(±9) years, HbA1c 8.3(±2.8), BMI 32.6(±5.9), average METs 1.2(0.2). Significant differences were reported in mean(SD) steps/day (5,859(±2,381) in DNIL; 5,007(±3,349) in DPN and 3,271(±2,417) in DFU's and daily energy expenditure (10,868(±1,307)kJ in DNIL; 11,060(±1,916)kJ in DPN and 13,006(± 3,559) in DFU's(p <0.05). No significant differences were reported for average METs, physical activity duration or energy expenditure, sleep time or Epworth score (p>0.1). Conclusions Preliminary findings suggest people with diabetes are sedentary. Results indicate that patients with a diabetic foot ulcer work significantly less than those with neuropathy or nil complications and use significantly more energy to do so. Sleep Parameters showed no differences. Recruitment is still on going.

Social determinants of health and diabetic foot disease

Background Diabetic foot disease (DFD) is the leading cause of hospitalisation and lower extremity amputation (LEA) in people with diabetes. Many studies have established the relationship between DFD and clinical risk factors, such as peripheral neuropathy and peripheral arterial disease. Other studies have identified the relationship between diabetes and non-clinical risk factors termed social determinants of health (SDoH), such as socioeconomic status. However, it appears very few studies have investigated the relationship between DFD and SDoH. This paper aims to review the existing literature investigating the relationship between DFD and the SDoH factors socioeconomic status (SES), race and geographical remoteness (remoteness). Process Electronic databases (MEDLINE, CINAHL, and PubMed) were searched for studies reporting SES, race (including Aboriginal and Torres Strait Islander in Australia) and remoteness and their relationship to DFD and LEA. Exclusion criteria were studies conducted in developing countries and studies published prior to 2000. Findings Forty-eight studies met the inclusion criteria and were reviewed; 10 in Australia. Overall, 28 (58%) studies investigated LEA, 10 (21%) DFD, and 10 (21%) DFD and LEA as the DFD-related outcome. Thirty-six (75%) studies investigated the SDoH risk factor of race, 22 (46%) SES, and 20 (42%) remoteness. SES, race and remoteness were found to be individually associated with LEA and DFD in the majority of studies. Only four studies investigated interactions between SES, race and remoteness and DFD with contrasting findings. All four studies used only LEA as their investigated outcome. No Australian studies investigate the interaction of all three SDoH risk factors on DFD outcomes. Conclusions The SDoH risk factors of SES, race and GR appear to be individually associated with DFD. However, only few studies investigated the interaction of these three major SDoH risk factors and DFD outcomes with contrasting results. There is a clear gap in this area of DFD research and particularly in Australia. Until urgent future research is performed, current practice and policy does not adequately take into consideration the implication of SDoH on DFD.

IASDR 2015 Interplay Exhibition 2-5 NOV 2015

It has been said that we are living in a golden age of innovation. New products, systems and services aimed to enable a better future, have emerged from novel interconnections between design and design research with science, technology and the arts. These intersections are now, more than ever, catalysts that enrich daily activities for health and safety, education, personal computing, entertainment and sustainability, to name a few. Interactive functions made possible by new materials, technology, and emerging manufacturing solutions demonstrate an ongoing interplay between cross-disciplinary knowledge and research. Such interactive interplay bring up questions concerning: (i) how art and design provide a focus for developing design solutions and research in technology; (ii) how theories emerging from the interactions of cross-disciplinary knowledge inform both the practice and research of design and (iii) how research and design work together in a mutually beneficial way. The IASDR2015 INTERPLAY EXHIBITION provides some examples of these interconnections of design research with science, technology and the arts. This is done through the presentation of objects, artefacts and demonstrations that are contextualised into everyday activities across various areas including health, education, safety, furniture, fashion and wearable design. The exhibits provide a setting to explore the various ways in which design research interacts across discipline knowledge and approaches to stimulate innovation. In education, Designing South African Children’s Health Education as Generative Play (A Bennett, F Cassim, M van der Merwe, K van Zijil, and M Ribbens) presents a set of toolkits that resulted from design research entailing generative play. The toolkits are systems that engender pleasure and responsibility, and are aimed at cultivating South African’s youth awareness of nutrition, hygiene, disease awareness and prevention, and social health. In safety, AVAnav: Avalanche Rescue Helmet (Jason Germany) delivers an interactive system as a tool to contribute to reduce the time to locate buried avalanche victims. Helmet-mounted this system responds to the contextual needs of rescuers and has since led to further design research on the interface design of rescuing devices. In apparel design and manufacturing, Shrinking Violets: Fashion design for disassembly (Alice Payne) proposes a design for disassembly through the use of beautiful reversible mono-material garments that interactively responds to the challenges of garment construction in the fashion industry, capturing the metaphor for the interplay between technology and craft in the fashion manufacturing industry. Harvest: A biotextile future (Dean Brough and Alice Payne), explores the interplay of biotechnology, materiality and textile design in the creation of sustainable, biodegradable vegan textile through the process of a symbiotic culture of bacteria and yeast (SCOBY). SCOBY is a pellicle curd that can be harvested, machine washed, dried and cut into a variety of designs and texture combinations. The exploration of smart materials, wearable design and micro-electronics led to creative and aesthetically coherent stimulus-reactive jewellery; Symbiotic Microcosms: Crafting Digital Interaction (K Vones). This creation aims to bridge the gap between craft practitioner and scientific discovery, proposing a move towards the notion of a post-human body, where wearable design is seen as potential ground for new human-computer interactions, affording the development of visually engaging multifunctional enhancements. In furniture design, Smart Assistive chair for older adults (Chao Zhao) demonstrates how cross-disciplinary knowledge interacting with design strategies provide solution that employed new technological developments in older aged care, and the participation of multiple stakeholders: designers, health care system and community based health systems. In health, Molecular diagnosis system for newborns deafness genetic screening (Chao Zhao) presents an ambitious and complex project that includes a medical device aimed at resolving a number of challenges: technical feasibility for city and rural contexts, compatibility with standard laboratory and hospital systems, access to health system, and support the work of different hospital specialists. The interplay between cross-disciplines is evident in this work, demonstrating how design research moves forward through technology developments. These works exemplify the intersection between domains as a means to innovation. Novel design problems are identified as design intersects with the various areas. Research informs this process, and in different ways. We see the background investigation into the contextualising domain (e.g. on-snow studies, garment recycling, South African health concerns, the post human body) to identify gaps in the area and design criteria; the technologies and materials reviews (e.g. AR, biotextiles) to offer plausible technical means to solve these, as well as design criteria. Theoretical reviews can also inform the design (e.g. play, flow). These work together to equip the design practitioner with a robust set of ‘tools’ for design innovation – tools that are based in research. The process identifies innovative opportunity and criteria for design and this, in turn, provides a means for evaluating the success of the design outcomes. Such an approach has the potential to come full circle between research and design – where the design can function as an exemplar, evidencing how the research-articulated problems can be solved. Core to this, however, is the evaluation of the design outcome itself and identifying knowledge outcomes. In some cases, this is fairly straightforward that is, easily measurable. For example the efficacy of Jason Germany’s helmet can be determined by measuring the reduced response time in the rescuer. Similarly the improved ability to recycle Payne’s panel garments can be clearly determined by comparing it to those recycling processes (and her identified criteria of separating textile elements!); while the sustainability and durability of the Brough & Payne’s biotextile can be assessed by documenting the growth and decay processes, or comparative strength studies. There are however situations where knowledge outcomes and insights are not so easily determined. Many of the works here are open-ended in their nature, as they emphasise the holistic experience of one or more designs, in context: “the end result of the art activity that provides the health benefit or outcome but rather, the value lies in the delivery and experience of the activity” (Bennet et al.) Similarly, reconfiguring layers of laser cut silk in Payne’s Shrinking Violets constitutes a customisable, creative process of clothing oneself since it “could be layered to create multiple visual effects”. Symbiotic Microcosms also has room for facilitating experience, as the work is described to facilitate “serendipitous discovery”. These examples show the diverse emphasis of enquiry as on the experience versus the product. Open-ended experiences are ambiguous, multifaceted and differ from person to person and moment to moment (Eco 1962). Determining the success is not always clear or immediately discernible; it may also not be the most useful question to ask. Rather, research that seeks to understand the nature of the experience afforded by the artefact is most useful in these situations. It can inform the design practitioner by helping them with subsequent re-design as well as potentially being generalizable to other designers and design contexts. Bennett et. al exemplify how this may be approached from a theoretical perspective. This work is concerned with facilitating engaging experiences to educate and, ultimately impact on that community. The research is concerned with the nature of that experience as well, and in order to do so the authors have employed theoretical lenses – here these are of flow, pleasure, play. An alternative or complementary approach to using theory, is using qualitative studies such as interviews with users to ask them about what they experienced? Here the user insights become evidence for generalising across, potentially revealing insight into relevant concerns – such as the range of possible ‘playful’ or experiences that may be afforded, or the situation that preceded a ‘serendipitous discovery’. As shown, IASDR2015 INTERPLAY EXHIBITION provides a platform for exploration, discussion and interrogation around the interplay of design research across diverse domains. We look forward with excitement as IASDR continues to bring research and design together, and as our communities of practitioners continue to push the envelope of what is design and how this can be expanded and better understood with research to foster new work and ultimately, stimulate innovation.

Evaluating China’s aspirations for cultural soft power in a post-globalisation era

‘Soft power’ has been a concept that has generated great political and scholarly interest in China, as it raises the question of how to achieve cultural standing commensurate with the nation’s growing economic significance. But from the perspectives of communication and cultural studies, we can identify limits with both ‘soft power’ as a concept and how it understands culture and communication, and the assumptions made about the capacities of state cultural promotion through media to appeal to global audiences. Drawing upon case studies of the United States, the United Kingdom, Russia, India, Japan and South Korea, this article identified challenges and opportunities for China in growing its international cultural soft power in a ‘post-globalisation’ era.

Evaluating the effectiveness of a self-management exercise intervention on wound healing, functional ability and health-related quality of life outcomes in adults with venous leg ulcers: a randomised controlled trial

Exercise that targets ankle joint mobility may lead to improvement in calf muscle pump function and subsequent healing. The objectives of this research were to assess the impact of an exercise intervention in addition to routine evidence-based care on the healing rates, functional ability and health-related quality of life for adults with venous leg ulcers (VLUs). This study included 63 patients with VLUs. Patients were randomised to receive either a 12-week exercise intervention with a telephone coaching component or usual care plus telephone calls at the same timepoints. The primary outcome evaluated the effectiveness of the intervention in relation to wound healing. The secondary outcomes evaluated physical activity, functional ability and health-related quality of life measures between groups at the end of the 12 weeks. A per protocol analysis complemented the effectiveness (intention-to-treat) analysis to highlight the importance of adherence to an exercise intervention. Intention-to-treat analyses for the primary outcome showed 77% of those in the intervention group healed by 12 weeks compared to 53% of those in the usual care group. Although this difference was not statistically significant due to a smaller than expected sample size, a 24% difference in healing rates could be considered clinically significant. The per protocol analysis for wound healing, however, showed that those in the intervention group who adhered to the exercise protocol 75% or more of the time were significantly more likely to heal and showed higher rates for wound healing than the control group (P = 0·01), that is, 95% of those who adhered in the intervention group healed in 12 weeks. The secondary outcomes of physical activity, functional ability and health-related quality of life were not significantly altered by the intervention. Among the secondary outcomes (physical activity, functional ability and health-related quality of life), intention-to-treat analyses did not support the effectiveness of the intervention. However, per protocol analyses revealed encouraging results with those participants who adhered more than 75% of the time (n = 19) showing significantly improved Range of Ankle Motion from the self-management exercise programme (P = 0·045). This study has shown that those participants who adhere to the exercise programme as an adjunctive treatment to standard care are more likely to heal and have better functional outcomes than those who do not adhere to the exercises in conjunction with usual care.