A rehabilitation intervention to promote physical recovery following intensive care: a detailed description of construct development, rationale and content together with proposed taxonomy to capture processes in a randomised controlled trial.

Background: increasing numbers of patients are surviving critical illness, but survival may be associated with a constellation of physical and psychological sequelae that can cause on going disability and reduced health-related quality of life. Limited evidence currently exists to guide the optimum structure, timing, and content of rehabilitation programmes. There is a need to both develop and evaluate interventions to support and expedite recovery during the post-ICU discharge period. This paper describes the construct development for a complex rehabilitation intervention intended to promote physical recovery following critical illness. The intervention is currently being evaluated in a randomised trial (ISRCTN09412438; funder Chief Scientists Office, Scotland). Methods: the intervention was developed using the Medical Research Council (MRC) framework for developing complex healthcare interventions. We ensured representation from a wide variety of stakeholders including content experts from multiple specialties, methodologists, and patient representation. The intervention construct was initially based on literature review, local observational and audit work, qualitative studies with ICU survivors, and brainstorming activities. Iterative refinement was aided by the publication of a National Institute for Health and Care Excellence guideline (No. 83), publicly available patient stories (Healthtalkonline), a stakeholder event in collaboration with the James Lind Alliance, and local piloting. Modelling and further work involved a feasibility trial and development of a novel generic rehabilitation assistant (GRA) role. Several rounds of external peer review during successive funding applications also contributed to development. Results: the final construct for the complex intervention involved a dedicated GRA trained to pre-defined competencies across multiple rehabilitation domains (physiotherapy, dietetics, occupational therapy, and speech/language therapy), with specific training in post-critical illness issues. The intervention was from ICU discharge to 3 months post-discharge, including inpatient and post-hospital discharge elements. Clear strategies to provide information to patients/families were included. A detailed taxonomy was developed to define and describe the processes undertaken, and capture them during the trial. The detailed process measure description, together with a range of patient, health service, and economic outcomes were successfully mapped on to the modified CONSORT recommendations for reporting non-pharmacologic trial interventions. Conclusions: the MRC complex intervention framework was an effective guide to developing a novel post-ICU rehabilitation intervention. Combining a clearly defined new healthcare role with a detailed taxonomy of process and activity enabled the intervention to be clearly described for the purpose of trial delivery and reporting. These data will be useful when interpreting the results of the randomised trial, will increase internal and external trial validity, and help others implement the intervention if the intervention proves clinically and cost effective.

Consciousness, solidarity and hope as prevention and rehabilitation

This paper grapples with the question of how progressive criminologists might approach working with people who have committed violent or predatory crimes, or are ‘at risk’ of doing so. Progressives have often been uneasy about ‘intervention’ with people who offend: but in the face of the destructiveness of violence, especially in some parts of the world, a posture of simple non-intervention won’t suffice. I suggest three central principles – which I call consciousness, solidarity and hope – that may guide us in developing ways of working with offenders that are both progressive and effective.

Women, environmental changes and forestry-related development : Gender-affected roles of rural people in land degradation and environmental rehabilitation in a dry region of Sudan

The purpose of the present study was to increase understanding of the interaction of rural people and, specifically, women with the environment in a dry area in Sudan. The study that included both nomadic pastoralists and farmers aimed at answering two main research questions, namely: What kinds of roles have the local people, and the women in particular, had in land degradation in the study area and what kinds of issues would a gender-sensitive, forestry-related environmental rehabilitation intervention need to consider there? The study adopted the definition of land degradation as proposed by the United Nations Convention to Combat Desertification (UNCCD), which describes land degradation as reduction or loss the biological or economic productivity and complexity of land in arid, semi-arid and dry sub-humid areas. The Convention perceives desertification as land degradation. The dry study area in Sudan, South of the Sahara, has been the subject of land degradation or desertification discussions since the 1970s, and other studies have been also conducted to assess the degradation in the area. Nevertheless, the exact occurrence, scale and local significance of land degradation in the area is still unclear. This study explored how the rural population whose livelihood depended on the area, perceived environmental changes occurring there and compared their conceptions with other sources of information of the area such as research reports. The main fieldwork methods included interviews with open-ended questions and observation of people and the environment. The theoretical framework conceptualised the rural population as land users whose choices of environmental activities are affected by multiple factors in the social and biophysical contexts in which they live. It was emphasised that these factors have their own specific characteristics in different contexts, simultaneously recognising that there are also factors that generally affect environmental practices in various areas such as the land users' environmental literacy (conceptions of the environment), gender and livelihood needs. The people studied described that environmental changes, such as reduced vegetation cover and cropland production, had complicated the maintenance of their livelihoods in the study area. Some degraded sites were also identified through observations during the fieldwork. Whether a large-scale reduction of cropland productivity had occurred in the farmers' croplands remained, however, unclear. The study found that the environmental impact of the rural women's activities varied and was normally limited. The women's most significant environmental impact resulted from their cutting of trees, which was likely to contribute, at least in some places, to land degradation, affecting the environment together with climate and livestock. However, when a wider perspective is taken, it becomes questionable whether the women have really played roles in land degradation, since gender, poverty and the need to maintain livelihood had caused them to conduct environmentally harmful activities. The women have had, however, no power to change the causes of their activities. The findings further suggested that an inadequate availability of food was the most critical problem in the study area. Therefore, an environmental programme in the area was suggested to include technical measures to increase the productivity of croplands, opportunities for income generation and readiness to co-operate with other programmes to improve the local people's abilities to maintain their livelihoods. In order to protect the environment and alleviate the women's work burden, the introduction of fuel-saving stoves was also suggested. Furthermore, it was suggested that increased planting of trees on homesteads would be supported by an easy availability of tree seedlings. Planting trees on common property land was, however, perceived as extremely demanding in the study area, due to scarcity of such land. In addition, it became apparent that the local land users, and women in particular, needed to allocate their labour to maintain the immediate livelihood of their families and were not motivated to allocate their labour solely for environmental rehabilitation. Nonetheless, from the point of view of the existing social structures, women's active participation in a community-based environmental programme would be rather natural, particularly among the farmer women who had already formed a women's group and participated in communal decision making. Forming of a women group or groups was suggested to further support both the farmer women's and pastoral women's active participation within an environmental programme and their general empowerment. An Environmental programme would need to acknowledge that improving rural people's well-being and maintaining their livelihood in the study area requires development and co-operation with various sectors in Sudan.

Depression and anxiety symptoms affect change in exercise capacity during cardiac rehabilitation

BACKGROUND: To study whether symptoms of depression and anxiety would affect changes in exercise capacity and body mass index (BMI) during rehabilitation. DESIGN: Comprehensive cardiac outpatient rehabilitation intervention program. METHODS: We investigated exercise capacity, BMI, and symptoms of depression and anxiety before and after cardiac rehabilitation in 114 patients with coronary artery disease. The Hospital Anxiety and Depression Scale (HADS) was applied to assess symptoms of depression (HADS-D) and anxiety (HADS-A). RESULTS: Exercise capacity increased (127+/-47 vs. 144+/-51 watts, P<0.001) and symptoms of depression (4.0+/-3.6 vs. 2.7+/-2.7, P<0.001) and anxiety (5.4+/-4.4 vs. 4.1+/-3.6, P<0.001) decreased with the program, whereas BMI did not change. After controlling for covariates, HADS-D (r=-0.19, P=0.47) and HADS-A (r=0.17, P<0.09) correlated with change in exercise capacity. Change in HADS-A also correlated with that in exercise capacity (r=0.18, P<0.06). Changes in depression and anxiety were not significantly related to those in BMI. CONCLUSION: Symptoms of depression and anxiety affected change in exercise capacity during cardiac rehabilitation. Depressive symptoms may impair improvement in exercise capacity, thereby mitigating the cardiovascular benefit achieved by cardiac rehabilitation programs.

The template: A cooperative approach to evaluating community rehabilitation services

This article describes a workshop and consultation process utilized by four community rehabilitation services and other stakeholders. This process led to the development of an evaluation Template upon which to plan a service evaluation. The Template comprises a number of guiding questions within three broad domains. These are, the people domain (pertaining to the client, their disability, their family and service context), the program domain (pertaining to the service and its activities), and the perspective domain (pertaining to the broader social and community context). It is suggested that the Template, the process by which it was developed, and the guidelines for its use will have relevance to rehabilitation managers, administrators, and others involved in evaluation of community rehabilitation services.

Vocational rehabilitation in psychiatry: A re-evaluation

Objective: To highlight the vocational gap in the provision of psychiatric rehabilitation, to outline the goals and conceptual framework of psychiatric rehabilitation, and to discuss rehabilitation interventions with specific reference to vocational rehabilitation and the evidence base for supported employment. Conclusions and service implications: Vocational psychiatric rehabilitation has been a neglected area of practice in Australian psychiatry. Psychiatric treatment needs to adopt a more balanced approach in the provision of a range of services, including vocational rehabilitation, in order to improve long-term outcomes for people suffering from psychiatric disability. A vocational focus should be included in psychiatric rehabilitation and better integration between mental health services and vocational services needs to take place. Supported employment is an evidence-based practice that is designed to help people with psychiatric disabilities participate as much as possible in the competitive job market.

Effects of pelvic floor muscle rehabilitation on PFM function and morphology in older women

Aims The purpose of this study was to examine the effect of a pelvic floor muscle (PFM) rehabilitation program on incontinence symptoms, PFM function, and morphology in older women with SUI. Methods Women 60 years old and older with at least weekly episodes of SUI were recruited. Participants were evaluated before and after a 12-week group PFM rehabilitation intervention. The evaluations included 3-day bladder diaries, symptom, and quality of life questionnaires, PFM function testing with dynamometry (force) and electromyography (activation) during seven tasks: rest, PFM maximum voluntary contraction (MVC), straining, rapid-repeated PFM contractions, a 60 sec sustained PFM contraction, a single cough and three repeated coughs, and sagittal MRI recorded at rest, during PFM MVCs and during straining to assess PFM morphology. Results Seventeen women (68.9 ± 5.5 years) participated. Following the intervention the frequency of urine leakage decreased and disease-specific quality of life improved significantly. PFM function improved significantly: the participants were able to perform more rapid-repeated PFM contractions; they activated their PFMs sooner when coughing and they were better able to maintain a PFM contraction between repeated coughs. Pelvic organ support improved significantly: the anorectal angle was decreased and the urethrovescial junction was higher at rest, during contraction and while straining. Conclusions This study indicated that improvements in urine leakage were produced along with improvements in PFM co-ordination (demonstrated by the increased number of rapid PFM contractions and the earlier PFM activation when coughing), motor-control, pelvic organ support.

Effects of pelvic floor muscle rehabilitation on PFM function and morphology in older women

Aims The purpose of this study was to examine the effect of a pelvic floor muscle (PFM) rehabilitation program on incontinence symptoms, PFM function, and morphology in older women with SUI. Methods Women 60 years old and older with at least weekly episodes of SUI were recruited. Participants were evaluated before and after a 12-week group PFM rehabilitation intervention. The evaluations included 3-day bladder diaries, symptom, and quality of life questionnaires, PFM function testing with dynamometry (force) and electromyography (activation) during seven tasks: rest, PFM maximum voluntary contraction (MVC), straining, rapid-repeated PFM contractions, a 60 sec sustained PFM contraction, a single cough and three repeated coughs, and sagittal MRI recorded at rest, during PFM MVCs and during straining to assess PFM morphology. Results Seventeen women (68.9 ± 5.5 years) participated. Following the intervention the frequency of urine leakage decreased and disease-specific quality of life improved significantly. PFM function improved significantly: the participants were able to perform more rapid-repeated PFM contractions; they activated their PFMs sooner when coughing and they were better able to maintain a PFM contraction between repeated coughs. Pelvic organ support improved significantly: the anorectal angle was decreased and the urethrovescial junction was higher at rest, during contraction and while straining. Conclusions This study indicated that improvements in urine leakage were produced along with improvements in PFM co-ordination (demonstrated by the increased number of rapid PFM contractions and the earlier PFM activation when coughing), motor-control, pelvic organ support.

Changes in urethral sphincter size following rehabilitation in older women with stress urinary incontinence

Introduction and hypothesis The purpose of this study was to evaluate the effects of a pelvic floor muscle (PFM) rehabilitation program on the striated urethral sphincter in women over 60 years with stress urinary incontinence (SUI). We hypothesized that the PFM rehabilitation program would also exercise the striated urethral sphincter and that this would be demonstrated by hypertrophy of the sphincter on magnetic resonance imaging (MRI). Methods Women with at least weekly episodes of SUI were recruited. Participants were evaluated before and after a 12-week group PFM rehabilitation intervention with T2-weighted fast-spin-echo MRI sequences recorded in the axial plane at rest to assess urethral sphincter size. Data on SUI symptoms and their bother were also collected. No control group was included. Results Seventeen women participated in the study. The striated urethral sphincter increased significantly in thickness (21 %, p < 0.001), cross-sectional area (20 %, p = 0.003), and volume (12 %, p = 0.003) following the intervention. The reported number of incontinence episodes and their bother also decreased significantly. Conclusions This study appears to demonstrate that PFM training for SUI also trains the striated urethral sphincter and that improvement in incontinence signs and symptoms is associated with sphincter hypertrophy in older women with SUI. These findings support previous ultrasound (US) data showing an increase in urethral cross-sectional area following PFM training and extend the previous findings by more specifically assessing the area of hypertrophy and by demonstrating that older women present the same changes as younger women when assessed using MRI data.

Changes in urethral sphincter size following rehabilitation in older women with stress urinary incontinence

Introduction and hypothesis The purpose of this study was to evaluate the effects of a pelvic floor muscle (PFM) rehabilitation program on the striated urethral sphincter in women over 60 years with stress urinary incontinence (SUI). We hypothesized that the PFM rehabilitation program would also exercise the striated urethral sphincter and that this would be demonstrated by hypertrophy of the sphincter on magnetic resonance imaging (MRI). Methods Women with at least weekly episodes of SUI were recruited. Participants were evaluated before and after a 12-week group PFM rehabilitation intervention with T2-weighted fast-spin-echo MRI sequences recorded in the axial plane at rest to assess urethral sphincter size. Data on SUI symptoms and their bother were also collected. No control group was included. Results Seventeen women participated in the study. The striated urethral sphincter increased significantly in thickness (21 %, p < 0.001), cross-sectional area (20 %, p = 0.003), and volume (12 %, p = 0.003) following the intervention. The reported number of incontinence episodes and their bother also decreased significantly. Conclusions This study appears to demonstrate that PFM training for SUI also trains the striated urethral sphincter and that improvement in incontinence signs and symptoms is associated with sphincter hypertrophy in older women with SUI. These findings support previous ultrasound (US) data showing an increase in urethral cross-sectional area following PFM training and extend the previous findings by more specifically assessing the area of hypertrophy and by demonstrating that older women present the same changes as younger women when assessed using MRI data.

Terveyteen liittyvä elämänlaatu laitoskuntoutuksen vaikuttavuuden arvioinnissa : RAND-36-mittarin soveltuvuus työikäisten laitoskuntoutuksen ongelmaprofiilin määrittämiseen ja kuntoutuksen vaikutusten arvioimiseen

The aim of the present research was to examine the validity of the RAND-36 measure of health-related quality of life among the working age rehabilitation clients. The research included two cross-sectional studies and one follow-up study. The subjects of the first study (n = 794) participated in the first period of the five following types of rehabilitation: occupationally oriented medical rehabilitation, musculoskeletal rehabilitation, medical rehabilitation for job burnout, rehabilitation for supporting the work ability and capacity of disabled subjects (vocational rehabilitation) and individualized rehabilitation between October 2000 and October 2001. The subjects of the second study (n = 990) participated in the same rehabilitation during their first rehabilitation period between May 2007 and May 2008. The first subjects participated in a follow-up period no later than May 2003 with the exception of the individual rehabilitation clients (n = 588). Based on the ICF classification, the RAND-36 provides a diverse measure of the health-related quality of life and of the capacity for subjective, perceived physical and psycho-social functioning. The construct properties of the RAND-36 measure proved to be very consistent on the basis of both the cluster and confirmatory factor analyses. At the group level, the RAND-36 measure was shown to be illustrative and sensitive in differentiating the clients’ rehabilitation needs. The results of cluster analyses with the two cross-sectional data indicated a consistent five-cluster solution of rehabilitation groups on the basis of the eight subscales of health-related quality of life. Each of these clusters represented a clear difference in their need for rehabilitation. The RAND-36 measure proved to be sensitive to change. The changes observed in the pre- and post-conditions in relation to all the subscales of quality of life were statistically significant. Depending on the rehabilitation type, different changes in the subscales of the measure were observed, and these changes corresponded to the different emphasis and goals of the specific type of rehabilitation intervention. Similarly, changes in the subscales of the measure were observed in relation to the RAND groups formed by cluster analysis, which were logical and corresponded to the problem profiles of these groups. The confirmatory factor analysis indicated a two-factor solution: an index of the capacity for physical functioning (self-rated general health, bodily pain, physical functioning, physical role functioning) and an index of the capacity for psycho-social functioning (psychological well-being, social functioning, psychological role functioning and energy). These two indices describing functional capacity proved also to be sensitive to change. This two-factor solution seems to be usable for group level analyses when assessing the effects of rehabilitation. The moderately strong correlation between the RAND-36 and work ability index suggests that they partly measure the same phenomenon: perceived health-related quality of life, subjective capacity for activity and perceived work ability have strong links. As expected, the capacity for physical functioning had a stronger correlation with work ability index than with the capacity for psycho-social functioning. According to the present research, the RAND-36 measure can be considered as a screening method for rehabilitation orientation in relation to rehabilitation needs and as a follow-up measure for the health-related quality of life among the working age clients. The RAND-36 measure is also shown to be a useful instrument in estimating the benefits of rehabilitation as well as in effectiveness research.

Reabilitação de um Edifício de Serviços no Porto para função de Hotel

Este relatório de estágio aborda o tema da reabilitação, referindo-se a uma intervenção da especialidade e também construção de raíz, de um Hotel situado na rua do Heroísmo no Porto. Portugal possui um edificado que tem vindo a degradar-se ao longo dos últimos anos, devido essencialmente à falta de operações periódicas de manutenção, conservação e reabilitação. Esta degradação resulta não só do mau estado de conservação generalizado dos edifícios, mas também da inexistência de infra-estruturas urbanísticas em devido funcionamento. Tal conjunto de situações, leva a um movimento migratório dos habitantes das cidades para as respetivas periferias. A cidade do Porto não é uma exceção, estando a necessitar de um forte esforço de reabilitação para inverter esta situação. Ao longo dos últimos anos têm vindo a ser criados diversos apoios financeiros, nacionais e europeus, com o objetivo de ajudar as operações de reabilitação. Mais recentemente foi possibilitada a criação de Sociedades de Reabilitação Urbana (SRU), cujo objetivo é o de promover e orientar todo o processo de reabilitação, de forma a regula-lo nos centros das cidades. No entanto a intervenção de reabilitação de um edifício é uma operação complexa, com diversas especificidades e com inúmeras condicionantes devido às pré-existências próprias de cada edifício.

Relation of heart rate recovery to psychological distress and quality of life in patients with chronic heart failure

BACKGROUND: Psychological distress, poor disease-specific quality of life (QoL), and reduction in vagally mediated early heart rate recovery (HRR) after exercise, all previously predicted morbidity and mortality in patients with chronic heart failure (CHF). We hypothesized lower HRR with greater psychological distress and poorer QoL in CHF. DESIGN: All assessments were made at the beginning of a comprehensive cardiac outpatient rehabilitation intervention program. METHODS: Fifty-six CHF patients (mean 58+/-12 years, 84% men) completed the Hospital Anxiety and Depression Scale and the Minnesota Living With Heart Failure Questionnaire. HRR was determined as the difference between HR at the end of exercise and 1 min after exercise termination (HRR-1). RESULTS: Elevated levels of anxiety symptoms (P=0.005) as well as decreased levels of the Minnesota Living With Heart Failure Questionnaire total (P = 0.025), physical (P=0.026), and emotional (P=0.017) QoL were independently associated with blunted HRR-1. Anxiety, total, physical, and emotional QoL explained 11.4, 8, 7.8, and 9.0%, respectively, of the variance after controlling for covariates. Depressed mood was not associated with HRR-1 (P=0.20). CONCLUSION: Increased psychological distress with regard to elevated anxiety symptoms and impaired QoL were independent correlates of reduced HRR-1 in patients with CHF. Reduced vagal tone might explain part of the adverse clinical outcome previously observed in CHF patients in relation to psychological distress and poor disease-specific QoL.

Specialised supported education for Australians with psychotic disorders

Australia has a network of Federally funded disability employment and vocational rehabilitation services, including a proportion of outlets that specialise in providing services for persons with psychiatric disabilities. However, neither Federal nor State Governments currently provide or fund disability-specific education assistance to persons with psychiatric disabilities. To begin considering whether Specialised Supported Education is indicated for persons with psychotic disorders, we examined data collected in a national 'Survey of Disability, Ageing and Carers Australia, 1998'. International studies of the effectiveness of overseas Supported Education programs were also examined to identify the forms of assistance most likely to warrant consideration in Australia. U.S.A. evidence indicates that Specialised Supported Education is emerging as an effective career development option for persons with psychotic disorders. An example of an innovative Specialised Supported Education program is provided to illustrate how this type of program can be implemented in Australia.