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Background and Aims: Our large international RCT of early rehabilitation (AVERT), provided evidence that early high intensity training interferes with stroke recovery (The Lancet, 2015), and that most patients may be responsive to therapy if the right dose is provided. (Neurology 2016). The aim of AVERT DOSE is to define the optimal early training regimens for people with mild and moderate ischaemic stroke. Method(s): Multi-Arm, Multi-Stage, Covariate-Adjusted, Response- Adaptive, randomised trial in two specified stroke severity strata. (Mild: NIHSS 0-7; Moderate: NIHSS 8-16). Patients are randomised to one of four mobility training regimens in each strata (including a pre-specified reference group), and the intervention is delivered for up to 14 days. Inclusion criteria: Ischaemic stroke within 48 hours, >=18 years. Exclusion criteria: Severe stroke, medically unwell, no evident mobility problems. We will recruit 2,700 patients from 8 countries. Primary Outcome: Identification of the intervention regimen that results in fewer disabled patients (mRS 0-2) at 3 months post-stroke. Blinded assessments will occur at 3 and 6 months. An adaptive sample size re-estimation provides 80% power to detect a 10% absolute treatment effect or larger compared to the pre-specified reference group, with a significance threshold of p=0.025 per stratum. Analyses will be intention-to-treat. Result(s): Australian National Mutual Acceptance HREC approval for Australia has been received. International collaborations, site selection and development of an online database are underway. Conclusion(s): AVERT DOSE will provide information about the dose and timing of early rehabilitation after ischaemic stroke onset. The results will be generalisable globally.

Background: In 2015, we completed the landmark, international RCTof early rehabilitation, A Very Early Rehabilitation Trial (AVERT). We found that very early high intensity mobility training interferes with stroke recovery (The Lancet, 2015) and that most patients may be responsive to therapy if the right dose can be found (Neurology 2016). Aim(s): The aim of this study (AVERT DOSE) is to define the optimal early intervention regimens for people with mild and moderate stroke severity. Method(s): We will use a multi-arm, multi-stage, dose-finding, Covariate-Adjusted Response-Adaptive (CARA) randomised clinical trial in two specified (mild and moderate) stroke severity strata. We will test three separate rehabilitation intervention regimens in each strata against a pre-specified reference group to identify the intervention regimen that results in fewer disabled patients at 3 months post stroke (mRS 0-2). A sample size of 2,700 patients will allow us to independently observe pre-specified effects in these two strata with power 80% and significance threshold of p=0.025. All analyses will be intention-to-treat. Patients will be recruited using our existing and emerging trial networks in Australia, New Zealand, Singapore, Malaysia, India, Taiwan, Ireland and United Kingdom. Result(s): The trial protocol has been submitted to ethics for multi-site National Mutual Acceptance. Site selection is underway. Universal trial number: U1111-1221-2442 Discussion: AVERT DOSE will establish a clear, definitive, early intervention protocol that will ensure that stroke patients receive best evidence care, both in Australia and other developed nations as well as in developing health service systems.

Background: Use of environmental enrichment significantly improves sensorimotor recovery in experimental stroke. The AREISSA trial, a multi-site (N=4), cluster, cross-over trial, determined whether a patient-driven model of environmental enrichment reduced stroke survivor inactivity and was safe in the clinical setting. Aim(s): This qualitative sub-study within AREISSA sought to describe stroke survivor perceived barriers and enablers to engaging in activity during rehabilitation in a site that had implemented a patientdriven model of environmental enrichment. Method(s): The environmental enrichment under investigation in AREISSA included access to communal and individual physical, cognitive and social stimulation. Face to face semi-structured interviews were conducted (by a speech pathologist) with stroke survivors (n=31) following discharge from rehabilitation. Descriptive content qualitative methods using thematic analysis were used. Result(s): Seven main themes arose: (i) poor communication between staff and patients regarding activity options limits awareness and subsequent engagement, (ii) family provides lots of support and facilitates engagement, (iii) stroke related disability limits capacity for activity, (iv) personal preferences, beliefs and personality types influence activity choice, (v) socialisation (involving patients, visitors and staff) promotes activity, (vi) hospital rules, real or perceived can limit activity, and (vii) wayfinding and hospital layout has an effect on engagement. Conclusion(s): Stroke survivor heterogeneity (stroke & personality related factors), hospital culture and the built environment were perceived to impede activity in an enriched rehabilitation environment. Future iterations of this model of environmental enrichment must address these barriers and build in greater involvement of family and opportunities for socialisation.

Background: Use of environmental enrichment significantly improves sensorimotor recovery in experimental stroke. The AREISSA trial, a multi-site (N=4), cluster, cross-over trial, determined whether a patient-driven model of environmental enrichment reduced inactivity and was safe in the clinical setting. Aim(s): This qualitative sub-study within AREISSA sought to describe the staff experience of implementing a patient-driven model of environmental enrichment for stroke survivors in a mixed rehabilitation unit. Method(s): The environmental enrichment implemented by the multi-disciplinary teams at sites participating in AREISSA included access to communal and individual physical, cognitive and social stimulation. Purposive sampling of these teams was employed to ensure most disciplines were represented. Participants (n=22) completed telephone based semi-structured interviews. Descriptive content qualitative methods using thematic analysis were used. Result(s): Five main themes arose: (i) staff attitudes, awareness and engagement with the model of environmental enrichment influenced implementation, (ii) the built environment made implementation difficult, (iii) activity limitations restricted stroke survivor engagement with environmental enrichment, (iv) stroke survivor preference for how to spend non-therapy time differed, and (v) stroke survivor mood was variable and affected engagement in activity. Conclusion(s): Implementation and stroke survivor use of a patient-driven model of environmental enrichment was perceived by staff to be influenced predominantly by stroke survivor-specific variables. Staff behaviour and knowledge, and the built environment were also perceived to affect successful implementation. These results highlight the complexities of clinical translation of environmental enrichment and can inform future attempts to improve activity by stroke survivors.

Background and Aims: In 2015, we completed the landmark, international RCTof early rehabilitation (The Lancet, 2015).We determined that too much training early interferes with stroke recovery and that most patients may be responsive to therapy if the right dose can be found (Neurology 2016). The aim of this study is to define the optimal early intervention regimens for people with mild and moderate stroke severity. Method(s): We will use a multi-arm, dose-finding, Covariate-Adjusted, Response-Adaptive (CARA) Randomised Clinical Trial (Figure 1) in two specified mild and moderate stroke severity strata. We will test three separate rehabilitation intervention regimens in each strata against a prespecified control to identify the intervention regimen that results in fewer disabled patients at 3 months post stroke (mRS 0-2). A sample size of 2,572 patients will allow us to independently observe pre-specified effects in these two strata with power 80% and significance threshold of p=0.025. All analyses will be intention-to-treat. Patients with mild to moderate stroke will be recruited using our global trials network in Australia, New Zealand, Singapore, Malaysia, India and United Kingdom. Result(s): The trial protocol is in final stages of development with site identification underway. Conclusion(s): AVERT-DOSE will establish clear, definitive, early intervention protocols, that will ensure that stroke patients receive best evidence care, both here and in developing health service systems.

OBJECTIVES: To examine the personal and social experiences of younger adults after stroke. DESIGN: Qualitative study design involving in-depth semi-structured interviews and rigorous qualitative descriptive analysis informed by social constructionism. PARTICIPANTS: Nineteen younger stroke survivors aged 18 to 55 years at the time of their first-ever stroke. SETTING: Participants were recruited from urban and rural settings across Australia. Interviews took place in a clinic room of the Florey Institute of Neuroscience and Mental Health (Melbourne, Australia), over an online conference platform or by telephone. RESULTS: Four main themes emerged from the discourses: (1) psycho-emotional experiences after young stroke; (2) losing pre-stroke life construct and relationships; (3) recovering and adapting after young stroke; and (4) invalidated by the old-age, physical concept of stroke. While these themes ran through the narratives of all participants, data analysis also drew out interesting variation between individual experiences. CONCLUSIONS: For many younger adults, stroke is an unexpected and devastating life event that profoundly diverts their biography and presents complex and continued challenges to fulfilling age-normative roles. While adaptation, resilience and post-traumatic growth are common, this study suggests that more bespoke support is needed for younger adults after stroke. Increasing public awareness of young stroke is also important, as is increased research attention to this problem.

BACKGROUND: Dedicated Evidence-Based Practice (EBP) courses are often included in health professional education programs. It is important to understand the effectiveness of this training. This study investigated EBP outcomes in entry-level physiotherapy students from baseline to completion of all EBP training (graduation). METHODS: Mixed methods with an explanatory sequential design. Physiotherapy students completed two psychometrically-tested health professional EBP instruments at baseline and graduation. The Evidence-Based Practice Profile questionnaire collected self-reported data (Terminology, Confidence, Practice, Relevance, Sympathy), and the Knowledge of Research Evidence Competencies instrument collected objective data (Actual Knowledge). Focus groups with students were conducted at graduation to gain a deeper understanding of the factors impacting changes in students' EBP knowledge, attitudes, behaviour and competency. Descriptive statistics, paired t-tests, 95% CI and effect sizes (ES) were used to examine changes in outcome scores from baseline to graduation. Transcribed focus group data were analysed following a qualitative descriptive approach with thematic analysis. A second stage of merged data analysis for mixed methods studies was undertaken using side-by-side comparisons to explore quantitatively assessed EBP measures with participants' personal perceptions. RESULTS: Data were analysed from 56 participants who completed both instruments at baseline and graduation, and from 21 focus group participants. Large ES were reported across most outcomes: Relevance (ES 2.29, p ≤ 0.001), Practice (1.8, p ≤ 0.001), Confidence (1.67, p ≤ 0.001), Terminology (3.13, p ≤ 0.001) and Actual Knowledge (4.3, p ≤ 0.001). A medium ES was found for Sympathy (0.49, p = 0.008). Qualitative and quantitative findings mostly aligned but for statistical terminology, participants' self-reported understanding was disparate with focus group reported experiences. Qualitative findi

Catheter ablation (CA) for atrial fibrillation (AF) has emerged as a widespread first or second line treatment option. However, up to 45% of patients (pts) show recurrence of AF within 12 month after CA. We present prospective multicenter registry data comparing characteristics of pts with and without recurrence of AF within the first year after CA. This study comprises all pts with complete follow-up one year after CA (1-y-FU; n = 3679). During 1y-FU in 1687 (45.9%) pts recurrence of AF occurred. The multivariate analysis revealed female sex and AF type prior to the procedure as predictors for AF recurrence. Furthermore, comorbidities such as valvular heart disease and renal failure as well as an early AF relapse were also predictors of AF recurrence during 1-y-FU. However, despite an AF recurrence rate of 45.9%, the majority of these pts (72.4%) reported a significant alleviation of clinical symptoms. In conclusion in pts with initially successful CA for AF female sex, AF type, in-hospital AF relapse and comorbidities such as renal failure and valvular heart disease are independent predictors for AF recurrence during 1-y-FU. However, the majority of pts deemed their interventions as successful with significant reduction of symptoms irrespective of AF.

OBJECTIVE: To report and synthesize the perspectives, experiences, and preferences of stroke survivors undertaking inpatient physical rehabilitation through a systematic review of qualitative studies. DATA SOURCES: MEDLINE, CINAHL, Embase, and PsycINFO were searched from database inception to February 2014. Reference lists of relevant publications were searched. All languages were included. STUDY SELECTION: Qualitative studies reporting stroke survivors' experiences of inpatient stroke rehabilitation were selected independently by 2 reviewers. The search yielded 3039 records; 95 full-text publications were assessed for eligibility, and 32 documents (31 studies) were finally included. Comprehensiveness and explicit reporting were assessed independently by 2 reviewers using the consolidated criteria for reporting qualitative research framework. Discrepancies were resolved by consensus. DATA EXTRACTION: Data regarding characteristics of the included studies were extracted by 1 reviewer, tabled, and checked for accuracy by another reviewer. All text reported in studies' results sections were entered into qualitative data management software for analysis. DATA SYNTHESIS: Extracted texts were inductively coded and analyzed in 3 phases using thematic synthesis. Nine interrelated analytical themes, with descriptive subthemes, were identified that related to issues of importance to stroke survivors: (1) physical activity is valued; (2) bored and alone; (3) patient-centered therapy; (4) recreation is also rehabilitation; (5) dependency and lack of control; (6) fostering autonomy; (7) power of communication and information; (8) motivation needs nurturing; and (9) fatigue can overwhelm. CONCLUSIONS: The thematic synthesis provides new insights into stroke survivors' experiences of inpatient rehabilitation. Negative experiences were reported in all studies and include disempowerment, boredom, and frustration. Rehabilitation could be improved by increasing activity within formal

BACKGROUND: Evaluating the methodological quality of clinical practice guidelines is essential before deciding which ones which could best inform policy or practice. One current method of evaluating clinical guideline quality is the research-focused AGREE II instrument. This uses 23 questions scored 1-7, arranged in six domains, which requires at least two independent testers, and uses a formulaic weighted domain scoring system. Following feedback from time-poor clinicians, policy-makers and managers that this instrument did not suit clinical need, we developed and tested a simpler, shorter, binary scored instrument (the iCAHE Guideline Quality Checklist) designed for single users. METHODS: Content and construct validity, inter-tester reliability and clinical utility were tested by comparing the new iCAHE Guideline Quality Checklist with the AGREE II instrument. Firstly the questions and domains in both instruments were compared. Six randomly-selected guidelines on a similar theme were then assessed by three independent testers with different experience in guideline quality assessment, using both instruments. Per guideline, weighted domain and total AGREE II scores were calculated, using the scoring rubric for three testers. Total iCAHE scores were calculated per guideline, per tester. The linear relationship between iCAHE and AGREE II scores was assessed using Pearson r correlation coefficients. Score differences between testers were assessed for the iCAHE Guideline Quality Checklist. RESULTS: There were congruent questions in each instrument in four domains (Scope & Purpose, Stakeholder involvement, Underlying evidence/Rigour, Clarity). The iCAHE and AGREE II scores were moderate to strongly correlated for the six guidelines. There was generally good agreement between testers for iCAHE scores, irrespective of their experience. The iCAHE instrument was preferred by all testers, and took significantly less time to administer than the AGREE II instrument. However, th

BACKGROUND: Ultrasound is considered a reliable, widely available, non-invasive and inexpensive imaging technique for assessing soft tissue involvement in Lateral epicondylalgia. Despite the number of diagnostic studies for Lateral Epicondylalgia, there is no consensus in the current literature on the best abnormal ultrasound findings that confirm lateral epicondylalgia. METHODS: Eligible studies identified by searching electronic databases, scanning reference lists of articles and chapters on ultrasound in reference books, and consultation of experts in sonography. Three reviewers (VCDIII, KP, KW) independently searched the databases using the agreed search strategy, and independently conducted all stages of article selection. Two reviewers (VCDIII, KP) then screened titles and abstracts to remove obvious irrelevance. Potentially relevant full text publications which met the inclusion criteria were reviewed by the primary investigator (VCDIII) and another reviewer (CGS). RESULTS: Among the 15 included diagnostic studies in this review, seven were Level II diagnostic accuracy studies for chronic lateral epicondylalgia based on the National Health and Medical Research Council Hierarchy of Evidence. Based from the pooled sensitivity of abnormal ultrasound findings with homogenous results (p > 0.05), the hypoechogenicity of the common extensor origin has the best combination of diagnostic sensitivity and specificity. It is moderately sensitive [Sensitivity: 0.64 (0.56-0.72)] and highly specific [Specificity: 0.82 (0.72-0.90)] in determining elbows with lateral epicondylalgia. Additionally, bone changes on the lateral epicondyle [Sensitivity: 0.56 (0.50-0.62)] were moderately sensitive to chronic LE. Conversely, neovascularity [Specificity: 1.00 (0.97-1.00)], calcifications [Specificity: 0.97 (0.94-0.99)] and cortical irregularities [Specificity: 0.96 (0.88-0.99)] have strong specificity for chronic lateral epicondylalgia. There is insufficient evidence supporting the u

BACKGROUND: Functional decline (FD) is a largely preventable feature of aging, characterized as gradual erosion of functional autonomy. This reduces an older person's capacity for safe, independent community living. The healthcare needs of an unprecedented aging population places pressure on health systems to develop innovative approaches to ensuring older people live healthy and independent lives for as long as possible. TRIIFL aims to demonstrate that: 1. Incipient FD in older people can be identified using a simple telephone-screening process within four weeks of discharge from an emergency department presentation for a minor health event; and 2. Early engagement into a person-centered individualized intervention arrests or reduces the rate of FD over the next 12 months. METHODS/DESIGN: A randomized controlled trial (RCT) nested within a 13-month longitudinal cohort study. The RCT (conducted over 12 months) tests the effectiveness of a novel, early, home-based, personalized program (compared with no intervention) in arresting or slowing FD. TRIIFL focuses on older adults living independently in the community, who have not yet had a serious health event, yet are potentially on the cusp of FD. Participants in the longitudinal cohort study will be recruited as they present to one large tertiary hospital Emergency Department, providing they are not subsequently admitted to a ward. Sample size calculations indicate that 570 participants need to be recruited into the longitudinal study, with 100 participants randomized into the trial arms. Measures from all subjects will be taken face-to-face at baseline (recruitment), then subsequently by telephone at one, four, seven and thirteen months later. Measures include functional abilities, quality of life, recent falls, mobility dependence, community supports and health service usage. Specific to the nested RCT, the quality of life tool (SF12) applied at one month, will identify individuals with low mental component quality