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Introduction: American Indian (AI) people have protective factors embedded in cultural teachings that buffer against high-risk behaviors. This study applies a qualitative, grounded theory approach to identify cultural assets for a Diné (Navajo) mother-daughter intervention aimed at preventing substance abuse and teen pregnancy. Method: Focus groups and in-depth interviews were conducted with 28 AI females’ ages 8 years and older from the Navajo Nation. Results: Key themes were (a) preserving the Diné way of life, (b) cultural assets related to being a healthy Diné woman, (c) matrilineal networks as a source of strength/pride, (d) historical trauma as a source of resilience, (e) male influences as protective health factors, (f) Western education as a measure of success, and (g) integrating different belief systems. Discussion: Study findings may be applied as foundational elements for culturally grounded AI substance abuse and teen pregnancy prevention strategies, as well as culturally safe nursing practice.

What is central Europe? As I write this article in 2021, three decades after the fall of communism, this question seems as salient as ever. I am not the only Central European History reader to think about this topic in recent years. In a 2018 CEH article, provocatively titled “Habsburg History, Eastern European History … Central European History?,” Chad Bryant argued that scholarship on these three nominally distinct fields had become blurred in the wake of the post-communist opening of archives and the transnational turn. It was time, Bryant insisted, not only for CEH readers to reconsider the category of “central Europe” itself, but also to engage with a new set of questions, ones that would move beyond the predominant emphasis on “how and why regimes collapsed.” Compellingly, he advocated for studies that would help us understand the post-1989 era, such as the long-term legacies of communism, the integration of individual countries into the European Union, and present-day migration to the region.

American Indian (AI) and Indigenous peoples utilize traditional medicine/healing (TM/H) for health and well-being. Allopathic health care practitioners (HCPs) receive minimal training and education on TM/H and its application and integration into health care settings. Lack of knowledge and practice guidelines on how to navigate these 2 health care perspectives (allopathic and traditional) creates uncertainties in the treatment of AI and Indigenous peoples. Such conflicts can undermine patient autonomy and result in culturally incongruent practice. This article presents a case study showcasing suggestions for how HCPs can direct clinical decision making when working with AI/Indigenous patients who utilize TM/H. The article argues that health professions education institutions and HCPs must dedicate effort to expanding awareness of and education about TM/H to enhance the delivery of evidence-based and integrated clinical treatment for AI/Indigenous patients.

Objective The aims of this study were to (1) evaluate the relationships between stationary and dynamic associated reaction (AR) tests in people with acquired brain injury using surface electromyography (sEMG) muscle activity and three-dimensional motion analysis kinematic measures and (2) assess the test-retest reliability of sEMG and seated tests of ARs. Design Forty-two adults with acquired brain injury underwent AR testing with seated contralateral maximal voluntary isometric contraction tests and walking (self-selected and fast speeds). Associated reaction measurements included biceps brachii sEMG, elbow goniometry, and three-dimensional motion analysis kinematics during walking. Pearson correlations evaluated the relationships between seated and dynamic walking AR tests and between muscle activity and kinematic measures. Chronic participants were reassessed 1 wk later for reliability. Results A strong (r = 0.65) and moderate (r = 0.53) relationship existed for biceps brachii sEMG during seated and walking tests at self-selected and fast walk, respectively. A weak to moderate relationship existed between biceps brachii sEMG and kinematics during walking and between seated and walking measures of ARs (r = 0.23-0.53). All tests had strong to very strong test-retest reliability (intraclass correlation coefficients, >0.78). Conclusion Seated contralateral maximal voluntary isometric contraction tests correlate only weakly to moderately with AR walking kinematics and moderately to strongly with biceps brachii activation during walking. Moderate relationships exist between sEMG and kinematics, indicating that they may provide different information for ARs.

Purpose: Hózhó is the cultural wisdom that guides the Diné lifeway. This study examines understanding of cultural wisdom (CW) across three generations: elders, adults, and adolescents. Method: A focused ethnography was conducted on the Navajo Nation. Twenty-two Diné (Navajo) were recruited through convenience sampling. Data were collected via two semistructured interviews and photovoice methods. Data were analyzed using content analysis, thematic analysis, and participatory visual analysis of photos. Results: The Diné elders embodied the greatest in-depth understanding of CW followed by the adolescents. An unexpected finding was the scarcity of understanding of CW among the adults. Conclusion: The Diné understanding of CW is transferred through discussion with elders, listening to and speaking traditional language, cultural preservation activities, and participation in cultural practices. The Diné believe cultural wisdom is a health sustaining protective factor, therefore strategies to restore, promote, and support the intergenerational transfer of cultural wisdom remains a tribal priority.

From the start of the COVID-19 pandemic on the Navajo Nation, Diné (Navajo) traditional knowledge holders (TKHs), such as medicine men and women and traditional practitioners, contributed their services and healing practices. Although TKHs are not always fully acknowledged in the western health care system, they have an established role to protect and promote the health of Diné people. To date, their roles in mitigating the COVID-19 pandemic have not been fully explored. The purpose of this research was to understand the social and cultural contexts of the COVID-19 pandemic and vaccines based on the roles and perspectives of Diné TKHs. A multi-investigator consensus analysis was conducted by six American Indian researchers using interviews with TKHs collected between December 2021–January 2022. The Hózhó Resilience Model was used as a framework to analyze the data using four parent themes: COVID-19, harmony and relationships, spirituality, and respect for self and discipline. These parent themes were further organized into promoters and/or barriers for 12 sub-themes that emerged from the data, such as traditional knowledge, Diné identity, and vaccine. Overall, the analysis showed key factors that could be applied in pandemic planning and public health mitigation efforts based on the cultural perspective of TKHs.

BACKGROUND AND PURPOSE Physical therapy is important in the management of traumatic brain injury (TBI) and associated multitrauma. Providing therapy during the posttraumatic amnesia (PTA) phase is challenging, given that hallmark features including confusion, amnesia, agitation, and fatigue may impede the person's ability to engage in and benefit from rehabilitation. To date, there is little empirical evidence to guide the provision of therapy during PTA. This observational study aimed to explore the frequency, duration, location, and engagement of physical therapy provision during PTA and the impact of cognition, agitation, and fatigue. SUMMARY OF KEY POINTS The majority of patients were found to meaningfully engage and participate in physical therapy for the majority of sessions. Only a small proportion were unable to participate in physical therapy. Patient refusal and fatigue were identified as the most prominent barriers to rehabilitation. Despite fatigue and agitation reaching clinical levels, therapy could still successfully proceed on most occasions. RECOMMENDATIONS FOR CLINICAL PRACTICE Physical therapy is feasible during the acute recovery stages after TBI. Current results support the notion that therapy should commence early to minimize secondary complications and promote the recovery of mobility. A patient-centered therapeutic model that tailors the therapeutic approach to meet the individual's current physical and fluctuating cognitive capabilities may be most suited for this population. Clinicians working with people after TBI need experience in understanding and managing the cognitive limitations and associated symptoms of PTA to optimize the provision of therapy. These findings could inform guidelines for the management of patients in PTA.Video Abstract available for more insights from the authors (see the Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A368).

To investigate whether a three-dimensional (3-D) camera (Microsoft Kinect) and a smartphone can be used to accurately quantify the joint angular velocity and range of motion (ROM) compared to a criterion-standard 3-D motion analysis system during a lower limb spasticity assessment.Observational, criterion-standard comparison study.Large rehabilitation center.A convenience sample of 35 controls, 35 patients with a neurologic condition, and 34 rehabilitation professionals (physiotherapists and rehabilitation doctors) participated (N=104).Not applicable.The Modified Tardieu Scale was used to assess spasticity of the quadriceps, hamstrings, soleus, and gastrocnemius. Data for each trial were collected concurrently using the criterion-standard Optitrack 3-D motion analysis (3DMA) system, Microsoft Kinect, and a smartphone. Each healthy control participant was assessed by 1 health professional and each patient with a neurological condition was assessed by 3 health professionals. Spearman correlation coefficient and intraclass correlation coefficient with 95% confidence intervals were used to report the strength of the relationships investigated.The smartphone and Microsoft Kinect demonstrated excellent concurrent validity with the 3DMA system. Overall, 74.8% of the relationships investigated demonstrated a very strong (≥0.80) correlation across all of the testing parameters. The Microsoft Kinect was superior to the smartphone for measuring joint start and end angle, the smartphone was superior for measuring joint angular velocity, and the 2 systems were comparable for measuring total joint ROM.These findings provide preliminary evidence that user-friendly, low-cost technologies can be used to facilitate accurate measurements of joint angular velocity and angles during a lower limb spasticity assessment in a clinical setting.

Research Objectives To investigate the accuracy of subjective rating of upper limb associated reactions (ARs) during walking using the International Classification of Functioning, Disability and Health Framework's (ICF) Qualifiers Scale compared to criterion-reference three-dimensional motion analysis (3DMA). Design Cross-sectional observational study. Setting A major brain injury rehabilitation centre in Australia. Participants Forty-one participants with an ABI and hemiplegic upper limb AR during walking. Interventions N/A. Main Outcome Measures Participants underwent 3DMA at their self-selected walking speed to generate an AR outcome measure, quantifying upper limb kinematic deviation compared to healthy controls at each joint axis and whole upper limb. Three experienced neurological physiotherapists viewed video recordings of the participants’ walking trials and applied the ICF Qualifiers Scale to subjectively rate the global AR severity and severity at each upper limb joint on a 5-point scale. The comparative accuracy was calculated via quantifying relationships (Fisher's exact test), percentage agreement, sensitivity, and specificity. Results The ICF Qualifiers Scale had limited accuracy compared to 3DMA hemiplegic upper limb assessment. The wrist severity score was the only outcome demonstrating a significant relationship to the corresponding 3DMA outcome (p 0.80) for four of the seven outcomes. Conclusions Given that the ICF Qualifiers scale tended to under classify abnormality with false negatives likely, it cannot be confidently implemented in clinical practice. There appears to be a disconnect between 3DMA and subjective rating of ARs. Evaluation of ARs during walking may require objective assessment. Author(s) Disclosures There are no disclosures to report.

Background Upper limb associated reactions (ARs) are common in people with acquired brain injury (ABI). Despite this, there is no gold-standard outcome measure and no kinematic description of this movement disorder. The aim of this study was to determine the upper limb kinematic variables most frequently affected by ARs in people with ABI compared with a healthy cohort at matched walking speed intention. Methods A convenience sample of 36 healthy control adults (HCs) and 42 people with ABI who had upper limb ARs during walking were recruited and underwent assessment of their self-selected walking speed using the criterion-reference three dimensional motion analysis (3DMA) at Epworth Hospital, Melbourne. Shoulder flexion, abduction and rotation, elbow flexion, forearm rotation and wrist flexion were assessed. The mean angle, standard deviation (SD), peak joint angles and total joint angle range of motion (ROM) were calculated for each axis across the gait cycle. On a group level, ANCOVA was used to assess the between-group differences for each upper limb kinematic outcome variable. To quantify abnormality prevalence on an individual participant level, the percentage of ABI participants that were outside of the 95% confidence interval of the HC sample for each variable were calculated. Results There were significant between-group differences for all elbow and shoulder abduction outcome variables (p Conclusion This study provides valuable information on ARs, and highlights the need for clinical assessment of ARs to include all of the major joints of the upper limb. This may inform the development of a criterion-reference outcome measure or classification system specific to ARs.

Creating wearable sensor systems is a daunting prospect to healthcare professionals and novice developers: where to start and what to use? This chapter provides a pragmatic guide to low-cost software, hardware, and developer kits for those interested in exploring wearables in clinical populations. Firstly, the build, repurpose or outsource decision process is described. Secondly, key hardware and software design decisions are described to simplify the choice. This encompasses wireless/wired communication methods, data recording and graphical user interface design, choosing and efficiently using a 3D printer, and selecting the right sensors. Two detailed system design examples are then provided: (1) a wireless surface electromyography device; and (2) a global positioning system and accelerometer activity monitoring system. Finally, a brief summary of hardware and software systems available for people new to the field, including graphical and human readable programming languages, 3D modeling software and learn-to-program support, is given.

This chapter focuses on integrative strategies when working with American Indian communities. American Indians (AIs) have always had their own systems of health and wellness practices embedded within their lifestyles and rich cultural heritage. The history of the AI, before colonialism, is a story of strong, healthy, thriving AI tribal nations that collectively occupied the entirety of the geographical regions of North America. European and Spanish colonization of AI tribal nations resulted in the forced removal of tribal sovereignty, culture, language, health systems, health and wellness practices and innate life ways. Historical acts of genocide as well as the ongoing intentional erasure of AI tribal life ways and culture perpetrated by Spanish and European settlers contributed to an intergenerational cascade of AI social, physical, mental, emotional and spiritual hardship. Many of the once thriving tribal nations, villages, pueblos, and bands were significantly reduced in number while some were all together eliminated. These pivotal historical events contributed to AI distrust of the United States Federal government, the agency responsible for the treaty obligation to provide healthcare services to AIs. AIs continue to experience health inequity, disparity, and socioeconomic hardship. Despite these intergenerational and tired messages of genocide, discrimination, health disparity, and socioeconomic struggle, AI tribal communities rely on cultural philosophies, teachings and stories as sources of resilience, steadfastness, persistence and health that have enriched and sustained their livelihood. There is a growing awareness and eagerness among AIs, especially younger generations, to reclaim traditional knowledge on ways to sustain and promote health. AIs have engaged in revitalization efforts to better understand health sustaining cultural knowledge. AI communities are exploring ways to operationalize and integrate innate cultural health systems and traditional medicine practices alongside existing mainstream health systems to sustain and promote the health of their communities. A discussion on ancient and present-day AI health systems, significant historical events and accessible, preferred, and culturally aligned integrative approaches and strategies for AI health will be presented.

Upper limb kinematic abnormalities are prevalent in people with acquired brain injury (ABI). We examined if the Microsoft Kinect for Xbox One (Kinect) reliably (test-retest) and validly (concurrent) quantifies upper limb kinematics, and accurately classifies abnormalities (sensitivity/specificity), in an ABI cohort when compared to three-dimensional motion analysis (3DMA) and a subjective rating scale. We compared 42 adults with ABI to 36 healthy control (HC) participants. Walking trials were recorded by 3DMA and Kinect at self-selected (SSWS) and fast (FWS) walking speeds. When classifying abnormalities for 3DMA and Kinect, a 95% reference range (based on HC data) was calculated using the Kinematic Deviation Score worst axis (KDSw); values outside of this range were classified abnormal. Scores ≥ 2 in the subjective rating scale, based on International Classification of Functioning, Disability and Health Framework's Qualifiers Scale, were considered abnormal. Test-retest reliability and concurrent validity were determined using intra-class correlation coefficient (Absolute ICC2,1) and Pearson's or Spearman's correlation respectively. Fisher's Exact Test was conducted to determine sensitivity and specificity between each combination of the two methods. Strong test-retest reliability was observed for 3DMA (median(IQR) ICC:0.86(0.85-0.90)). Kinect showed overall strong SSWS test-retest reliability (ICC:0.87(0.84-0.91)) and moderate FWS test-retest reliability (ICC:0.61(0.56-0.65)). Concurrent validity between 3DMA and Kinect was overall moderate. Sensitivity and specificity between 3DMA, Kinect and subjective scores were overall modest. Our results suggest caution should be used if implementing Kinect as its validity is modest against criterion-reference 3DMA; however, given its reliability and similar sensitivity/specificity to 3DMA further responsiveness research is warranted.

Background Although it is well established that lower limb joint angles adapt to walking at various speeds, limited research has examined the modifications in joint angular velocity. There is currently no normative dataset for joint angular velocity during walking, which would be useful to allow comparisons for patient cohorts. Additionally, understanding normal joint angular velocity may assist clinical assessment and treatment procedures to incorporate methods that replicate the movement speed of the lower limb joints during walking. Research Question This study aimed to examine lower limb joint angles and angular velocities in a healthy population walking at various gait speeds. Methods Thirty-six healthy adult participants underwent three-dimensional gait analysis while walking at various speeds during habitual and slowed walking. The peak joint angles and angular velocities during important phases of the gait cycle were examined for the hip, knee and ankle in the sagittal plane. Data were grouped in 0.2 m/s increments from a walking speed of 0.4 m/s to 1.6 m/s to represent the range of walking speeds reported in studies of people with gait impairments. Results For joint angles and angular velocities, the shape of the gait traces were consistent regardless of the walking speed. However as walking speed increased, so did the peak joint angles and angular velocities for the hip, knee and ankle. The largest angular velocity occurred when the knee joint extended at the terminal swing phase of gait. For the ankle and hip joints, the largest angular velocity occurred during the push-off phase. Significance This study examined how lower limb joint angular velocities change with various walking speeds. These data can be used as a comparator for data from clinical cohorts, and has the potential to be used to match clinical assessment and treatment methods to joint angular velocity during walking.

Research Objectives To use criterion-reference three-dimensional motion analysis (3DMA) during walking to; 1.Define upper-limb associated reaction (AR) kinematics 2.Devise composite score outcome measures to quantify Ars. Design Cross-sectional observational study. Setting A major brain injury rehabilitation centre. Participants Forty-two participants with an ABI and hemiplegic upper-limb AR during walking and 36 healthy controls (HCs). Interventions N/A. Main Outcome Measures Participants underwent 3DMA upper-limb assessment at self-selected and fast walking speeds. The mean, standard deviation (SD), peak and total joint range of motion (ROM) were calculated for each axis across the gait cycle. The AR kinematics were evaluated according to between-group differences (analysis of covariance) and individually with calculation of the percentage of ABI participants classified as abnormal (i.e., ±1.96 SD of the HC mean). Composite score outcome measures were devised and evaluated for validity (Pearson's r correlation), test-retest reliability (intra-class correlation coefficient (ICC)) and responsiveness (Cohen's d effect size (ES), % change scores). Results Significant between-group differences existed for all elbow and shoulder abduction outcome variables (p 0.81). Conclusions All upper-limb joints may be implicated in ARs and therefore all warrant inclusion in clinical assessment. Composite scores were able to comprehensively assess the whole upper-limb AR, accurately classifies abnormality, and quantify severity with very strong clinimetrics. Author(s) Disclosures There are no disclosures or conflicts of interest for this abstract.

Research Objectives To determine which potential contributing factors are associated with upper limb associated reaction (AR) expression in individuals with acquired brain injury (ABI). Design Cross-sectional observational study. Setting A major brain injury rehabilitation centre in Australia. Participants Forty-two participants with an adult-onset, non-progressive ABI and an AR in their hemiplegic upper limb during walking were recruited. Interventions N/A Main Outcome Measures Participants underwent three-dimensional motion analysis at self-selected walking speed to generate an AR outcome measure, quantifying upper limb kinematic deviation compared to healthy controls. Clinical assessment of potential contributing factors included: upper and lower limb hypertonicity, spasticity and strength, balance, dynamic walking stability, arm and leg function, anxiety, arm pain/discomfort, and fear of falling. Results Significant, moderate-to-strong correlations (r = 0.42 - 0.74, p Conclusions Associated reactions are complex and multi-factorial. There were several significant correlations and factors that may influence AR severity. While positive upper motor neuron syndrome features should be prioritised for clinical assessment, these factors are not prerequisites for ARs. Author(s) Disclosures There are no disclosures or conflicts to declare.

Research Objectives To: 1. Evaluate relationships between stationary and dynamic associated reaction (AR) tests in people with acquired brain injury (ABI) using surface electromyography (sEMG) muscle activity and three-dimensional motion analysis (3DMA) kinematic measures 2. Assess test-retest reliability of sEMG and seated tests of Ars. Design Cross-sectional observational study. Setting A major brain injury rehabilitation centre in Australia. Participants Forty-two participants with an ABI and hemiplegic upper limb AR during walking. Interventions N/A. Main Outcome Measures Participants underwent AR testing with seated contralateral maximal voluntary isometric contraction (MVIC) tests and walking (self-selected and fast speeds). For seated tests, AR measurements included biceps brachii sEMG and elbow goniometry. For walking tests, AR measurement included biceps brachii sEMG and 3DMA kinematics. Pearson's correlations evaluated relationships between seated and dynamic walking AR tests and between muscle activity and kinematic measures. A subgroup of chronic participants (> 1year post injury) were reassessed one-week later for reliability. Results For biceps brachii sEMG during seated and walking tests, there was a strong (r = 0.65) and moderate (r = 0.53) relationship at self-selected and fast walk, respectively. A low-to-moderate relationship existed between biceps brachii sEMG and kinematics during walking, and between seated and walking measures of ARs (r = 0.23 to 0.53). All tests had strong-to-very strong test-retest reliability (intra-class correlation coefficients > 0.78). Conclusions Seated contralateral MVIC tests (measured by goniometry and biceps brachii sEMG) correlate only weak-to-moderately to AR walking kinematics, and moderately-to-strongly with biceps brachii sEMG during walking. Moderate relationships exist between sEMG and kinematics indicating they may provide different information for ARs. Author(s) Disclosures There are no disclosures for this abstract.

Objectives To examine the effect of agitation, cognitive impairment, fatigue, and pain on physical therapy participation and outcomes during posttraumatic amnesia (PTA) after traumatic brain injury (TBI). Design Prospective longitudinal study. Setting Inpatient rehabilitation hospital. Participants Participants (N=77) with moderate-to-severe TBI who were deemed to be experiencing PTA using the Westmead Post-Traumatic Amnesia Scale. Interventions Not applicable. Main Outcome Measures The Pittsburgh Rehabilitation Participation Scale and time in therapy (min) were recorded twice daily after routine physical therapy sessions during PTA. The FIM-motor (select items related to physical therapy) score rated on admission and after emergence from PTA was used to calculate FIM-motor change. Results Agitation was associated with lower participation in therapy. The presence of agitation and pain both predicted lower FIM-motor change at emergence from PTA. Higher levels of cognitive impairment and fatigue were also associated with lower participation and less time in therapy. Conclusions The presence of agitation, fatigue, pain, and cognitive impairment impede rehabilitation success during PTA. This study strengthens the case for implementing environmental and behavioral recommendations, such as conducting therapy earlier in the day within a familiar space (ie, on the ward) and tailoring session duration to patient needs. This is with the aim of minimizing fatigue, agitation, and pain, while promoting cognitive recovery and arousal during PTA to maximize physical gains. Further research is warranted to examine the factors associated with rehabilitation success across other therapeutic disciplines.

Background: Abnormal upper limb movements frequently affect people with acquired brain injury (ABI) during walking. Three-dimensional motion analysis (3DMA) can quantify upper limb abnormality kinematically, with composite scores condensing multiple joint axes data into a single score. Research Question: Are 3DMA-derived composite scores valid (known-groups and convergent validity), reliable and able to quantify speed-related changes in abnormal upper limb movement during walking? Methods: This observational study compared 42 adults with ABI and abnormal upper limb movements during walking with 36 healthy controls (HC) at a matched walking speed intention. Participants underwent 3DMA assessment of self-selected and fast walking speeds. Composite scores quantified the affected upper limb’s kinematic abnormality. The Arm Posture Score arithmetic mean version (APSam) and 1.96 standard deviation reference-range scaled versions; the Kinematic Deviation Score mean (KDSm) and worst score (KDSw) were evaluated for association with each other and subjective abnormality rating (Pearson’s r correlation), test-retest reliability (intra-class correlation coefficient (ICC)), and ability to quantify speed-related changes in abnormal upper limb movement (Cohen’s d effect size (ES), % change scores). Results: Very strong correlations existed between composite scores. The KDSm under-classified upper limb abnormality, whereas the KDSw captured the majority of ABI participants. All scores had moderate-strong correlations with subjective rating of abnormal upper limb movements (r = 0.54-0.79) and very strong test-retest reliability (ICCs>0.81). The APSam demonstrated a 16% (ES 0.76) walking speed-related increase in upper limb abnormality, whilst decreases were demonstrated in the KDSm 26% (ES 0.90) and KDSw 35% (ES 0.96). Significance: The APSam, KDSw, and number of abnormal joint axes comprehensively assess the whole upper limb abnormal movements, accurately classifies abnormality, and quantifies severity. This study illustrated notable presence of abnormal upper limb movements at self-selected walking speed and small increase at fast speeds. However, when scaled to HC variability, the fast walk kinematics became less abnormal due to increased HC movement variability.

Objective: The aim of this study is to determine inter-rater, test–retest and intra-rater reproducibility and responsiveness of subjective assessment of upper limb associated reactions in people with acquired brain injury using (1) the ‘Qualifiers Scale’ of the International Classification of Functioning, Disability and Health Framework, and (2) visually estimated elbow flexion angle during walking. Design: Observational study. Setting: A brain injury rehabilitation centre, Melbourne, Australia. Subjects: People with acquired brain injury and upper limb associated reactions and experienced neurological physiotherapists. Main measures: The Qualifiers Scale applied to individual upper limb joints and global associated reaction on a 5-point scale (0–4), a summed upper limb severity score and visually estimated elbow flexion angle. Results: A total of 42 people with acquired brain injury (mean age: 48.4 ± 16.5 years) were videoed walking at self-selected and fast speeds. A subset of 30 chronic brain injury participants (mean time post injury: 8.2 ± 9.3 years) were reassessed one week later for retest reproducibility. Three experienced neurological physiotherapists (mean experience: 22.7 ± 9.1 years) viewed these videos and subjectively rated the upper limb associated reactions. Strong-to-very strong test–retest, intra- and inter-rater reproducibility was found for elbow flexion angle (ICC > 0.86) and the Qualifiers Scale applied to global and individual upper limb joints (ICC > 0.60). Responsiveness of change from self-selected to fast walking speed (mean increase 0.46 m/s) was highest for elbow flexion angle (effect size = 0.83) and low-to-moderate for the Qualifiers Scale. Conclusion: Subjectively rated associated reactions during walking demonstrated strong reproducibility and moderate responsiveness to speed change. The Qualifiers Scale and elbow flexion angle can both subjectively quantify associated reactions during walking in a clinical setting.

Patterns and methods of scholarly communication have changed with the growth in information technology, particularly the Internet and the social web. The changes have necessitated a broader definition of scholarly communication and the role of social media in the research process. We sought to record the body of work that the Institute for Poverty, Land and Agrarian Studies (PLAAS), a research institute at the University of the Western Cape, produced over a 20-year period (1995–2015) – the first two decades of its existence – and to measure its visibility and impact using bibliometrics and altmetrics. A survey was also carried out to investigate to what extent PLAAS researchers knew and used social media in their research practice. Scopus and Google Scholar were used as citation indices and Altmetric.com provided Altmetric scores – a measure of impact through social and mainstream media. The full list of PLAAS outputs showed a composition of 54% grey literature and 46% journal articles and monographs. Given that over half of PLAAS research outputs were in the form of grey literature, and therefore not indexed in traditional bibliometric databases, we suggest that alternative metrics be used in conjunction with bibliometrics, to measure the impact of a body of work on the scholarly domain. Although the bibliometrics in this study were a useful quantitative indicator of the impact of PLAAS research, this study was inconclusive with regard to determining the impact of the research output via altmetrics, partly because not any of the grey literature, nor any author from PLAAS, had a unique identifier, thus making it difficult to track and find quantitative indicators. Nonetheless, the potential benefit for PLAAS of using altmetrics was demonstrated in selected case studies of the output of three PLAAS researchers active on social media platforms. Significance: This study demonstrates that the use of bibliometric and altmetric analyses can yield a rich picture of research output and significance, providing insight into the patterns of scholarly communication of research and policy institutions. The application of the research design in other research units and departments could generate results that are useful to research management within those institutions.

Metrics analysis of journal content has become an important point for debate and discussion in research and in higher education. The South African Journal of Libraries and Information Science (SAJLIS), a premier journal in the library and information science (LIS) field in South Africa, in its 85-year history, has had multiple editors and many contributing authors and has published over 80 volumes and 160 issues on a diversity of topics reflective of LIS theory, policy and practice. However, how discoverable and accessible has the LIS scholarship carried by the Journal been to its intended readership? SAJLIS transitioned to open access in 2012 and this new format in scholarly communication impacted the Journal significantly. The purpose of this paper is to report on a multiple metrics analysis of discoverability and accessibility of LIS scholarship via SAJLIS from 2012 to 2017. The inquiry takes a quantitative approach within a post-positivist paradigm involving computer-generated numerical data as well as manual data mining for extraction of qualitative elements. In using such a multiple metrics analysis to ascertain the discoverability and accessibility of LIS scholarship via SAJLIS in the period 2012 to 2017, the study employs performance metrics theory to guide the analysis. We highlight performance strengths of SAJLIS in terms of discoverability and accessibility of the scholarship it conveys; identify possible growth areas for strategic planning for the next 5 years; and make recommendations for further study for a more complete picture of performance strengths and areas for improvement. Significance: The importance of discoverability and accessibility of scholarship carried by a scholarly journal is conveyed. The need to use multiple metrics for objective evaluation of the discoverability and accessibility of the scholarly content of a journal is emphasised. The impact of open access on the discoverability and accessibility of the content of a scholarly journal is assessed.

This article describes how the Diné (Navajo) Hózhó wellness philosophy, along with nursing research and theory, informed the development of a theoretical nursing model, the Hózhó Resilience Model that can be used to generate patient-centered nursing knowledge through connections among our theories, research, and practice. The Hózhó Resilience Model is a model that can be used to understand American Indian worldviews in relation to health, and may also be used to guide future research and nursing practice with the American Indian population.

Objective: To determine the assessment methods for upper limb (UL) associated reactions (ARs) in people with acquired brain injury (ABI). Methods: A systematic search of 10 databases was performed for Stage 1 to identify methods that quantify ARs of the hemiplegic UL. Stage 2 searched four databases to examine the clinimetric properties and clinical utility of these methods. Two independent reviewers identified relevant articles, extracted data, assessed study methodological quality and rated the clinimetric properties and clinical utility. Results: Eighteen articles were included. The methods used to evaluate ARs were surface electromyography (11), goniometry (5), dynamometry (5), electrogoniometry (1), subjective clinician (2) and patient rating forms (2). Electromyography, electrogoniometry and dynamometry implemented stationary, seated positions using maximal voluntary contractions of the less impaired UL as the provocative task. Standard goniometry most frequently tested ARs dynamically, using a mobility task to provoke the AR. There was limited clinimetric data available. Only half of the assessment methods were deemed clinically feasible. The most common methods were laboratory-based. Conclusion: There were a limited number of methods used to assess ARs in people with ABI and the measurement properties of these outcomes were largely unreported. No gold standard was identified.

Anxiety is a sense of perceived threat to one’s physical safety or emotional wellbeing, and symptoms are experienced in body, mind, and spirit. This chapter focuses on anxiety as a normal reaction to stressors—external, internal, or existential. Everyone experiences anxiety, both trait anxiety and state anxiety at multiple points in their lives; however, prolonged and severe symptoms of anxiety can evolve into a clinical form of anxiety, such as generalized anxiety disorder, panic disorder, or posttraumatic stress disorder. This chapter reviews assessment of anxiety, including evidence-based screening measures and the patient-centered interview. Symptom identification and management incorporating integrative nursing principles are presented, including patient self-management strategies as well as provider-directed treatment options. In clinical decision-making for anxiety symptom management, concordance with the patient in establishing a treatment plan is emphasized. A case study highlights a patient-centered and culturally sensitive approach to the management of anxiety.

In order to investigate the use of e-books at South African university libraries, this study explored patrons’ attitudes to e-books, their current use of e-books, and their expectations of e-books in their academic libraries. Results showed that users were eager to use e-books but that there was a lack of awareness that libraries stocked them, or to what degree. Print was still preferred by many, but e-books were seen as a convenient alternative. Users were ignorant of the limitations that most e-book licensing agreements impose, expecting unlimited access to the content of e-books as they would with print books.

This paper will explore some of the views that were expressed during the Library and Information Association of South Africa (LIASA) workshop held in cooperation with the UK's Digital Curation Centre (DCC) in March 2014. The event provided an ideal opportunity to assess librarians' views on the changing research data management landscape and to consider how these changes might affect the role of academic librarians in South Africa. The paper compares these views with experiences garnered through the DCC's work to support universities in the UK.

American Indian Alaska Native people of the United States face challenges in attaining physical, mental, spiritual, and environmental health. This article presents a concept analysis of Diné Hózhó, a complex and misunderstood wellness concept the Diné (Navajo) strive to attain. Findings from a literature review are presented to explore anthropological definitions and uses of the concept Hózhó. The method of concept analysis of Walker and Avant is utilized, model cases are presented. Recommendations for application in nursing practice are presented.

Hózhó is the complex wellness philosophy and belief system of the Diné (Navajo) people, comprised of principles that guide one's thoughts, actions, behaviors, and speech. The alignment of integrative nursing principles and the Hózhó Wellness Philosophy illustrates the power that integrative nursing offers as a meta-theoretical perspective that can transform our healthcare system so that it is inclusive and responsive to the needs of our varied populations. Integrative nursing offers the opportunity to re-introduce cultural wellness wisdom, such as Hózhó, as a means to improve whole-person/whole-systems wellbeing and resilience. Integrative nursing, through the acceptance and validation of indigenous health-sustaining wisdom, contributes to the delivery of effective, authentic, culturally tailored, whole-person/whole-system, patient-centered, relationship-based healthcare. Highlighting the Diné Hózhó philosophy re-introduces this philosophy to the Diné, other American Indian/Alaska Native nations, global indigenous cultures, and even nonindigenous people of the world as a means to promote and sustain global health and wellbeing.美是一种复杂的健康理念和纳瓦 霍人的信仰体系，由人的思想、 行动、行为和言论组成。 综合 护理原则与美的健康理念整合， 说明综合护理提供了一种荟萃理论观点，能转换我们的医疗体 系，令其包容并对不同人群的需 求做出响应。 综合护理提供了 重新引入文化中的健康智慧（如 美）的机会，以作为一种改善全 人/全体系的健康和适应力的手 段。 综合护理通过接受和验证 土著健康维持智慧，从而有助于 提供有效、真实、文化量身定 制、全人/全体系、以患者为中心的、以关系为基础的医疗护 理。 突出纳瓦霍的美的理念， 将 这 一 理 念 重 新 引 入 了 纳 瓦 霍 人、其他美国印第安人/阿拉斯 加 原 住 民 国 家 、 全 球 的 土 著 文 化、甚至全球的原住民的生活， 作为一种促进和维持全球健康和 福祉的手段。.Hózhó es el complejo sistema de creencias y la filosofía del bienestar de los Diné (Navajos) que abarca los principios que guían los pensamientos, acciones, comportamientos y el habla de una persona. La convergencia de los principios de la atención integral con la filosofía Hózhó del bienestar ilustra el poder que la atención integral ofrece como perspectiva metateórica que puede transformar nuestro sistema sanitario, de forma que sea inclusivo y dé respuesta a las necesidades de nuestra variada población. La atención integral ofrece la oportunidad de volver a introducir el bagaje cultural relativo al bienestar, como el Hózhó, como un medio para mejorar el bienestar y la recuperación tanto en las personas como en los sistemas. La atención integral, a través de la aceptación y validación de la sabiduría indígena relacionada con la salud, contribuye a proporcionar una asistencia sanitaria efectiva, auténtica, adaptada culturalmente, individual, integral, centrada en el paciente y basada en los vínculos. Destacar la filosofía Hózhó de los Diné hace que esta filosofía vuelva a introducir a los Diné, a otras naciones nativas de indios americanos y de Alaska, a las culturas indígenas globales e incluso a las personas no indígenas del mundo como un medio para promover y mantener la salud y el bienestar global.

OBJECTIVE The aim of this study was to investigate the relationship between a clinical test of ankle plantarflexor strength and ankle power generation (APG) at push-off during walking. DESIGN This is a prospective cross-sectional study of 102 patients with traumatic brain injury. OUTCOME MEASURES Handheld dynamometry was used to measure ankle plantarflexor strength. Three-dimensional gait analysis was performed to quantify ankle power generation at push-off during walking. RESULTS Ankle plantarflexor strength was only moderately correlated with ankle power generation at push-off (r = 0.43, P < 0.001; 95% confidence interval, 0.26-0.58). There was also a moderate correlation between ankle plantarflexor strength and self-selected walking velocity (r = 0.32, P = 0.002; 95% confidence interval, 0.13-0.48). CONCLUSIONS Handheld dynamometry measures of ankle plantarflexor strength are only moderately correlated with ankle power generation during walking. This clinical test of ankle plantarflexor strength is a poor predictor of calf muscle function during gait in people with traumatic brain injury.

The aim of this systematic review was to investigate the task specificity of strength training programs for walking in neurologic rehabilitation. Nine electronic databases were searched from conception to October 2012 for randomized controlled trials that used strength training to improve walking in adult neurologic populations. The search identified 25 randomized controlled trials that investigated the efficacy of strength training to improve walking in people with a variety of neurologic conditions. The results revealed that despite significant strength gains, many studies failed to show a significant improvement in walking capacity. Most studies did not include exercises relating to all three main power events important for walking. Strength testing and strengthening exercises were prioritized for the knee extensors and flexors, despite their relatively minor role in human walking. Strengthening exercises performed in the neurologic population are not specific to the main muscle groups responsible for the power generation required for walking. There is a predisposition for strength testing and strengthening exercises to focus on the knee flexors and extensors despite their relatively minor role during walking. Further consideration of the specificity of strength training may provide greater translation of strength gains to improved walking outcomes.

OBJECTIVE The aim of this study was to investigate the relationship between a clinical test of ankle plantarflexor strength and ankle power generation (APG) at push-off during walking. DESIGN This is a prospective cross-sectional study of 102 patients with traumatic brain injury. OUTCOME MEASURES Handheld dynamometry was used to measure ankle plantarflexor strength. Three-dimensional gait analysis was performed to quantify ankle power generation at push-off during walking. RESULTS Ankle plantarflexor strength was only moderately correlated with ankle power generation at push-off (r = 0.43, P < 0.001; 95% confidence interval, 0.26-0.58). There was also a moderate correlation between ankle plantarflexor strength and self-selected walking velocity (r = 0.32, P = 0.002; 95% confidence interval, 0.13-0.48). CONCLUSIONS Handheld dynamometry measures of ankle plantarflexor strength are only moderately correlated with ankle power generation during walking. This clinical test of ankle plantarflexor strength is a poor predictor of calf muscle function during gait in people with traumatic brain injury.

Objective: To determine whether the revised High-Level Mobility Assessment Tool (HiMAT) was valid for measuring mobility for people with multi-trauma orthopaedic lower limb injuries. Design: Cross-sectional study. Subjects: Participants with lower limb multi-trauma orthopaedic injuries. Methods: One complete revised HiMAT was obtained for 106 people within 12 weeks of being allowed to fully weight bear. Rasch analysis was used to assess the overall fit of the model for individuals and items, differential item functioning, local dependency, targeting of items and dimensionality. Results: The mean revised HiMAT score was 10.5 (SD = 6.8) with a range of 5–30. Rasch analysis of revised HiMAT showed adequate overall fit to the model ( P = 0.29) with no misfitting items (fit residual SD = 0.69) or persons (fit residual SD = 0.62). The scale showed good internal consistency (Person Separation Index = 0.91). One item (hopping) demonstrated disordered thresholds, however this item had good fit to the model in all other aspects. The revised HiMAT was unidimensional, and no differential item functioning was detected for gender or age. The revised HiMAT was well targeted for this group with a range of items across all ability levels. Conclusion: The results of this study support the internal construct validity of the revised HiMAT as a well-targeted, unidimensional measure of high-level mobility with no ceiling or floor effect for males and females recovering from multi-trauma orthopaedic lower limb injuries.

To investigate the concurrent validity, responsiveness, and ceiling effect of the revised High-Level Mobility Assessment Tool (HiMAT) in persons after orthopedic multitrauma.Cross-sectional sample of convenience.A large tertiary rehabilitation hospital.Forty-three participants with orthopedic multitrauma lower limb injuries that resulted from motor vehicle accidents.This study compared the concurrent validity, responsiveness, and ceiling effects of the revised HiMAT, motor subsection of the Functional Independence Measure (FIM) instrument. Performances for all participants were concurrently scored on the motor FIM, revised HiMAT, and the Lower Extremity Functional Scale (LEFS) at initial testing, and 6 and 12 weeks after the decision to fully bear weight.Revised HiMAT, motor FIM, and LEFS.The correlation between the revised HiMAT and the motor FIM was moderate (r = 0.49; P .001) and partly induced by a ceiling effect in the motor FIM. After 12 weeks of full weight bearing, 51.2% of participants achieved the maximum score on the motor FIM. The correlation between the revised HiMAT and LEFS was weak (r = 0.39; P = .012), which indicated a weak relationship between self-reported mobility problems and actual performance. The revised HiMAT was more responsive than the motor FIM and the LEFS, based on the proportion of persons who exceeded the minimal detectable change score over a period of 6 and 12 weeks.The revised HiMAT is more responsive to change than the LEFS and motor FIM, and less susceptible to a ceiling effect than the motor FIM for persons with orthopedic multitrauma. It has poor-to-moderate concurrent validity with the LEFS and motor FIM, which suggests that it may be measuring a different aspect of mobility.

While e-journals have successfully be integrated into library collections, the same cannot be said about e-books. In this paper, the obstacles to e-book adoption in academic libraries is discussed using a review of the English-language literature published over the period 2007 to 2013. Issues identified are the changing roles of libraries in the digital age; collection development strategies; complex e-book purchase models offered to libraries; questions of copyright, licensing and digital rights management; format considerations; and availability of hardware and software on which to read e-books. Libraries continue to face these challenges today.