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Objective: To determine if self-management programs, supported by a health professional, in rehabilitation are cost effective., Data Sources: Six databases were searched until December 2023., Study Selection: Randomized controlled trials with adults completing a supported self-management program while participating in rehabilitation or receiving health professional input in the hospital or community settings were included. Self-management programs were completed outside the structured, supervised therapy and health professional sessions. Included trials had a cost measure and an effectiveness outcome reported, such as health-related quality of life or function. Grading of Recommendations, Assessment, Development, and Evaluations was used to determine the certainty of evidence across trials included in each meta-analysis. Incremental cost-effectiveness ratios were calculated based on the mean difference from the meta-analyses of contributing health care costs and quality of life., Data Extraction: After application of the search strategy, two independent reviewers determined eligibility of identified literature, initially by reviewing the title and/or abstract before full-text review. Using a customized form, data were extracted by one reviewer and checked by a second reviewer., Data Synthesis: Forty-three trials were included, and 27 had data included in meta-analyses. Where self-management was a primary intervention, there was moderate certainty of a meaningful positive difference in quality-of-life utility index of 0.03 units (95% confidence interval, 0.01-0.06). The cost difference between self-management as the primary intervention and usual care (comprising usual intervention/therapy, minimal intervention [including education only], or no intervention) potentially favored the comparison group (mean difference=Australian dollar [AUD]90; 95% confidence interval, -AUD130 to AUD310). The cost per quality-adjusted life year (QALY) gained for self-management programs as a stand-alone intervention was AUD3000, which was below the acceptable willingness-to-pay threshold in Australia per QALY gained (AUD50,000/QALY gained)., Conclusions: Self-management as an intervention is low cost and could improve health-related quality of life., (Copyright © 2024 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Background: Self-management programs can increase the time spent on prescribed therapeutic exercises and activities in rehabilitation inpatients, which has been associated with better functional outcomes and shorter hospital stays., Objectives: To determine whether implementation of a self-management program ('My Therapy') improves functional independence relative to routine care in people admitted for physical rehabilitation., Methods: This stepped wedge, cluster randomized trial was conducted over 54 weeks (9 periods of 6-week duration, April 2021 - April 2022) across 9 clusters (general rehabilitation wards) within 4 hospitals (Victoria, Australia). We included all adults (≥18 years) admitted for rehabilitation to participating wards. The intervention included routine care plus 'My Therapy', comprising a sub-set of exercises and activities from supervised sessions which could be performed safely, without supervision or assistance. The primary outcomes were the proportion of participants achieving a minimal clinically important difference (MCID) in the Functional Independence Measure, (FIM™) and change in total FIM™ score from admission to discharge., Results: 2550 participants (62 % women) were recruited (control: n = 1458, intervention: n = 1092), with mean (SD) age 77 (13) years and 37 % orthopedic diagnosis. Under intervention conditions, participants reported a mean (SD) of 29 (21) minutes/day of self-directed therapy, compared to 4 (SD 14) minutes/day, under control conditions. There was no evidence of a difference between control and intervention conditions in the odds of achieving an MCID in FIM™ (adjusted odds ratio 0.93, 95 % CI 0.65 to 1.31), or in the change in FIM™ score (adjusted mean difference: -0.27 units, 95 % CI -2.67 to 2.13)., Conclusions: My Therapy was delivered safely to a large, diverse sample of participants admitted for rehabilitation, with an increase in daily rehabilitation dosage. However, given the lack of difference in functional improvement with participation in My Therapy, self-management programs may need to be supplemented with other strategies to improve function in people admitted for rehabilitation., Trial Registration: Australian New Zealand Clinical Trials Registry (ACTRN12621000313831), https://www.anzctr.org.au/., Competing Interests: Declaration of competing interest None., (Copyright © 2024 The Authors. Published by Elsevier Masson SAS.. All rights reserved.)

Purpose: To evaluate the implementation of a self-management program, My Therapy, designed to increase inpatient rehabilitation therapy dosage via independent practice., Materials and Methods: A process evaluation of My Therapy for adult patients admitted for rehabilitation for any condition supervised by physiotherapists and occupational therapists across eight rehabilitation wards compared usual care. Outcomes included reach , dosage , fidelity and adaptation., Results: The mean (SD) age of the process evaluation sample ( n  = 123) was 73 (11) years with a mean (SD) length of stay of 14.0 (6.6) days. The My Therapy program reached 68% of participants ( n  = 632/928), and resulted in an average increase in therapy dosage of 26 (95% CI 12 to 40) minutes/day of independent practice. All My Therapy audited programs ( n  = 28) included body function/structure impairment-based exercises, and half ( n  = 13/28) included activity/participation-based exercises. On average, participants completed programs 1.8 (SD 1.2) times/day, which were prescribed in accordance with the My Therapy criteria, demonstrating fidelity . There were no between-group differences in daily steps or standing time, however, My Therapy participants spent more time sitting ( p  ≤ 0.05). Implementation adaptations were minimal., Conclusion: A self-management rehabilitation program was implemented with fidelity for two in three rehabilitation patients, resulting in increased therapy dosage with minimal adaptations.

Purpose: To investigate patients' perceptions of participating in self-directed activities, outside supervised occupational and physiotherapy, within rehabilitation settings., Methods: Semi-structured interviews were undertaken with 16 patients and in three instances, their carers, from three health services in Victoria, Australia, two offering inpatient and one offering home-based rehabilitation care. A thematic analysis was performed using a framework approach., Results: Themes identified included the role of the clinicians in encouraging patients and instilling confidence, giving feedback and "just being there"; considerations in program delivery, including different formats, support from peers and relatives, and program familiarity and flexibility; patients' different intrinsic driving and limiting forces, including following orders, seeing results, desiring autonomy and having an "inner athlete"; and the environment, including functional activities, space, equipment, time and availability., Conclusions: Patients and their carers reported positive experiences of participating in self-directed therapy programs within rehabilitation settings, with programs perceived as beneficial in optimising recovery. Patients reported a range of driving and limiting factors in relation to completing self-directed activities. Understanding these factors, relating to the patient, their environment and other people, is critical for clinicians so that they can modify their delivery accordingly, ensuring uptake and sustained implementation of self-directed activities in rehabilitation care.

Objective My Therapy is an allied health guided, co-designed rehabilitation self-management program for residents of aged care facilities. This study aimed to determine the feasibility of implementing My Therapy in a residential aged care setting. Methods This observational study was conducted on a 30-bed wing, within a 90-bed metropolitan residential aged care facility, attached to a public health service, in Victoria, Australia. Staff and resident data were collected prospectively over 6 weeks (staff focus groups, patient surveys, and audits) to evaluate the feasibility domains of acceptability , reach and demand , practicality , integration , limited efficacy testing and adaptations . Results Twenty-six residents and five allied health staff (physiotherapy and occupational therapy) participated. My Therapy was acceptable to residents (survey) and staff (focus groups). Via initial My Therapy discussions between the resident and the therapists, to determine goals and resident preferences, My Therapy reached 26 residents (n  = 26/26, 100% program reach ), with 15 residents subsequently receiving a rehabilitation program (n  = 15/26, 58% program demand ). The remaining 11 residents did not participate due to resident preference or safety issues (n  = 11/26, 42%). Collecting physical function outcome measures for limited efficacy testing was practical , and the cost of My Therapy was AUD$6 per resident per day, suggesting financial integration may be possible. Several adaptations were required, due to limited allied health staff, complex resident goal setting and program co-design. Conclusion My Therapy has the potential to improve the rehabilitation reach of allied health services in residential aged care. While introducing this low-cost intervention is feasible, adaptations were required for successful implementation.

Background: Self-directed therapy activities are not currently part of routine care during inpatient rehabilitation. Understanding patient and clinician perspectives on self-directed therapy is key to increasing implementation. The aim of this study was to investigate barriers and facilitators to implementing a self-directed therapy programme ("My Therapy") in adult inpatient rehabilitation settings., Methods: My Therapy was recommended by physiotherapists and occupational therapists and completed by rehabilitation inpatients independently, outside of supervised therapy sessions. Physiotherapists, occupational therapists, and patients were invited to complete an online questionnaire comprising open-ended questions on barriers and facilitators to prescribing and participating in My Therapy. A directed content analysis of free-text responses was undertaken, with data coded using categories of the Capability, Opportunity, and Motivation Model of Behaviour (COM-B model)., Results: Eleven patients and 20 clinicians completed the questionnaire. Patient capability was reported to be facilitated by comprehensive education by clinicians, with mixed attitudes towards the format of the programme booklet. Clinician capability was facilitated by staff collaboration. One benefit was the better use of downtime between the supervised therapy sessions, but opportunities for patients to engage in self-directed therapy were compromised by the lack of space to complete the programme. Clinician opportunity was reported to be provided via organisational support but workload was a reported barrier. Patient motivation to engage in self-directed therapy was reported to be fostered by feeling empowered, engaged, and encouraged to participate. Clinician motivation was associated with belief in the value of the programme., Conclusion: Despite some barriers to rehabilitation patients independently practicing therapeutic exercises and activities outside of supervised sessions, both clinicians and patients agreed it should be considered as routine practice. To do this, patient time, ward space, and staff collaboration are required. Further research is needed to scale-up the implementation of the My Therapy programme and evaluate its effectiveness., (© 2023 The Authors. Australian Occupational Therapy Journal published by John Wiley & Sons Australia, Ltd on behalf of Occupational Therapy Australia.)

Objective: To test the feasibility, safety and effectiveness of the My Therapy programme for inpatients with mild-moderate cognitive impairment., Design: Observational pilot study., Patients: Rehabilitation inpatients with mild-moderate cognitive impairment., Methods: During their inpatient admission, participants received My Therapy, a programme that can increase the dose of rehabilitation through independent self-practice of exercises, outside of supervised therapy. Outcomes included My Therapy participation, falls, Functional Independence Measure (FIM) and 10-m walk test. Outcomes were compared with those of participants without cognitive impairment from the original My Therapy study ( n = 116) using χ 2 and independent t -tests., Results: Eight participants with mild-moderate cognitive impairment (mean (standard deviation (SD)) age 89.6 years (4.8); 3 women) were included. All participants completed the My Therapy programme on at least one day of their admission, with no associated falls. Participants had an 8.4 s (SD 5.1) reduction in their 10-m walk test and a 21.5 point (SD 11.1) improvement on FIM scores from admission to discharge. There were no significant between-group differences in feasibility, safety or effectiveness for participants with and without cognitive impairment., Conclusion: This pilot study has shown that including exercise self-management as part of inpatient rehabilitation is feasible, safe and effective for patients with cognitive impairment., Competing Interests: The authors have no conflicts of interest to declare., (Journal Compilation © 2022 Foundation of Rehabilitation Information.)

Abstract: Auditory hallucination is common in schizophrenia, influencing emotional state and behavior. Most patients experience high levels of distress, paranoia, and depression. After participating in the "Hearing Voices" auditory simulation, which involved rotating through various workstations while listening to distressing voices, nursing students (n = 39) completed the Kiersma-Chen Empathy Scale. All were satisfied with the auditory simulation; 90 percent perceived the experience as beneficial to their role as a registered nurse. This innovative teaching strategy, utilizing simulation, provided an opportunity to experience auditory hallucinations, thereby increasing both understanding and empathy., Competing Interests: The authors have declared no conflict of interest., (Copyright © 2021 National League for Nursing.)

Background: Process evaluations have been recommended alongside clinical and economic evaluations to enable an in-depth understanding of factors impacting results. My Therapy is a self-management program designed to augment usual care inpatient rehabilitation through the provision of additional occupational therapy and physiotherapy exercises and activities, for the patient to complete outside of supervised therapy. The aims of the process evaluation are to assess the implementation process by investigating fidelity, quality of implementation, acceptability, adoption, appropriateness, feasibility and adaptation of the My Therapy intervention; and identify contextual factors associated with variations in outcomes, including the perspectives and experiences of patients and therapists., Methods: The process evaluation will be conducted alongside the clinical and economic evaluation of My Therapy, within eight rehabilitation wards across two public and two private Australian health networks. All participants of the stepped wedge cluster randomised trial (2,160 rehabilitation patients) will be included in the process evaluation (e.g., ward audit); with a subset of 120 participants undergoing more intensive evaluation (e.g., surveys and activity logs). In addition, 24 staff (occupational therapists and physiotherapists) from participating wards will participate in the process evaluation. The mixed-methods study design will adopt a range of quantitative and qualitative research approaches. Data will be collected via a service profile survey and audits of clinical practice across the participating wards (considering areas such as staffing profiles and prescription of self-management programs). The intensive patient participant data collection will involve structured therapy participation and self-management program audits, Exercise Self Efficacy Scale, patient activity logs, patient surveys, and patient-worn activity monitors. Staff data collection will include surveys and focus groups., Discussion: The process evaluation will provide context to the clinical and economic outcomes associated with the My Therapy clinical trial. It considers how clinical and economic outcomes were achieved, and how to sustain the outcomes within the participating health networks. It will also provide context to inform future scaling of My Therapy to other health networks, and influence future models of rehabilitation and related policy., Trial Registration: This study was prospectively registered with the Australian and New Zealand Clinical Trials Registry (ACTRN12621000313831; registered 22/03/2021, http://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=380828&isReview=true )., (© 2021. The Author(s).)

Background: Ensuring patients receive an effective dose of therapeutic exercises and activities is a significant challenge for inpatient rehabilitation. My Therapy is a self-management program which encourages independent practice of occupational therapy and physiotherapy exercises and activities, outside of supervised therapy sessions., Methods: This implementation trial aims to determine both the clinical effectiveness of My Therapy on the outcomes of function and health-related quality of life, and cost-effectiveness per minimal clinically important difference (MCID) in functional independence achieved and per quality adjusted life year (QALY) gained, compared to usual care. Using a stepped-wedge cluster randomised design, My Therapy will be implemented across eight rehabilitation wards (inpatient and home-based) within two public and two private Australian health networks, over 54-weeks. We will include 2,160 patients aged 18 + years receiving rehabilitation for any diagnosis. Each ward will transition from the usual care condition (control group receiving usual care) to the experimental condition (intervention group receiving My Therapy in addition to usual care) sequentially at six-week intervals. The primary clinical outcome is achievement of a MCID in the Functional Independence Measure (FIM™) at discharge. Secondary outcomes include improvement in quality of life (EQ-5D-5L) at discharge, length of stay, 30-day re-admissions, discharge accommodation, follow-up rehabilitation services and adverse events (falls). The economic outcomes are the cost-effectiveness per MCID in functional independence (FIM™) achieved and per QALY gained, for My Therapy compared to usual care, from a health-care sector perspective. Cost of implementation will also be reported. Clinical outcomes will be analysed via mixed-effects linear or logistic regression models, and economic outcomes will be analysed via incremental cost-effectiveness ratios., Discussion: The My Therapy implementation trial will determine the effect of adding self-management within inpatient rehabilitation care. The results may influence health service models of rehabilitation including recommendations for systemic change to the inpatient rehabilitation model of care to include self-management. Findings have the potential to improve patient function and quality of life, and the ability to participate in self-management. Potential health service benefits include reduced hospital length of stay, improved access to rehabilitation and reduced health service costs., Trial Registration: This study was prospectively registered with the Australian and New Zealand Clinical Trials Registry (ACTRN12621000313831; registered 22/03/2021, http://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=380828&isReview=true )., (© 2021. The Author(s).)

We studied a telediabetes programme that had been in operation for 10 years, to identify the factors in its sustainability. We reviewed archive documents, conducted interviews with programme administrators and primary care providers, observed diabetes consultations and surveyed patient satisfaction. Three success factors were identified: the administration took a long-term view of the value of the telemedicine service; telediabetes enabled structured use of staff time and facilities; and service delivery followed national diabetes standards and a well defined cycle of care within a long-term quality improvement programme. However, the present study did not address the three other key theoretical dimensions of systems design beyond sustainability: size, scalability and scope.

Strains of Aspergillus nidulans carrying the conditional-lethal mutation sodVIC1 (stabilization of disomy) are defective in nuclear division and hyphal extension. The mutation affects both the establishment and maintenance of polar growth, since mutant spores do not germinate at restrictive temperature and preexisting hyphae stop growing upon upshift. The defect is reversible within the first 3-4 h at restrictive temperature but longer periods of incubation are lethal due to cell lysis and morphological abnormalities. There is no evidence for a specific cell cycle lesion, suggesting the existence of a feedback mechanism whereby hyphal extension is coordinated with nuclear partitioning. The sodVIC gene has been cloned from a chromosome VI-specific cosmid library and its product exhibits strong homology to the alpha-COP subunit of the coatomer complex involved in the secretory pathway in yeast and higher organisms. Molecular disruption of the gene is lethal, indicating that SodVIC is essential for growth in A. nidulans., (Copyright 1999 Academic Press.)

The mitotic and meiotic stabilities of transgenes were evaluated in the oomycete, Phytophthora infestans. Genes encoding beta-glucuronidase (GUS), neomycin phosphotransferase (NPT) and hygromycin phosphotransferase (HPT), fused to one of six promoters from P. infestans or other oomycetes, were usually stably expressed during continued asexual culture and transmitted to progeny. However, the activity of these genes became undetectable in many strains during asexual or sexual propagation. Over 33 months of growth, transgene expression stopped each month in 1-3% of the transformants. Silencing of the genes was not associated with their deletion, mutation, or hypermethylation. The conformation of the integrated sequences was similar in strains destined to continue or terminate expression of the transgenes. Expression of the genes was not associated with a loss of fitness during growth in vitro and in planta, which might otherwise have selected for silencing events.