Agile Journal 2008 Autumn

Autumn/Winter issue
A study to explore the predictive validity of Performance-oriented Assessment of Mobility (POAM) for falls in older people National Clinical Guidelines for Stroke 2008 Research Proposal: A Survey to investigate the range of and indications for specific outcome measures used in the rehabilitation of the older person
Chartered Physiotherapists working with Older People
AGILITY
2008 No 2
Contents
Editorial Contact details of Agiles Executive Committee Contact details of Agiles Regional Representatives An update on the Agile Standards revision A study to explore the predictive validity of Performance-oriented Assessment of Mobility (POAM) for falls in older people Impact report 2007-8 An update to the AGILE continence exercises 1 3 3 4 5 10 11 Agile Conference 2008 Report National Clinical Guidelines for Stroke 2008 Research Proposal: A Survey to investigate the range of and indications for specific outcome measures used in the rehabilitation of the older person List of articles of interest Guidelines for authors Items for sale Membership Form 12 14 16 32 33 34 35
Editorial
elcome to AGILITY, Winter 2008! This being my first edition as the editor, it may be a little rough around the edges, but please bear with me as I settle into my new role... and any feedback will be welcomed. This is your journal, so let me know what youd like to see done with it. This time around, were lucky enough to have an editorial written by Amanda Squires, a co-founder of Agiles predecessor and some interesting reading. First up, a study exploring the predictive validity of the POAM and some details on the National Stroke Guidelines 2008, and also a research proposal from last year that some of you will hopefully have taken part in and maybe we can see the results in the next edition (if youre like me, roll on summer!!). Theres feedback from conference 2008 as well as a report written by our former chair, Vicki Goodwin, on the impact of Agile. Enjoy the reading, if you can fit it in with Christmas shopping, and why not make a contribution (article/report/critique) to AGILITY one of your New Years Resolutions?! Carrie-Ann Reynolds
GUEST EDITORIAL
Prior to the second World War, people who reached old age and had no relatives or funds were largely looked after by fitter inmates in the infirmaries attached to parish workhouses. The demand for acute beds during the war led to evacuation of chronically ill patients from hospitals to infirmaries, accompanied by qualified junior staff. One such junior doctor, Marjorie Warren, realised that specialisation, surroundings, assessment, diagnosis, prioritisation, foot wear and clothing, treatment and discharge were possible. This start to rehabilitation coincided with the discharge of PT instructors from the Army being taken on by innovative units. By the 1970s, an increasing number of people were living into old and very old age as a direct result of Victorian public health improvements. More of them were living alone as a result of war bereavement, social mobility and the changing expectations of their families. This was coupled with pressure on health service funding as a result of an oil crisis. An increasing number of older people, through age and absence of carers, were taking up hospital beds, and rehabilitation and discharge of older people was being seen as an opportunity to free up beds. The specialty of geriatrics was, however, low in the social and funding hierarchy, and most of us worked single handed with assistants with poor equipment and in poor premises (many still the original workhouse infirmaries). Despite this, teamwork with
Copyright
The material in this Journal is copyright to AGILITY and may not be published in another journal without the permission of the editor. Authors will be advised of any requests to reprint their articles in other journals. Opinions expressed in this Journal are not necessarily those of the Editor of AGILITY, AGILE or the publisher.
AGILITY Autumn/Winter 2009
other disciplines was excellent as we fought against all manner of odds as a team. The Health Advisory Service, set up by the government following scandals in the vulnerable areas of mental health, learning disabilities, paediatrics and elderly care, sent teams to every such unit around the country on rotation. It was at such a visit that Margot Hawker, the physiotherapist on the team and the first to promote the opportunities of physiotherapy in elderly care, and myself as a nervous physiotherapist being visited met, and discussed the issue of isolation from colleagues battling with similar challenges. We subsequently set up the forerunner of AGILE to promote high standards of physiotherapy with older people through education, communication and support. AGILEs membership, past and present, have been crusaders in the cause of improving elderly care. We have largely focussed at a local, national and single
discipline level in hospitals based on the original principles. As we mature as an organisation, we need to ratchet up our focus to a political and more interdisciplinary, interagency and international influence. By 2025 there will be an estimated 800 million older people in the world, with the fastest growth in developing countries. In developed countries more older people are in care than in hospital and we need to consider how we reach them more effectively. Sharing information based on international interdisciplinary interagency experience should be our future.
Amanda Squires PhD, MSc, FCSP Co founder and former secretary and president of AGILE Ref. Physiotherapy with older people. AGILITY Commemorative 21st Anniversary Issue April 1999
Do you need financial support to attend a course or do some research?

The AGILE Education and Research Fund can help you.
A research fund for AGILE members was established in early 2005 and a total of 600 per year is available with the idea that up to three awards will be made each year. The funding is available towards research that relates to physiotherapy and the older person including that being undertaken as part of a higher degree or as part of a local research project. Other potential uses are purchasing equipment, transcribing costs or producing conference posters to disseminate research findings. You may be surprised to find some support for attending a course overseas and you wont know until you apply! More information about the Research Fund can be found on the AGILE website or contact Lynne Bakewell, Treasurer.
Data Protection Act

Members details are held on a computer database. Questionnaires may be sent by students undertaking dissertations this will be via the membership secretary. The database address list may also be provided to a third party if the National Executive believe it would be beneficial to members interest in older people. Please write to the membership secretary if you do not want your details disclosed in either of these circumstances.
AGILE National Executive Officers November 2008

PRESIDENT Bob Laventure Email: bob.laventure@ntlworld.com CHAIR Mandy Tyler Email: mandy.tyler@gwent.wales.nhs.uk VICE CHAIR Lynn Sutcliffe Email: lynn.sutcliffe@cumbriapct.nhs.uk SECRETARY Janet Thomas Email: janetthomas@nhs.net MEMBERSHIP SECRETARY Julie George Email: julie.George4@nhs.net
NOTES SECRETARY Vacant TREASURER Lynne Bakewell Email: lynne.bakewell@derbyshire.gov.uk JOURNAL EDITOR Carrie Reynolds Email: carrie_reynolds@hotmail.com RESEARCH OFFICER Vivien Astbury Email: vivien.astbury@trafford.nhs.uk iCSP REP Vicky Johnston Email: vickyjohnston@tiscali.co.uk PRO Jo Hurford Email:joanne.hurford@gwent.wales.nhs.uk EDUCATION OFFICER Ursula Martindale Email: ursulamartindale@nhs.net
AGILE Regional Representatives

NORTH LYNN SUTCLIFFE Email: lynn.sutcliffe@cumbriapct.nhs.uk VIVIEN ASTBURY Email: vivien.astbury@trafford.nhs.uk EAST LOUISE BRIGGS Email: louise.briggs@stgeorges.nhs.uk LYNNE BAKEWELL Email: lynne.bakewell@derbyshire.gov.uk WEST JUDE DOUCH Email: judith.douch@plymouth.nhs.uk CATHERINE SAUNDERS Email: catherine.saunders2@nhs.net SCOTLAND JANET THOMAS Email: janetthomas@nhs.net NORTHERN IRELAND GAIL MCMILLAN Email: gail.mcmillan@belfasttrust.hscni.net WALES MANDY TYLER Email: mandy.tyler@gwent.wales.nhs.uk
Agile Standards Revision

By Janet Thomas
ith this edition of Agility you should have received your copy of the AGILE Revised Standards of Physiotherapy Practice Supplementary Paper.
on areas pertinent to physiotherapy practice with older people. One particular point to note is that the section on staffing does not consist of AGILE recommended staffing levels. Rather, we have tried to reflect how some current teams and departments have managed their case loads with regard to staffing levels, skill mix and caseload mix. All AGILE members are urged to ensure that their physiotherapy practice follows the good practice highlighted in this revised standards paper. AGILE would welcome feedback on this revised standards paper please send any comments to the Secretary at janetthomas@nhs.net On behalf of the Agile Standards working group
AGILE published the Standards of Physiotherapy Practice Supplementary Paper in 2004 and whilst much of the information in that document is still current and relevant, the Executive Committee felt that there were aspects of the standards which required revising and updating. As with the 2004 edition, this revised supplementary paper has been mapped against the standards contained in the CSP documents, the Core Standards of Physiotherapy Practice and Service Standards of Physiotherapy Practice. As such, it should be read in conjunction with both CSP standards documents; it is not a stand-alone paper. Additional guidance has only been added where essential, and has been focussed
Using AGILITY for your announcements/vacancies etc

AGILE Study Days / Events : Staff vacancies: Commercial advertisements: no charge 75.00 per half page for AGILE members 150.00 per full page for AGILE members 100.00 per half page 200.00 per full page
Closing date for publication in Spring/Summer 2009 issue, available beginning of June 2009, is 30th April 2009
Please send in any queries to the Journal Editor
Carrie_Reynolds@hotmail.com
A study to explore the predictive validity of Performance-oriented Assessment of Mobility (POAM) for falls in older people
By Kiran Katikaneni, Dr Alexander Nowicky
INTRODUCTION Although there are many therapy outcome tools available, choosing the most appropriate one proves to be difficult, given either the limited available research evidence base or the practical difficulties in administering them. However, POAM is an outcome tool that is believed to be valid and reliable, and at the same time easy to administer (Thomas and Lane, 2005). This study, which was of single blind type, aimed to establish its predictive validity in identifying older people at high risk of falling by administering POAM, on a sample of 50 participants, all aged above 65 years. This study also aimed to test the hypothesis that there will be a significant difference in falls status between older people scoring less than and greater than 19 out of a possible total of 28 on POAM. In other words, it was hypothesised that the participants scoring less than 19 on POAM will be the individuals with history of persistent falling and also with a high risk of future falling. The key issue of concern is not merely that of falls in older people, as young people sustain frequent falls too, but rather the unique co-presentation of a high incidence and a high susceptibility by older people to serious injuries. Although only a small percentage of falls result in fractures, the annual cost of these fractures to the NHS is staggering. Apart from economical fallout, fractures and subsequent events might force individuals to lose independence and experience a poor quality of life. In a study done to evaluate the psychological state of the older people, it was observed that the individuals preferred death to fracturing their hips and subsequent transfer to a nursing home (Salkeld et al. 2000). Rationale & Development of the Research Question POAM was developed for several reasons by M. E. Tinetti, viz. to identify components of mobility that could be problematic whilst performing the activities of daily living; to explore potential reasons for trouble in carrying out certain manoeuvres; an individuals susceptibility to falling; and to aid in diagnosis, prevention and management of problems having a potential to interfere with functional mobility (Tinetti, 1986). POAM combines both balance and gait components for a thorough evaluation of the functional mobility. It is scored out of a possible 28 points, with higher the score the better the balance and gait parameters. A cut-off point of 19 is considered to be unsafe as regards to functional mobility, and those individuals scoring less than 19 are deemed to be at high risk of potential falling. POAM is divided into balance and gait sub-sections, and all the activities within are scored on a cardinal scale of 0 for being unable to do, 1 for able to do with help or on more than one attempt, and 2 for independent completion of the activity being assessed. However, the gait parameters are scored only 0 and 1 for inability and ability respectively to do
an activity. Balance and gait activities are scored independently for a total of 16 and 12 respectively; and the final total is 28. However, despite extensive literature review, only one study was found which tested the validity of POAM with 3 other balance and mobility tools (Thomas and Lane, 2005). To sum up the known risk factors in falls, and aid a health care professional in identifying individuals at risk, De Moraes Barros (2006) suggests use of a mnemonic- I HATE FALLING- by all those who are involved in falls management or come across older people in their practice. Table 1 illustrates the mnemonic. I Inflammation of joints (or joint deformity) H Hypotension (orthostatic blood pressure changes) A Auditory and visual abnormalities T Tremor (Parkinsons Disease or other cause) E Equilibrium (balance) problem F A L L I N G Foot problems Arrhythmia, heart block, or valvular disease Leg length discrepancy Lack of conditioning (generalised weakness) Illness Nutrition (poor; weight loss) Gait disturbance
or above was used in this study. All the participants were referred to, and attending the day hospital as part of their ongoing rehabilitation programme. Recruitment Criteria The inclusion criteria to participate in the study were; participants aged 65 years of above, to have a score of 13 and above on MMSE, and with good vision. As the study aimed to explore the validity of a falls measurement tool, it is imperative that the participants are from the population that are at high risk of falls. The exclusion criteria were; the participants aged less than 65 years; with blindness and those with a score of less than 13 on the MMSE. Intact vision is an essential prerequisite for completion of this test. Information & Consent Forms Research participant consent and information forms were designed as per the Central Office for Research Ethics Committees (COREC) recommendations. Data Collection & Analysis POAM was administered on the participant by the researcher on one-to-one basis. For balance activities, the participant was seated in a hard, armless chair whilst all the manoeuvres were tested. In case of gait related tasks, the participant was asked to walk across the room at his/her usual pace with the researcher following him/her closely behind for safety of the participant. Collected data were analysed for sensitivity and specificity using a 2x2 table to identify the number of participants with true positives and negatives, and false positives and negatives. A 2x2 table (Table 2) was helpful in clear separation of the participants based on their true falls status and their POAM scores. For the purpose of the study, participants scoring less than 19 who were also persistent fallers were considered to be truepositives, whilst those persistent fallers scoring more than 19 were considered as false-negatives. Participants who were non-fallers but scoring less than 19 were considered as false-positives, and those non-fallers scoring more than 19 were identified as true-negatives.
POAM (Cut-off=19) Number of participants with POAM 19 Persistent-Fallers Non-Fallers
Table 1: A mnemonic for key physical findings in elderly people who fall or nearly fall (De Moraes Barros GDV (2006) Falls in elderly people. The Lancet 367: 729-730.)
DEVELOPMENT OF METHOD Research Question This study aimed to test the hypothesis that there is a difference in falls status depending on the POAM scores. The null hypothesis of the study being that there will be no difference in falls status based on POAM scores. Secondly, based on results, it was proposed to recommend implementation of POAM, the outcome tool under study, as a standardised objective assessment for falls in the older people in Physiotherapy departments. Therefore, this study aimed to recommend the use of POAM as a specific outcome tool in older people referred for falls management. Research Design Sensitivity and specificity of the POAM was determined following the construction of a 2x2 table; and ROC was subsequently plotted to determine the validity of POAM. Sample Participants were recruited from the Day Hospital. A convenience sample of 50 older people, aged 65 years
A True Test-Positives C False Test-Negatives A+C
B False Test-Positives D True Test-Negatives B+D
Number of participants with POAM 18
Table 2: 2x2 Table for POAM Study
RESULTS The mean SD age of the participants was 79.1 8.4 years. The mean age of the female participants was 80.2 9.3 years, whilst that of the male participants being 78 7 years. There were 24 (48%) participants with score of less than 19 on POAM, whilst the mean POAM score being 18 5.3. There were 24 (48%) participants who have had persistent falls, whilst the remaining 28 (56%) have had either no or just 1 fall in the preceding 1 year duration. As identified by the POAM, there were 24 (48%) individuals with true positive on the test, 3 (6%) with false positive; and 15 (30%) with true negative whilst 8 (16%) individuals tested false negative on the tool. Of 50 participants, 12 (24%) were diagnosed with Parkinsons disease whilst 2 (4%) were suspected to have the disease, 9 (18%) have had Stroke, 17 (34%) were under treatment for a cardio-respiratory condition, and 10 (20%) have sustained a fracture on falling. 1(2%) participant with a history of persistent falls was diagnosed to have Mnires disease, and 6 (12%) have had joint replacement surgeries, either knee or hip. It was significant to observe that 5 (10%) individuals of them were found to be persistent fallers, and 4 (8%) of them tested positive on the tool. Table 3 shows the participant characteristics. Analysing the data for determining its distribution by histogram showed the frequency distribution with superimposed normal curve. The Figure 1 below illustrates histogram plotting the frequency distribution of POAM and the superimposed normal Table 3: Participant Characteristics
Age: Mean Sex: Female Male Domiciliary Status: Spouse/ Carer Independent Diagnosis: Cardio-respiratory condition Parkinsons disease Fracture Stroke Joint Replacement Surgery Mnires disease Falls History: Persistent Fallers POAM: Mean True Positive True Negative False Negative False Positive
curve. The histogram shows the mean POAM to be 18.12 5.
Figure 1: Histogram for frequency distribution of POAM
T-test for falls status versus POAM proved to be significant (p=0.0001, 95% CIE of 3.919 and 9.075. This T-test was done to determine significance of POAM on predicting falls status but without separating gender of the participants. Mean POAM in older people with persistent falls was 15.78 4.668 where n=32. In Table 4, 0 denotes the number of nonfallers, whilst 1 denotes the number of participants with history of persistent falls.
79.1 8.4 years 28 (mean age- 80.2 9.3 years (56%) 22 (mean age- 78 7 years (44%) 32 (64%) 18 (36%) 17 (34%) 12 (24%) 10 (20%) 9 (18%) 6 (12%) 1 (2%) 32 (64%) 18 (36%) 5.3 24 (48%) 15 (30%) 8 (16%) 3 (6%)
Table 4: Group Statistics for POAM versus Falls Status POAM Falls Status 0 1 N 18 32 Mean 22.28 15.78 Std. Deviation 3.707 4.668 Std. Error Mean .874 .825
2x2 table was constructed to identify the number of participants testing true and false positive; and true and false negative on POAM; and furthermore to calculate its sensitivity and specificity. Table 5 shows the 2x2 table.
POAM (Cut-off=19) Number of participants with POAM 19 Persistent-Fallers Non-Fallers
out of the total 18 non-fallers. To be deemed to be significant, a diagnostic tool should have high sensitivity and specificity levels. Therefore, the study presented is the first to provide strong supporting evidence to recommend the use of POAM as a valid falls assessment tool in older people. This study also showed that for patients with Parkinsons disease, POAM reliably detected those individuals with falls history. 57% of them had a falls history with all of them testing positive on POAM. This puts forth a strong case for use of POAM as a valid falls assessment tool in Parkinsons disease over the use of other mobility and balance tests. POAM was also successful in identifying persistent fallers who have had co-morbid conditions like stroke, cardiorespiratory diseases etc. POAM was shown to have best sensitivity in a study that compared it with three other balance and gait outcome tools (Thomas and Lane, 2005). This could be explained based on its inclusion of multifunctional manoeuvres and also both predictive and reactive equilibrium adjustments. In addition, POAM tests the strength in lower limb muscles by sit-to-stand manoeuvre and also the impact of visual input on balance mechanisms. As POAM incorporates all these aspects in its balance sub-section, and based on the findings of the present study, it can be strongly recommended for use as a routine clinical assessment. Limitations of the Study The sample size was n=50 therefore the results could be generalised, though with caution, to the population. However, given the existing and projected changes in demographics of older people, larger sample size would have substantiated the findings and helped in making stronger assertions. The present study did not test any other balance and gait tests, thereby providing no opportunity to compare the efficacy of POAM with that of the other tests. There was no provision made in the design of the study for testing intra-rater reliability in administering the POAM. Thomas and Lane (2005) in their study on various balance and gait outcome tools have reported fare to excellent intra-rater reliability. Areas of Further Research Further research in the field of falls prevention and management could be in the areas of testing validity and reliability of various assessment tools in general and POAM in particular as pre and post intervention outcome measures. CONCLUSION This study aimed to establish the predictive validity of POAM as a falls assessment tool by establishing its sensitivity and specificity.
A True Test-Positives 24 C False Test-Negatives 8 A+C=32
B False Test-Positives 3 D True Test-Negatives 15 B+D=18
Number of participants with POAM 18
Table 5: 2x2 Table for calculating Sensitivity and Specificity of POAM
A A+C i.e. number of true test-positives/ number of true testpositives + number of false test-negatives D B+D i.e. number of true test-negatives/ number of false test-positives + number of true test-negatives Sensitivity, was found to be 0.75; and specificity was 0.83. POAM could identify 75% of persistent falling participants who tested true positive on the test; and 83% of participants without history of persistent falls who all tested true negative. Specificity =
Sensitivity =
DISCUSSION The results obtained on data analysis prove that for our sample (n=50) the hypothesis that the persistent fallers scored significantly lower then the cut-off 19 on POAM. The most important finding of this study is that the POAM could be effectively used as a valid assessment tool in predicting falls risk and incidence of future falls in older people. As hypothesised, the score on POAM for the older people with a history of persistent falls was found to be lower than 19, and in some instances it was significantly lower than this cutoff point. The most important finding, being that evidence for the use of POAM as a valid tool in falls assessment is shown by having high rates of true positives and true negatives. As detected by the 2x2 table and further analysis of sensitivity and specificity, there were 24 (75%) fallers with true positive out of the total 32 fallers, and 15 (83%) of non-fallers tested true negative
The present study was successful in establishing the predictive validity of POAM in identifying the recurrent fallers and also predicting the risk of their future falling by rejecting the null hypothesis. Alternatively, it can be stated that the findings of the current study have indicated that there is a difference in falls status between the participants scoring less than and greater than 19 on POAM. The POAM is one such tool, and its efficacy and ease of use warrants its widespread use by the clinicians and researchers alike in the field of elderly rehabilitation. This dissertation was submitted as a part fulfilment for the MSc Neurorehabilitation, Brunel University, Uxbridge, Middx. UB8 3PH Acknowledgements: Staff of the Physiotherapy Department & The Pendre Day Hospital, Princess of Wales Hospital, Bridgend, Mid Glam, Wales Dr Louise Marston, Brunel University, Uxbridge, Middx. Address for Communication Contact the author for a full reference list. Kiran Katikaneni, Senior Physiotherapist, St Richards Hospital, Chichester, West Sussex PO19 6SE, kiran.katikaneni@rws-tr.nhs.uk Dr Alexander Nowicky, Course Leader, MSc Neurorehabilitation, Brunel University, Uxbridge, Middx. UB8 3PH
REFERENCES Cumming RG, Salkeld G, Thomas M, Szonyi G (2000). Prospective study of the impact of fear of falling on activities of daily living, SF-36 scores, and nursing home admission. Journals of Gerontology. Series A, Biological Sciences and Medical Sciences 55 (5): 299-305. De Moraes Barros GDV (2006). Falls in elderly people. Lancet 367: 729-730. Salkeld G, Cameron ID, Cumming RG et al (2000). Quality of life related to fear of falling and hip fracture in older women: a time trade off study. British Medical Journal 320: 341-345. Salkeld G, Cumming RG, ONeil E, Thomas M, Szonyi G, Westbury C (2000). The cost effectiveness of a home hazard reduction programme to reduce falls among older persons. Australia and New Zealand Journal Public Health 24 (3): 265-271. Thomas JI, Lane JV (2005). A pilot study to explore the predictive validity of 4 measures of falls risk in frail elderly patients. Archives of Physical Medicine and Rehabilitation 86: 1636-1640. Tinetti ME (1986). Performance-Oriented Assessment of Mobility Problems in Elderly Patients. Journal of the American Geriatrics Society 34:119-126. Tinetti ME, Baker DI, Gottschalk M, Williams CS, Pollack D, Garrett P et al (1999). Home-based multicomponent rehabilitation program for older persons after a hip fracture: a randomised trial. Archives of Physical Medicine and Rehabilitation 80: 916-922.
Impact Report 2007-8

By Victoria Goodwin (Outgoing Chair)
his is a summary of achievements, activities and forward planning during the year 2007-8 that you would have enjoyed if you attended the conference in October 2008. We look forward to a similarly busy and successful 2008-9, and thank the NEC for all their hard work.
Rehabilitation framework (Scotland) NHS Wales restructuring OA guidelines Intermediate care strategy Dementia Strategy Older peoples system reform
National Executive Committee President Chair Vice Chair Secretary Membership Secretary Treasurer Journal Editor Research Officer Minutes Secretary Diversity Officer iCSP Officer PRO + Regional representatives + Project officers Education 10 Regional study days 1 National conference 4 study days cancelled due to lack of interest Publications Agility (2) Newsletters (3) Standards 2008 Undergraduate pack review Supplements Outcome measures (TUAG) National falls and bone health audit papers Responses to national documents and publications Falls clinics Stroke guidelines
Committee membership/working groups RCP Falls and Bone Health Steering group RCP Stroke working group BGS Falls and Bone Health Section National Coalition for Active Ageing Older Peoples Specialist Forum Parkinsons Disease Society IPTOP EUNAAPA DoH falls and fracture commissioning expert panel CSP related work Scrutinising of post-graduate courses for CSP accreditation Workforce development ARC CIGLC Pebblepad pilot Icsp Media enquiries and interviews 2008-9 Streamlining Website Outcome supplement Exercise supplement Study days Conference 2009
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AGILE Continence Exercises
n 2006 AGILE published their Incontinence and Pelvic Floor Muscle exercises supplement in conjunction with Jeanette Haslam on behalf of CPPC and ACPWH. The information was also replicated in the Autumn/Winter edition of Agility (2006). Following this, the AGILE committee have received some requests for clarification about using the exercises, and in particular about the need for assessment of the pelvic floor prior to prescribing pelvic floor muscle exercises (PFME). AGILE have consulted with Jeanette Haslam and the following is a clarification of the need for assessment prior to using PFME. The guidelines state that Routine digital assessment of pelvic floor muscle contraction should be undertaken before the use of
supervised pelvic floor muscle training for the treatment of Urinary incontinence [NICE Clinical guideline 40 Page 26]. In other words, if incorporating PFMEs into class work or general healthy living advice then digital assessment is not deemed necessary. However if a person with urinary incontinence is referred for treatment of their incontinence then a digital assessment is necessary to ensure a patient specific exercise programme. This would also ensure they are capable of doing the exercises. Any other form of intervention such as electrical stimulation would also need a digital examination. You may also assess a PFM contraction using real time ultrasound if you have the appropriate machine and training. You would also need to digitally examine before using any vaginal or anal device.
Got anything interesting to share?

Have you recently undertaken some research, and audit or been on an amazing course? Are you prepared to share your results with your colleagues? Why not prepare your report for publication and send it to me for submitting. Details of the latest guidelines for authors can be found within this issue. Your report could be published as early as June 2009. Any research or relevant topics will be considered.
Please contact the AGILITY editor:
Carrie_Reynolds@hotmail.com
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Agile National Conference 2008 Report

By Lynn Sutcliffe
he Agile National Conference this year was held on the 4th and 5th October at the Copthorne Hotel in Reading, which is in a lovely setting by a lake and the topic was Stroke Rehabilitation: Ideas and Innovations.
Dr Andre van Wyk presented on The Ageing Brain and Cerebrovascular Disease which included an overview of the theories behind the aging process, the functions and pathophysiology of the brain and classification of Stroke. The presentation Orthotic Principles and Normal Movement Concepts in Stroke Rehabilitation and the workshop Practical application of orthotic principles and assessment methods delivered by Mr Paul Charlton, Senior Orthotist were very interesting and thought provoking. Having been qualified a number of years it was interesting to see that the Orthotist and the Physiotherapist were now working very closely together in some areas of the U.K. Ankle-foot orthoses are now being incorporated into therapy sessions in early stroke rehabilitation in order to facilitate a normal gait pattern as opposed to just being used as an adaptation when there is thought to be no further gains likely with rehabilitation. I will definitely be able to incorporate these ideas into my own clinical practice. I found the workshop Community Physiotherapy after Stroke by Mrs Laura Shelling, Clinical Specialist Physiotherapist useful as it is always interesting to discover what services are being delivered in different areas of the U.K. and to compare it to your own area. During the group discussions there appeared to be many different ways in which people could access services in the community following a stroke with varied involvement from health, social services, voluntary sectors and charities. The conclusion was that we need to continue to collect evidence to support the need for physiotherapy in a community setting in order to increase and improve service delivery. Ms Rhoda Allison, Consultant Physiotherapist presented on Management of Spasticity after Stroke and this included the use of botox injections which is a field I am not familiar with but it made me think that this may be a technique that has been found to be beneficial for stroke patients could also be used
Due to it being Agiles 30th Anniversary it was appropriate to have Dr Amanda Squires, one of the founder members of Agile as the key note speaker to open the Conference. Dr Amanda Squires and Margaret Hawker who unfortunately was unable to attend showed dynamic thinking in setting up Agile in 1978 and we have them to thank for the success that Agile is today and the progress that has been made in raising the profile of older people. The first presentation was a review of the Stroke Guidelines presented by Dr Sheila Lennon. I found this very useful especially the advice to concentrate on the top ten tips from the national audit that has been carried out and the top 21 recommendations from the guidelines as it is sometimes overwhelming to receive a great deal of information and it sometimes gets put on the back burner to review at a later date. Also it was good to see that Physiotherapy has been acknowledged as an important part of recovery from a stroke within these guidelines. It is always useful to gain in-sight into the carers perspective and Mrs Cross who spoke to us regarding her husbands experiences following a stroke was able to give us that view-point. Even though Mr & Mrs Cross appeared to have had a challenging journey there was a light at the end of the tunnel and the Community Physiotherapist and this gentleman were working together in order to progress his functional mobility which was improving. It was good to hear that this gentleman was being given the opportunity to improve following his discharge from hospital and the rehabilitation unit as this service is not available in all areas of the U.K.
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with the wider elderly population who develop contractures that are often extremely uncomfortable and painful. Dr Ruth Greenhalgh, Consultant Clinical Psychologist who lectured at last years Agile Conference returned this year to present on Psychological aspects of stroke and strategies for management. In clinical practice it is always interesting to link the persons functional deficits to the areas of the brain that are affected and in the same way it is interesting to link a persons behaviour. From this presentation I learnt that consistency within the multi-disciplinary team is very important from a psychological viewpoint and things may get worse before they get better but it is worthwhile persevering. It is also important that psychology has an impact on the persons physical recovery and it is useful to be aware of psychological strategies that can be incorporated into our clinical practice by working alongside a Clinical Psychologist. The final two presentations were very innovative: Training reaching following severe stroke using the SMARTArm by Dr Sandra Brauer from Queensland,
Australia demonstrated following research that it was a useful rehabilitation tool and that upper limb function could be improved with the use of this device but further research is needed. Robot-aided neuro-rehabilitation: science fiction or innovation by Mr Rui Loureiro, Senior Research Fellow. This research is in its infancy and may be most useful in the early stages of Stroke Rehabilitation when it can have the greatest influence on neural plasticity and brain recovery. A more comprehensive clinical trial is planned to gather further evidence. Overall this was a very successful conference including the Gala Dinner on the Saturday evening with an entertaining after dinner speaker. Thank you to the organising committee for putting on the conference which is also a great place to network as well as gaining knowledge and ideas from the presentations, workshops, posters and the sponsors.
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National Clinical Guidelines for Stroke 2008

By Christine FitzPatrick
AGILE Project Officer for RCP Stroke
BACKGROUND TO THE PROCESS The third edition of the U.K national clinical guideline on the management of stroke collated by the Clinical Effectiveness and Evaluation Unit Stroke Programme at the Royal College of Physicians together with the Intercollegiate Stroke Working Party (ISWP) aims to improve the quality of care for stroke patients. The ISWP is made up of representatives from all organisations involved in stroke management. Physiotherapists are key members of the multidisciplinary team, led by Sheila Lennon representing the CSP supported by Nicola Hancock ACPIN and Christine FitzPatrick AGILE. These updated guidelines have 300 recommendations interpreted by the ISWP from systematic searching of computerised databases and the use of qualitative evidence from 2002 up until September 2007 as well as the members expertise. Content The guideline consists of seven chapters covering all aspects of stroke management. For the first time the scope of the guidelines incorporate the NICE recommendations on acute diagnosis and initial management of acute stroke for the first 48 hours and TIA treatment; specific guidance on commissioning stroke services (Chapter 2 pages 21 -26) and also a section on mental capacity and consent. The chapters of particular interest to physiotherapists are Chapters 6 and 7 (pages 71 110) that focus on rehabilitation from a few days to 6 months, then progressing to the longer-term management of stroke patients Profession specific guidelines, including the Physiotherapy Concise Guidelines for Stroke (pages 134 139) have been compiled by extracting recommendations from the full guidelines. Members should consider the document to be a working tool and consider whether new evidence on a topic may alter existing recommendations. Examples of Key Recommendations Relevant to Physiotherapists 3.13.1 A Treatment Intensity. Patients should undergo as much therapy appropriate to their needs as they are willing and able to tolerate and in the early stages they should receive a minimum of 45 minutes daily of any therapy that is required. (NICE): Early Intervention A People with acute stroke should be mobilised as soon as possible (when their clinical condition permits) as part of an active management programme of a specialist stroke unit C People with acute stroke should be helped to sit up as soon as possible (when their condition permits) 5.3.1 Lifestyle Measures B All patents should be advised to take regular exercise as far as they are able: The aim should be to achieve moderate physical activity (sufficient to become slightly breathless) for 25 30 minutes each day. 6.13.1 Self Efficacy Training A All patients should be offered training in selfmanagement skills, to include active problem solving and individual goal- setting B any patient whose recovery is delayed or limited should be assessed for changes in self identity, self -esteem, and self- efficacy as well as changes in mood. 6.2.1 Evaluating and Stopping Treatments A Every patient should have progress measured against goals set at regular intervals determined by the patients rate of change, for example using goal attainment scaling. B When the goal is not achieved the reason should be established and: the goal should be
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adjusted; the intervention should be adjusted or no further intervention should be given towards that goal. C When the therapist or team stops giving goals the therapist should: discuss the reasons with the patient; ensure that continuing support that the patient needs to maintain and/ or improve health is provided; teach the patients and if necessary carers and family how to maintain health; provide clear instructions how to contact the service for re-assessment and outline what specific events or changes should trigger further contact. 7.1.1 Further Rehabilitation B Any patient with residual impairment should be offered formal review at least every six months, to consider whether further interventions are warranted and should be referred for specialist intervention if: new problems, not present when last seen by the specialist service are present the patients physical or social environment has changed. 7.5.1 Carers B The carer of every patient with stroke should be involved in the management process from the outset, specifically: as an additional source of important information about the patient both clinically and socially; being given accurate information about the stroke, its nature and prognosis and what to do in the event of a further stroke, being given emotional and practical support as required.
CONCLUSION Everyone should be aware of the most important recommendations relevant to their practice. This is the first time that the intensity of treatment a minimum of 45 minutes daily (Recommendation 3.1.13) has been specified. Comparative studies in Europe suggest that U.K face-to- face therapist contact time is lower than other countries. There is strong evidence for the link between the intensity of rehabilitation and recovery in particular for gait and ADL, and this will provide a challenge for commissioners, managers and therapists to provide adequate resources in order to fulfil this commitment to rehabilitation. The guideline focuses on stroke-specific matters. However, because rehabilitation is essential to provide a high quality, effective service some recommendations are based on general principles of rehabilitation and are a useful source of evidence. Useful Links for Stroke Information National Clinical Guideline for Stroke- Third Edition available at: http://www.rcplondon.ac.uk/pubs/brochure.aspx?e=250 Profession Specific Audit of Stroke: A Multidisciplinary Pilot Study: Profession Specific Audit of Stroke Organisational and Clinical Audit Version 2 available at www.csp.org.uk
Spring/Summer AGILITY 2009

Submissions for the Spring/Summer issue of AGILITY should reach the editor, by 30th April 2009 at the latest
AGILITY Autumn/Winter 2009 15
A Survey to investigate the range of and indications for specific outcome measures used in the rehabilitation of the older person. Proposal
By Stephanie Grace
INTRODUCTION Physiotherapy has prided itself on the scientific basis of its practice without asking whether treatments work over the past number of years (Wyatt & Gully, 2002). This realisation has resulted in a focus on evidencebased therapy (Wyatt & Gully, 2002; Sackett et al, 1997; Sackett et al, 1996), and in the rehabilitation of the older person, many objective measures are used (Morris et al, 2007; Chartered Society of Physiotherapists (CSP), 2006; Nitz et al, 2006; Scott et al, 2007). This proposal aims to: Develop a comprehensive research proposal on objective measures used in the rehab of the older person, including full research protocol. Demonstrate selection of appropriate research methods including exclusion and inclusion criteria. Suggest a data collection strategy and identify suitable approach for data analysis. Demonstrate critical evaluation skills and the ability to apply a problem solving approach to a research question by means of a questionnaire. population (Hill & Schwarz, 2004). 30% of people over the age of 65 fall within a twelve-month period Increasing to over 50% for those aged 80 years, and10% of all falls result in serious injuries.. Falls in the elderly population cost the NHS and social care sector more than 1.7 billion per year (Street et al, 2007; Nandy et al, 2004; Bogle-Thorbahn & Newton, 1996). They have an adverse affect on the patient and there is often a loss of confidence, resulting in decreased mobility and further deconditioning, which puts the patient at a higher risk of falls and therefore in need of more care (Street et al 2006). Physiotherapists use objective measures as part of the rehabilitation programme, and play a key role in preventing falls in the elderly (Scott et al, 2007; BogleThorbahn & Newton, 1996). When a persons risk of falling is assessed and appropriate action taken, falls are reduced by 50% (AGILE, 2006). Physiotherapy aims to screen people and give necessary treatment before a fall becomes a reality. Currently there is no data that informs what measures are used, and why, by physiotherapists and therefore, best evidence based practice is limited (Scott et al, 2007). Literature review Figure one highlights the key words and databases used by the author. The literature found no previous surveys identifying which objective measures are used in the rehabilitation of the older person. Based on this, the author chose to highlight the objective
Background In the rehabilitation of the older person, the main aim of physiotherapy is to prevent a fall (Street et al, 2007). Identifying and managing the risk factors has been shown to reduce fall rates in the older
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measures used in the rehab of the older person. In order to show skills of prioritisation of the most relevant information, there is a brief discussion on different objective measures. Those discussed were those found to be most prevalent. The author would like to direct the reader to Appendix A for more information on the measures. The Berg Balance Scale measures impairment in older adults through a specific performance-based test (Berg et al, 1999; Berg et al, 1995; Berg et al, 1992; Steffen et al 2002; Riddle & Stratford 1999; BogleThorbahn & Newton 1996; Stevenson 2001; Boularides et al, 2003; Brauer et al, 2000). The total sample size measured for different population subgroups is shown in Appendix A. The tool comprises of 14 common movement tasks and has a recommended cut-off score of 45 to 56 (Berg et al, 1992; Berg et al, 1989). On further study, Riddle & Stratford (1999) recommended the use of a lower cutoff point of 40 to assist clinical decision-making. The tool is reliable (Appendix A) and its validity lies in identifying individuals who are not at risk of falls (Bogle-Thorbahn & Newton 1996). There is little Figure 1: Key words and databases searched.
evidence as to the sensitivity of the test apart from work with post-stroke patients (Stevenson 2001). The scale has evidence of use with patients who have osteoarthritis and rheumatoid arthritis (Noren et al, 2001; Birmingham et al, 2001). From a physiotherapy point of view, the scale does not include elements of gait, and the assessor has to record this separately (Brauer et al 2000). The Tinetti Performance-Orientated Mobility Assessment (POMA) is used in Physiotherapy to measure balance and gait in the older person (Tinetti 1986; Tinetti & Ginter 1988; Cipriany-Dacko et al, 1997; Raiche et al, 2000; Whitney et al, 1998; Tinetti 1998; Arnadottir & Stemmons 1999; Van Swearingen & Brach 2001). POMA is an assessment of seven gait characteristics, including initiation of step length and height, step symmetry, step continuity, path, trunk stability and walking stance (Tinetti 1986). The validity and reliability of POMA are highlighted in Appendix A along with the tested population. There have been many modifications to this tool (Harada et al, 1995; Tinetti & Ginter 1988; Robbins et al, 1989) for example, a number of physiotherapists use only the
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balance aspect of the POMA (BPOMA). Harada et al (1989) recommend a cut-off score of 14-16 on the BPOMA using the assessment to identify patients in a nursing home who would benefit from physiotherapy. The assessment tool has also predicted the risk of future recurrent falls in the same population (Thapa et al, 1996). Shumway-Cook et al (1997) used the tool to test the response of a multidimensional exercise programme on balance and mobility in community dwelling adults. The outcome was shown to be highly relevant to this population. There are a number of versions of POMA, and some studies showed a lack of coherence as to what aspects of the tool were used (Arnadottir & Stemmons, 1999; Van Swearingen & Brach, 2001). This assessment is appropriate to physiotherapy because it is effective in screening older adults for falls risk and identifying those who would benefit from strength training (Harada et al 1995; Thapa et al, 1996; Shumway-Cook et al, 1997) although is not clinically appropriate as an outcome measure for higher functioning adults (Thapa et al, 1996). Physiotherapy to evaluate basic mobility skills of frail elderly patients uses the Timed Up and Go test (TUG) (Podsiadlo & Richardson 1991; Mathias et al, 1986; Eekhoff et al, 2004; Rockwood et al 2000; ShumwayCook et al, 2000; Medley & Thompson 1997; Steffen et al, 2002; McMeeken et al, 1999), which times, in seconds, how long it takes for a patient to rise from sitting in a standard armchair, walk three metres, turn, walk back to the chair and sit down. Validity and reliability along with tested population are emphasised in Appendix A. The patient should be wearing regular footwear and note made of any aids used. Shumway-Cook et al (2000) showed a cut-off score of >13.5 seconds predicted falls in communitydwelling, deconditioned older people. Podsiadlo & Richardson (1991) proposed that scores of >30 seconds correspond to functional dependence in people with certain pathologies. However, the TUG did not assist the treatment of the cognitively impaired population with Medley & Thompson (1997) finding 35.5% of the population unable to perform the task. Gunter et al (2000) studied the performance of community-dwelling subjects with a history of falls and patients with a history of falls. The results were a lot slower for the community-based population. Wall et al (2000) identified elderly patients at risk of falls using this test. However, this was compared with healthy subjects. Other studies have shown arthritis and history of falls affect the outcome of TUG scores amongst the elderly (Shumway-Cook et al 2000). The Dynamic Gait Index (DGI) looks at patient responses to task demands with focus on their gait (Krishnan et al, 2002; Whitney et al 2000; ShumwayCook 1997; Wrisley 1998; Whitney et al, 1997). There are eight items on the scale to evaluate patients, and its reliability and validity is highlighted in Appendix A. This measurement has been tested on a relatively
small population (Appendix A). Shumway-Cook et al (1997) and Whitney et al (1997) recommend a cut-off score of <19. There are modifications of this tool. Krishnan et al (2002) also looked at speed of task, assisted devices used and quality of gait pattern. There have been many studies investigating the use of this tool and patients with vestibular dysfunction (Whitney et al, 1997; Wrisley 1998; Whitney et al 2000). The strength of this tool is that it is functional for the patient, and it measures the gait adaptation to facilitate environmental factors. Significance/Relevance of Research There are a number of assessment tools used in the rehabilitation of the older person. It became clear, having read the evidence, that the choice of tool physiotherapists use in clinical settings must correspond with a given population. Choosing which tool to use is, however, further complicated by the lack of consistency and recordings in studies. A number of studies claim to be evidence-based but often lack validity and reliability (e.g. DGI). The author did not find that any of the above objective measures could be applied across the board in different settings. If physiotherapists adapt or use only part of any objective measures, this measure should not be used until it is retested, revised and shows evidence of validity and reliability (HCANJ 2005). A survey to highlight what objective measures are used by physiotherapists, and why, would provide information on current practice and facilitate movement towards more evidence-based practice. Research Questions Following the literature search, a number of possible research questions were identified: What is the best method of identifying those at highest risk of a fall? What assessment tools highlight the needs of the general older person population? What are the most cost and clinically effective methods for screening older people? What outcome measures are used and why do physiotherapists use certain outcome measures?
The author decided on a research proposal to investigate the range of, and indications for, specific outcome measures used in the rehabilitation of the older person (>65 years). Aims/Intentions The aim of this research is to contribute to physiotherapy knowledge. Research has the potential to change and improve current practice, thus improving healthcare on a large scale. (Wyatt & Gully, 2002) These improvements may take a variety of forms, including a reduction in one or more of the following: death rate, pain, hospital stay, long-term morbidity or hospital costs (CSP, 2006; AGILE, 2006 & Wyatt & Gully, 2002).
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PLAN OF INVESTIGATION Methodology The study will take the form of a qualitative research design and the project timetable is outlined in Appendix E. A qualitative study explores the beliefs and understanding needed to find out why the results of research are not implemented in practice (Haines Jones, 1994). However, this type of research is controversial and not recognised by many members (Denzin & Lincoln, 1998). In addition, in qualitative research there tends to be a lack of agreement on criteria of assessment (Pope & Mays, 1995). The research will be in the form of a mail survey using questionnaires. The advantages of this method are the low cost and elimination of bias (often as much as 75 percent) compared with interviews (Brambilla & McKinlay 1987). The disadvantages are a potentially low response rate, the time taken to return the questionnaire and potential bias (Harrison et al, 2002; Siemiatycki et al, 1984). Figure 2: Population Inclusion/Exclusion criteria
Ethical Considerations The author will seek approval from AGILE to attend and distribute questionnaire packs at the November conference in Newcastle from the committee board. Population The study will target physiotherapists in the United Kingdom (UK) through an AGILE conference. AGILE are a clinical interest group of the CSP for therapists working with older people. The mission statement is, To deliver the highest possible physiotherapy practice with older people (AGILE, 2006) The regions included are the UK, Wales and Scotland. The group produce a journal twice a year and hold two conferences annually. Inclusion and exclusion criteria of physiotherapists are outlined in table form in Figure 2.
TOOLS OF INVESTIGATION Questionnaire To collect relevant data for the research proposal, the author will use a questionnaire system (Appendix C).
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Figure 3: Literature search for questionnaire.
While this is cost effective (Edwards et al, 2002; Subar et al, 2001), some authors suggest this method has some negative points: Lower response rates and therefore high risk of nonresponse bias due to differential response rates in different social groups. Lower quality response. Biased comparisons due to different quality responses in different population subgroups (Siemiatycki et al, 1984). The author was unsure of a number of points concerning the questionnaire: What questions should be included? How long should the questionnaire be? Do I include a cover note? Will I publish a copy in a medical journal for other physiotherapists? Do I give a financial or gift incentive? Do I include a stamped addressed envelope? Following a literature search Figure 3 and a Thought Shower session, it was decided on the current questionnaire (Appendix C). Reliability and Validity Response rates of a survey are very important (Smeeth & Fletcher 2002; Siemiatycki et al, 1984) a more accurate result is found when there is a large response from the population (Edwards et al, 2002; Sahar et al,
1993). There are a number of reasons why people dont respond to questionnaires, including timelimitations and lack of motivation (Edwards at al, 2002; Smeeth & Fletcher 2002). The type of survey questions included are openended (Appendix C) to facilitate open and honest answers from the participants (Edwards et al, 2002). In order to fulfil the aims of the research, the questions are clear, precise and short (Subar et al, 2001). To minimise response bias the author has omitted double-barrelled questions, double negatives and loaded questions (Smeeth & Fletcher 2002). The length of the questionnaire is two pages. While length of questionnaire does have effect on response rates, quality of responses is not affected. (Iglesias & Torgerson, 2000) The inclusion of a cover note (Appendix B) and the option of receiving the results of the study can increase response rates. (Edwards et al, 2002) Instructions on filling out the questionnaire are also included (Appendix D) in order to minimise misunderstanding of the questions. Mail surveys published in medical journals have a high response rate (68%) from non-physicians. The survey will be advertised in AGILE monthly magazine for its members. To offer any kind of incentive raises major ethical issues and involves bias. (Smeeth & Fletcher, 2002) The author will include a first class stamped addressed envelope for return of questionnaire as
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Figure 4: Seidels model of Noticing, Collecting and Thinking.
studies have shown this results in the best response rate (Harrison et al, 2002). The incentives and techniques to elicit response are: Carry out a mail questionnaire with stamped addressed envelope included and cover letter (Appendix B) (Edwards et al, 2002; Harrison et al 2002; Brambilla & McKinlay, 1987). Include a questionnaire in an edition of AGILE magazine a month before the conference highlighting the aim of the survey (Asch et al, 1997). A reminder letter (Appendix F) and advertisement four weeks after the conference (Armstrong et al, 1995; Subar et al, 2001; Asch et al, 1997). Motivation, through delivery of a summary of the research findings after the data is analysed (Alreck & Settle, 1995). Expected method of Data Analysis & Minimising Researcher Bias Having collected the questionnaires, the author will draw out themes and patterns from the written content of the data. Compared with quantitative data, qualitative data sets tend to be larger (Driscoll et al, 2000) and in order to process this, the author will apply Seidels (1998) Noticing, Collecting and Thinking model (Figure 4). This would break the data into samples according to themes and topics (Seidel, 1998). In order to ensure validity of data, the author proposes investigator validity to draw out new themes and data. This will facilitate the findings of another professional and compare results with the researcher (Guion, 2002; Barbour, 2001). The information and themes yielded from the study would then provide a Grounded Theory (Barbour, 2001). The author also proposes a multiple coding system to ensure further reliability (Barry et al, 1999). This will involve the cross checking of coding strategies and interpretation of data by independent researchers. (Barbour, 2001) This requires the training of people
and defining rating systems and terms, thus ensuring inter-rater reliability. Mauther et al (1998) outlined how researchers original interpretations may change when they revisit previously collected data. Alternatively, the author could use a computer system to generate the data collected from the questionnaires. A computer assisted qualitative data analysis (CAQDA) program is quick and the coding and retrieval of items is made a lot easier (Kelle & Seidel 1995; Seidel 1998). Results Brambilla & McKinley et al (1987) looked at the highest responding population to mailed surveys and found that women aged between 45-55 years made up 77% of responses. Harrison et al (2002) found similar results for the older population, highlighting men and younger people have the poorest response rates. However, the study did not define the latter. Due to this fact, it is expected similar rates will be found in this population. Statistics Out of a population of 47000 physiotherapists registered with the C.S.P., 668 are members of AGILE. In order to determine the sample size of respondents, the author first calculated the confidence interval that was 3.76. The author then calculated a sample size of 337 physiotherapists at a 95 percent confidence level (Pope & Mays 1995). BRIEF SUMMARY Analysing data is very labour intensive and time consuming. The results however have the potential to provide relevant information. In the rehabilitation of the older person, appropriate standardised outcome measurements take the subjectivity out of assessment. They also offer universal communication, objectivity and qualification on which to base decisions amongst physiotherapists (Barbour, 2001) thus, influencing clinical practice. This assignment developed a comprehensive research proposal including full research protocol. It also
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demonstrated selection of appropriate research method and data collection strategy and identified suitable approach for data analysis. The author has also demonstrated critical evaluation skills and the ability to apply a problem solving approach to a research question. References AGILE (2006) [online] Available from: http://www.agileuk.org [accessed on 14 March 2007] Alreck, P. & Settle, R. (1995) Guidelines and strategies for conducting a survey. The Survey research handbook. Second Edition. Chicago, I.L.: Irwin Professional Publishing. Armstrong, B., White, E. & Saracci, R. (1995) Principals of exposure measurement in epidemiology. Monographs in epidemiology and biostatistics. Oxford University Press: New York, 21, pp.294321. Arnadottir, S. & Stemmons, V. (1999) Functional assessment in geriatric physical therapy. Issues Aging, 22, pp.3-12. Asch, D. Jedrziewski, M. & Christakis, N. (1997) Response rates to mail surveys published in medical journals. Journal of clinical Epidemiology, 50 (10), pp.1129-36. Barbour, R. (2001) Checklists for improving rigour in qualitative research: a case of the tail wagging the dog? British Medical Journal: Education and Debate, 322, pp.1115-7. Barry, C. Britten, N. Barber, N. Bradley, C. & Stevenson, F. (1999) Using reflexitivity to optimise teamwork in qualitative research. Qualitative Health Resources, 9, pp.26-11. Berg, K., Wood-Dauphinee, S. & Williams, J. (1995) The Balance Scale: reliability assessment with elderly residents and patients with an acute stroke. Scandinavian Journal of Rehabilitation, 27, pp.27-36. Berg, K., Maki, B., Williams, J., Holliday, P. & WoodDauphinee, S. (1992) Clinical and laboratory measures of postural balance in an elderly Physical Medical population. Archive Rehabilitation, 73, pp.1073-80. Berg, K., Wood-Dauphinee, S., Williams, J. & Gayton, D. (1989) Measuring balance in the elderly: preliminary development of and instrument. Physiotherapy Canada, 41, pp.304-11. Birmingham, T., Kramer, J., Kirkley, A., Inglis, J., Spaulding, S. & Vandervoort, A. (2001) Association among neuromuscular and anatomic measures for patients with knee osteoarthritis. Archive Physical Medical Rehabilitation, 82, pp.1115-8. Bogle-Thorbahn, L. & Newton, R. (1996) Use of Berg Balance Test to Predict Falls in Elderly Persons. Physical Therapy, 76 (6), pp.576-585. Boulgarides, L. McGinty, S. Willet, J. & Barnes, C. (2003) Use of Clinical and Impairment-Based Tests
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the functional reach and the timed up and go tests in the Canadian study of health and aging. Journal of Gerontology Archives Biological Science, 55, pp.70-3. Sackett, D., Richardson, W. & Rosenburg, W. (1997) Evidence-based medicine- how to practice and teach EBM. Churchill Livingstone, London. Sackett, D., Rosenberg, W. & Gray, J. (1996) Evidencebased medicine: what it is and what it isnt. British Medical Journal, 312, pp.71-2. Scott, V., Votova, K., Scanlan, A. & Close, J. (2007) Multifactorial and functional mobility assessment tools for fall risk among older adults in community, home-support, long-term and acute care settings. Age and Ageing, 36, pp.130-139. Shumway-Cook, A., Gruber, W., Baldwin, M. & Liao, S. (1997) The effect of multidimensional exercises on balance, mobility, and fall risk in communitydwelling older adults. Physical Therapy, 77, pp.46-57. Siemiatycki, J., Campbell, S., Richardson, L & Aubert, D. (1984) Quality of response in different population groups in mail and telephone surveys. American journal of Epidemiology, 120 (2), pp.302-314. Smeeth, L. & Fletcher, A. (2002) Improving the response rates to questionnaires. British Medical Journal, 324, pp.1168-1169. Steffen, T., Hacker, T. & Mollinger, L. (2002) Age- and gender-related test performance in communitydwelling elderly people: Six-Minute Walk Test, Berg Balance Scale, Timed Up & Go Test, and gait speeds. Physical Therapy, 82, pp.128-37. Stevenson, T. (2001) Detecting change in patients with stroke using the Berg Balance Scale. Australian Journal of Physiotherapy, 47, pp.29-38. Street, A., Hill, K., Sussex, M., Warners, M. & Scully, M. (2006) Haemophilia and aging. Haemophilia, 12 (3), pp.8-12. Subar, A., Zieglar, R., Thompson, F., Johnson, C., Weissfeld, J., Reding, D., Kavounis, K. & Hayes, R. (2001) Is shorter always better? Relative importance of Questionnaire length and cognitive ease response rates and data quality for two dietary questionnaires. American Journal of Epidemiology, 153 (4), pp.404-409. Thapa, P., Gideon, P., Brockman, K., Fought, R. & Ray, W. Clinical and biomechanical measures of balance as fall predictors in ambulatory nursing home residents. Journal Gerontology Archives Biological Science Medical Science, 51, pp.239-46. Tinetti, M. (1986) Performance-oriented assessment of mobility problems in elderly patients. Journal of American Geriatrics Society, 34, pp.119-26. Tinetti, M. & Ginter, S. (1988) Identifying mobility dysfunctions in elderly patients: standard neuromuscular examination or direct assessment? Journal of American Medical Archives, 259, pp.1190-3.
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VanSwearingen, J. & Brach, J. (2001) Making geriatric assessment work: selecting useful measures. Physical Therapy, 81, pp.1233-52. Wall, J., Bell, C., Campbell, S. & Davies, J. (2000) The timed get-up-and-go test revisited: measurement of the component tasks. Journal Rehabilitation Research Development, 37, pp.55-67. Whitney, S., Hudak, M. & Marchetti, G. (2000) The dynamic gait index relates to self-reported fall history in individuals with vestibular dysfunction. Journal of Vestibular Research, 10, pp.99-105. Whitney, S., Poole, J. & Cass, S. (1998) A review of balance instruments for older adults. American Journal Occupational Therapy, 52, pp.666-71. Whitney, S., Walsh, M., Pieffer, M. & Furman, J. (1997) Concurrent validity of the Berg Balance Scale and the Dynamic Gait index in people with vestibular dysfunction. Neurology Report, 21, p.167. Wrisley, D. (1998) [Master Thesis] Reliability of the dynamic gait index in vestibular disorders. Old Dominion University. Wyatt, J. & Gully, H. (2002) Identifying the research question and planning the project. Emergency Medical Journal, 19, pp.318-321.
APPENDICES
Appendix A: Summary of Literature Appendix B: Cover Letter Appendix C: Questionnaire Appendix D: Additional Information Appendix E: Project Timetable Appendix F: Reminder Letter
24
Validity
Content
Reliability
Validated populations
Sample size & Population
Berg Balance Scale

<15 minutes Performance
Measure/Scale
>60 years of age and post stroke and post hip fracture. High inter-/ intrarater reliability. As an indicator of balance. Sensitivity to falls moderate. Limited evidence of clinical meaningful change. Changes in scores with intervention studies. No formal studies. Changes in response to intervention.
Method of administration
Time for administration
Responsiveness
Supportive Housing Community (265) (113) Long-term care setting (60) Older adults and patients with vestibular disorders.
To examine static and dynamic balance control.

High inter and intrarater reliability for total score. Lack of evidence for individual items. High inter and intrarelater reliability. Valid as an indicator of gait adaptability. Can predict the risk of falling. Frail older people and community dwelling adults. Patients with stroke, Arthritis, and Vertigo. Valid as an No evidence of indicator of clinical meaningful balance and lower change. extremity function. High sensitivity and specificity predict falls.
Dynamic Gait Index
99 Community
Measure balance impairment through modification of gait during task commands.
Timed Up and Go (TUG)
Community (1135) Long-term care setting (323)
Tests basic mobility of elderly patients. Rise from a standard arm chair, walk 3 metres, turn, walk back to chair, sit using regular footwear and walking aid. Older Adults both frail and community dwelling.
<15 minutes
Tinetti Performance Orientated Mobility Assessment (POMA)

Performance
Community (225) Long-term care setting (118)
Measures balance and Gait in older persons through balance and Gait tasks.
Moderate interrater reliability for the balance component.
Valid as an indicator of balance and function. Can predict if patients will benefit from intervention.
No evidence of clinical meaningful change.
25
Appendix A: Summary of Literature
Appendix B: Cover Letter for Questionnaires
School of Health Studies, University of Bradford 25 Trinity Rd. Bradford United Kingdom BD5 OBB Tel. +44 01274 236367 Fax. +44 01274 236302 1 November 2007
To Whom It May Concern, You will find enclosed a questionnaire concerning older people and assessment tools. The purpose of this questionnaire is to address the attitudes and beliefs held by physiotherapists in this specific client group with reference to assessment tools. The changing face of physiotherapy now requires a more evidence-based practice. With this in mind, there is a need to identify current reasoning behind the choice of assessment tool. The Author of this Qualitative study will identify common themes from the data collected. This information will then go on to inform a Quantitative study in the future. This study heavily relies in your participation in the form of filling out the questionnaire. The information will be to advise physiotherapy in the future of best practice.
Thanking You, Stephanie Grace Physiotherapist
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Appendix C: Questionnaire for population.
Questionnaire
CODE 001
This questionnaire is part of an audit to assess what assessment tools physiotherapists use and why. The information you give on this page will inform evidence-based practice and a further study of an assessment tool. Please fill in thoroughly and carefully in black ink pen and capital letters. Position held: Trust: Department: 1. Do you use an assessment tool/objective measure in the treatment of your patient group? (Circle answer) YES NO
If NO, Why? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2. If the answer .. . . . . . . . . . .. . . . . . . . . . .. . . . . . . . . . Why do .. . . . . . .. . . . . . .. . . . . . to .. .. .. question ....... ....... ....... one is yes, what tool(s) do you use? ........................................................... ........................................................... ...........................................................
3.
you use this tool(s)? ........................................................................ ........................................................................ ........................................................................
4.
What are the Advantages/Disadvantages in using this particular type of tool(s)? Advantages Disadvantages .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5.
How often do you use this tool(s)? .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
6.
How can this tool(s) be improved? .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
7.
Does this tool(s) inform your practice? .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
27
8.
Have or would you recommend this tool(s) to a colleague? .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Do you use the tool in co-ordnance with patients? .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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9.
the specific guidelines or do you adapt it to suit your . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
..... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
10.
Do you record how you carry out the testing of the tool? .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
28
Appendix D: Additional Information on Questionnaire Question 1 May include the following assessment tools: Berg Balance Scale TUG test Dynamic Gait index Gait velocity Physical Performance test Timed chair stand Tinetti performance orientated mobility
Code 001
You may answer No if you are not aware of or do not use any Tools/Measurements in the rehabilitation of the older person. You must say why.
Question 2 Outline what tool(s) you use in the rehabilitation of the older person. Question 3 This may be because you find one tool easier to use or understand compared with another. The tool may also yield better results or you may simply not know any other tools. Question 4 More specific reasons for using the tool. Question 5 For example is the tool used: Each separate treatment session Admission and discharge only Once only Other Question 6 Can the tool(s) be improved? How, what are the limiting factors? Are the tool(s) only suited to a particular patient or environment? Question 7 Does the tool(s) add to your treatment and assessment? Question 8 If so, Why? If not, why havent you? Question 9 Do you use the tool in accordance with the specific guidelines or do you adapt it to suit you and your patients? Question 10 Do you record fully and clearly how the testing of the tool was carried out? Including equipment and patient compliance on the day.
29
Appendix E: Project Timetable
Awareness Publish information on survey in addition of AGILE and inform people of presence at the November conference.
Conference Distribute questionnaire packs and collect addresses on cards in order to send reminder. Researcher available for questions on the survey. November 2007
Reminder Send reminder letter to addresses collected. Publish a copy of the questionnaire and reminder in AGILE.
Data Analysis Picking out themes and information.
Presentation Complete a paper on the findings and recommendations for further study. Distribute paper. Print in copy of AGILE.
June 2007
February 2008
March 2008
October 2008
30
Appendix F: Reminder Letter
School of Health Studies University of Bradford 25 Trinity Rd. Bradford UK Tel. +44 01274 236367 Fax +44 01274 236302 1 February 2008
REMINDER LETTER
Dear Participant, It has come to our attention that you still have not returned your completed questionnaire on A Survey to investigate the range of and indications for specific outcome measures used in the rehabilitation of the older person. Your information and participation is vital to our study. Please return the completed questionnaire immediately. Do not hesitate to contact us if you have any problems. Yours Sincerely,
Stephanie Grace Physiotherapist
31
Articles of interest Various topics

By Vivien Astbury AGILES Research Officer
1. Lena Ziden et al. (2008) A life-breaking event: early experiences of the consequences of a hip fracture for elderly people. Clinical Rehabilitation Vol 22, No 9, 801-811 (2008) Jacqueline OReilly et al. Post acute care for older people in community hospitals a cost effectiveness analysis within a multi centre randomised controlled trial. Age and Ageing 2008 37 (5): 513-520 Francesco Di Meo et al. Age does not hamper the response to pulmonary rehabilitation of COPD patients. Age and Ageing 2008 37 (5): 530-535 Danielle Harari et al. Promotion of health in older people: a randomised control trial of health risk appraisal in British general practice. Age and Ageing 2008 37 (5): 565-571 5. Eric J Lense et al. Does depression, apathy or cognitive impairment reduce the benefit of inpatient rehabilitation facilities for hip fracture patients? General Hospital Psychiatry 2007: 29 (2): 141 -146 Andrew D Beswick et al. Complex interventions to improve physical function and maintain independent living in elderly people: a systematic review and meta-analysis. Lancet 2008 March: 371 (9614): 725-735
2.
6.
3.
With many thanks to Paula Elliott, Library Manager, Trafford Healthcare Trust, for all her help and support.
4.
New AGILE National Executive Committee Members from our AGM in October 2008
Chair Mandy Tyler Vice Chair Lynn Sutcliffe Secretary Janet Thomas Minutes secretary Treasurer Lynne Bakewell Educational officer Vivian Astbury Journal Editor Carrie Reynolds For more information on how you can get involved with Agile please contact The Chair of Agile: mandy.tyler@gwent.wales.nhs.uk or visit www.agile.org.uk
32
Guidelines for Authors

Thank you for contributing to AGILITY
Please submit the article or report on a CD, in Microsoft Word, labelled with your name and content title (email the editor for address) or send by e-mail as an attachment to the editor: Carrie_Reynolds@hotmail.com Include an address for correspondence purposes References, where appropriate, should be in the Harvard style - In the text one surname followed by date of publication (Jones et al, 2003) - In the reference lists for journals: names and initials of all authors, title of article, full name of journal, volume number, issue number and first and last page numbers. For books: names and initials of all authors, followed by year of publication, title, place of publication and chapter or page numbers or both. Articles should be about 2,000 words long. Reports should be as short as possible (usually not more than one page when printed in Times New Roman, 10 point, on A4 size paper). However exceptions can be made accordingly and at the editors discretion. AUTHORS PLEASE NOTE: Manuscripts should be in the English language Submissions will be acknowledged Material published becomes copyright to AGILITY. Authors will be advised of any requests to reprint their articles in other journals Authors name will be published, however, professional or academic qualifications are not usually indicated. Post titles may sometimes be relevant Reports & articles for inclusions in the journal should reach the Editor by the deadline for submissions Submissions for deadlines are usually 6-8 weeks prior to the journal being posted to members Articles should, if possible, be submitted well in advance of the deadline. Authors should bear in mind that editing and reviewing takes time. For this reason, inclusion in the next issue cannot be guaranteed.
The deadline for an article or report to be received is by the 30th April 2009 if it is aiming to go into the Spring/Summer 09 Issue but will be at the editors discretion.
33
CHARTERED PHYSIOTHERAPISTS WORKING WITH OLDER PEOPLE
AGILE items for sale 2009

1. The Evidence Based Exercise Manual 2nd Edition (2006) This is currently out of print and due to be replaced by a CD version 2. The Outcome Measures Manual (2005) The Outcome Measures Manual is the second edition of the Handbook of Functional Assessment Tools in Elder Rehabilitation (2000) produced for the AGILE membership. The tools included in this manual represent assessment and outcome measures most commonly used by AGILE members. The current manual contains an introductory section, plus a comprehensive review and proformas for 5 measures: Berg balance Scale Performance Oriented Assessment of Mobility (Tinetti) Turn 180 Functional Reach Elderly Mobility Scale
A new supplement will be published annually that can be purchased for 2.50 plus 1 p&p through AGILE. The currently available supplement is the Timed Up and Go on CD Price: P&P Members UK Europe International 7.50 5.00 8.00 12.50 Non-members UK Europe International 10.00 5.00 8.00 12.50
3. The Undergraduate Physiotherapy Resource Booklet Older People (2005) This resource booklet forms the basis from which undergraduate physiotherapists working with older people can source further information. This is different to the Resource Pack that has been distributed to universities and comprised of the contents of the Evidence-based Exercise Manual, the Outcome Measures Manual, and Physiotherapy for Older People Standards. This booklet is about physiotherapy and older people. It is not intended as a full, stand-alone text in itself, and hence, not fully referenced, as an academic script would be. It is, however, anticipated that the references and websites provided will be used in conjunction with the document to enhance understanding and learning. Price: P&P Members UK Europe International FREE 1.00 2.00 3.00 Non-members UK Europe International 5.00 1.00 2.00 3.00
4. Physiotherapy for Older People: Standards of physiotherapy practice and service standards supplementary paper (2008) This booklet is the updated version of the AGILE standards and has been distributed free to all members. A .pdf version will be available via the AGILE website.
If you require an order form for any of the merchandise, please email the request to Julie George at julie.George4@nhs.net N.B. We are not able to invoice Trusts and companies, so order forms will need to be accompanied by cheques made payable to AGILE
34 AGILITY Autumn/Winter 2009
PHYSIOTHERAPY WITH OLDER PEOPLE

A form should be completed annually and sent with the membership fee to ensure that details are up to date
PLEASE COMPLETE ALL APPROPRIATE FIELDS
AGILE
Members Application Form (1st January 2009 31st December 2009)
CSP No. Title E-mail address Preferred Mailing Address including postcode First Name
AGILE No. Surname
Group Name (where applicable) For distribution of information
New Member REGIONAL GROUP
Membership Renewal West Wales
Lapsed Member East Scotland Overseas *
Honorary Member
North Northern Ireland
* Overseas Members please choose a region for regular updates on activities
AREA OF WORK (CHOOSE MORE THAN ONE IF APPROPRIATE) Community Hospital Wards Outpatients / Day Hospital Care Home Education Research AREA OF INTEREST(S) GRADE AfC Band / Whitley Grade Role Student MEMBERSHIP FEES Group 30 Individual 25 Associate 25 Other (please state)
Intermediate Care Hospice / Respite Retired
Assistant / Student 5 Cheque Enclosed
Cheques should be made payable to AGILE and sent with this application form to Julie George, Project Manager-Flexible Workforce, Workforce Planning, NHS Eastern & Coastal Kent, Brook House, John Wilson Business Park, Reeves Way, Chestfield, CT5 3DD If you have problems paying by cheque please contact the national treasurer OFFICE USE ONLY Membership Secretary
Stage Date Initials Form sent to Membership Sec.
National Treasurer
Payment Processed
DATA PROTECTION ACT Members details are held on a computer database. Questionnaires may be sent by students undertaking dissertations this will be via the membership secretary. The database address list may also be provided to a third party if the National Executive believe it would be beneficial to members interest in older people. Please write to the membership secretary if you do not want your details disclosed in either of these circumstances.
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A True Test-Positives C False Test-Negatives A+C

B False Test-Positives D True Test-Negatives B+D

Number of participants with POAM 18

Table 2: 2x2 Table for POAM Study

AGILITY Autumn/Winter 2009

curve. The histogram shows the mean POAM to be 18.12 5.

Figure 1: Histogram for frequency distribution of POAM

AGILITY Autumn/Winter 2009

A True Test-Positives 24 C False Test-Negatives 8 A+C=32

B False Test-Positives 3 D True Test-Negatives 15 B+D=18

Number of participants with POAM 18

Table 5: 2x2 Table for calculating Sensitivity and Specificity of POAM

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AGILITY Autumn/Winter 2009

Impact Report 2007-8

AGILITY Autumn/Winter 2009

AGILE Continence Exercises

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Figure 3: Literature search for questionnaire.

AGILITY Autumn/Winter 2009

Figure 4: Seidels model of Noticing, Collecting and Thinking.

AGILITY Autumn/Winter 2009

AGILITY Autumn/Winter 2009

AGILITY Autumn/Winter 2009

AGILITY Autumn/Winter 2009

Sample size & Population

Berg Balance Scale

Time for administration

To examine static and dynamic balance control.

AGILITY Autumn/Winter 2009

Dynamic Gait Index

Measure balance impairment through modification of gait during task commands.

Timed Up and Go (TUG)

Community (1135) Long-term care setting (323)

Tinetti Performance Orientated Mobility Assessment (POMA)

Community (225) Long-term care setting (118)

Moderate interrater reliability for the balance component.

No evidence of clinical meaningful change.

Appendix A: Summary of Literature