A lifestyle management programme focused on exercise, diet and physiotherapy support for patients with hip or knee osteoarthritis and a body mass index over 35: a qualitative study

The Lifestyle Management Programme (LMP) is an exercise and weight management programme with physiotherapy support for people with hip or knee osteoarthritis (OA) and a body mass index (BMI) over 35. This qualitative study explored views and experiences of the LMP among patients and professionals, and offers insight for future programmes. Five referring clinicians and six delivering professionals participated in focus groups. Three referring GPs and nine patients who attended the LMP took part in semi-structured interviews. Topics included: referral, reasons for taking up and continuing the programme or not, and experiences and outcomes. Framework method was used to analyse the qualitative data. Overall, patients and professionals valued the multidisciplinary nature of the LMP. However, professionals explained feeling guilty about delaying patients on the orthopaedic waiting list and believed that the programme should be redirected to those with less severe OA and a lower BMI. Referring clinicians differed in their interpretation of the referral criteria and expressed varying levels of autonomy when making referrals. Patients referred after a consultation with their general practitioner appeared to be more satisfied with the referral process. Patients were also encouraged by the opportunity to improve health, their likelihood of surgery and social benefits. However, patients were discouraged by inconvenience, cost, lack of readiness to change and embarrassment. In conclusion, shared decision-making about lifestyle management without delaying orthopaedic opinion is preferable, and more psychological support may increase participation. Importantly, the programme may be better focused on rehabilitation for patients with a lower BMI and less severe symptoms

Patient perspectives on delays in diagnosis and treatment of cancer: a qualitative analysis of free-text data

Background: Earlier cancer diagnosis is crucial in improving cancer survival. The International Cancer Benchmarking Partnership Module 4 (ICBP4) is a quantitative survey study that explores the reasons for delays in diagnosis and treatment of breast, colorectal, lung, and ovarian cancer. To further understand the associated diagnostic processes, it is also important to explore the patient perspectives expressed in the free-text comments. Aim: To use the free-text data provided by patients completing the ICBP4 survey to augment the understanding of patients’ perspectives of their diagnostic journey. Design and setting: Qualitative analysis of the free-text data collected in Wales between October 2013 and December 2014 as part of the ICBP4 survey. Newly-diagnosed patients with either breast, ovarian, colorectal, or lung cancer were identified from registry data and then invited by their GPs to participate in the survey. Method: A thematic framework was used to analyse the free-text comments provided at the end of the ICBP4 survey. Of the 905 patients who returned a questionnaire, 530 included comments. Results: The free-text data provided information about patients’ perspectives of the diagnostic journey. Analysis identified factors that acted as either barriers or facilitators at different stages of the diagnostic process. Some factors, such as screening, doctor–patient familiarity, and private treatment, acted as both barriers and facilitators depending on the context. Conclusion: Factors identified in this study help to explain how existing models of cancer diagnosis (for example, the Pathways to Treatment Model) work in practice. It is important that clinicians are aware of how these factors may interact with individual clinical cases and either facilitate, or act as a barrier to, subsequent cancer diagnosis. Understanding and implementing this knowledge into clinical practice may result in quicker cancer diagnoses

The effects of aerobic and resistance exercise on markers of large joint health in stable rheumatoid arthritis patients:a pilot study

Objective: exercise is beneficial for people with rheumatoid arthritis (RA). However, patients and health professionals have expressed concern about the possible detrimental effects of exercise on joint health. The present study investigated the acute and chronic effects of high-intensity, low-impact aerobic and resistance exercise on markers of large joint health in RA.Methods: eight RA patients and eight healthy, matched control (CTL) participants performed 30 minutes’ high-intensity, low-impact aerobic and lower-body resistance exercise, one week apart. Primary outcome measures assessing joint health were serum cartilage oligomeric matrix protein (sCOMP) and knee joint synovial inflammation (Doppler ultrasound colour fraction; CF). These measures were taken at baseline, immediately after and 0.5, one, two, six and 24 hours post-exercise. In a separate study, nine RA patients completed eight weeks of progressive exercise training. The same outcome measures were reassessed at baseline, and at one hour post-exercise of training weeks 0, 1, 4 and 8.Results: RA patients showed higher overall sCOMP [RA: 1,347 ± 421, CTL: 1,189 ± 562 ng/mL; p < 0.05; effect size (ES) = 0.32] and CF when scanned longitudinally (RA: 0.489 ± 0.30 × 10–3, CTL: 0.101 ± 0.13 × 10–3; p < 0.01; ES = 1.73) and transversely (RA: 0.938 ± 0.69 × 10–3, CTL: 0.199 ± 0.36 × 10–3; p < 0.01; ES = 1.33) than CTL. However, no acute effects on joint health were observed post-exercise. Similarly, no chronic effects were observed over eight weeks of combined aerobic and resistance training in RA, with positive effects on physical fitness and function.Conclusions: RA patients on stable treatment with low disease activity were able to perform an individually prescribed high-intensity, low-impact aerobic and resistance exercise without changes in markers of large joint health

'Function First - Be Active, Stay Independent' - Promoting physical activity and physical function in people with long-term conditions by primary care: A protocol for a realist synthesis with embedded co-production and co-design.

Introduction: People with long-term conditions typically have reduced physical functioning, are less physically active and therefore become less able to live independently and do the things they enjoy. Long-term conditions are managed routinely in primary care, however support rarely emphasises physical function and physical activity. This project aims to develop evidence-based recommendations about how primary care can optimally help people to become more physically active in order to maintain and improve their physical function, thus promoting independence. Methods and analysis: This study takes a realist synthesis approach, following RAMESES guidance, with embedded co-production and co-design. Stage 1 will develop initial programme theories about physical activity and physical function for people with long-term conditions, based on a review of the scientific and grey literature, and two multisector stakeholder workshops using LEGO® SERIOUS PLAY®. Stage 2 will involve focused literature searching, data extraction and synthesis to provide evidence to support or refute the initial programme theories. Searches for evidence will focus on physical activity interventions involving the assessment of physical function that are relevant to primary care. We will describe ‘what works’, ‘for whom’ and ‘in what circumstances’ and develop conjectured programme theories using (C)ontext, (M)echanism and (O)utcome (CMO) configurations. Stage 3 will test and refine these theories through individual stakeholder interviews. The resulting theory-driven recommendations will feed into Stage 4 which will involve three sequential co-design stakeholder workshops where practical ideas for service innovation in primary care will be developed. Ethics and dissemination: Healthcare and Medical Sciences Academic Ethics Committee (Reference 2018-16308) and NHS Wales Research Ethics Committee 5 approval (References 256729 and 262726) have been obtained. A knowledge mobilisation event will address issues relevant to wider implementation of the intervention and study findings. Findings will be disseminated through peer-reviewed journal publications, conference presentations, and formal and informal reports

Benefits of Exercise in Rheumatoid Arthritis

This paper aims to highlight the importance of exercise in patients with rheumatoid arthritis (RA) and to demonstrate the multitude of beneficial effects that properly designed exercise training has in this population. RA is a chronic, systemic, autoimmune disease characterised by decrements to joint health including joint pain and inflammation, fatigue, increased incidence and progression of cardiovascular disease, and accelerated loss of muscle mass, that is, “rheumatoid cachexia”. These factors contribute to functional limitation, disability, comorbidities, and reduced quality of life. Exercise training for RA patients has been shown to be efficacious in reversing cachexia and substantially improving function without exacerbating disease activity and is likely to reduce cardiovascular risk. Thus, all RA patients should be encouraged to include aerobic and resistance exercise training as part of routine care. Understanding the perceptions of RA patients and health professionals to exercise is key to patients initiating and adhering to effective exercise training

A rapid review of the effectiveness of interventions/innovations relevant to the Welsh NHS context to support the recruitment & retention of clinical staff

Background: The National Health Service (NHS) is experiencing an acute workforce shortage in every discipline, at a time when waiting times are at a record high and there is a growing backlog resulting from the COVID-19 pandemic. This Rapid Review aimed to explore the effectiveness of interventions or innovations relevant to the Welsh NHS context to support health professionals’ (HPs) recruitment and retention. The review used the findings of existing reviews supplemented by a more in-depth evaluation of included primary studies conducted in the UK or Europe. Methods: Searches were conducted across seven databases for English language publications from 2015 to February 2022 including: Medline, EMBASE, Ovid Emcare, HMIC, CINAHL, Epistemonikos and Cochrane Library. Organisational websites were also searched for grey literature. Two reviewers title/abstract screened all citations in CovidenceTM, resolving any conflicts. Full-text screening was conducted by two reviewers. All demographic and outcome data were extracted by one reviewer and checked by a second. Eligible systematic reviews were critically appraised by one reviewer and checked by a second using the JBI critical appraisal checklist for systematic reviews. The data were reported narratively as a series of thematic summaries structured around the type of intervention. Results: Systematic (n=8) and scoping reviews (n=1) were included and focused on dentists; general practitioners; physicians; the medical workforce and undergraduates; medical undergraduates; and a variety of different HPs including those in training. Most reviews looked for interventions within rural, remote or underserved areas. The interventions were mapped across five WHO (2010) categories: educational, regulatory, financial incentives, personal and professional support and bundled interventions (activities that cover two or more different categories). Regarding educational interventions, moderate-quality evidence indicated positive association between rural-based training programmes and HPs’ recruitment/retention. Moderate-low quality evidence showed positive association between student selection based on rural background or including rural health topics in teaching and recruitment. Low-quality evidence demonstrated positive relationship between locating education institutions in rural areas, continuing education for rural HPs and recruitment/retention. However, low-quality mixed evidence was identified regarding the effect of rural clinical placements/fellowships/internships on recruitment/retention. All identified regulatory interventions requiring return of service (RoS) in rural areas were based on low-quality evidence. Bonded schemes, scholarships, and bursaries had a positive association with HPs’ recruitment. Loan repayments, accelerated training, enhanced scope of practice, and compulsory service were associated with HPs’ retention. Furthermore, a National Health Insurance scheme had a positive relationship with recruitment/retention, although it was based on one study. Mixed evidence was found regarding the effect of Visa waivers and financial incentives (with RoS). Interventions focusing on access to professional licences were associated with low retention. Low-quality evidence showed that financial incentives without RoS, such as loan repayments, had a positive association with retention. However, benefits that make rural areas attractive (e.g. higher salaries, subsidies for free housing) were found inconclusive. Personal and professional support in the form of improvements in living and working conditions in rural areas had a positive association with retention, although was based on low-quality evidence. There was consensus that bundled strategies positively impacted on recruitment/retention of rural workforce. Implications:The review identified a range of interventions that can be used for enhancing recruitment and retention in Wales, supporting bundled strategies. The findings highlight the importance of providing and locating undergraduate and postgraduate training in rural locations and the use of bursary schemes for training. More robust evaluations, based on comparative studies, are required to assess the effectiveness of interventions to support HPs’ recruitment and retention