Physiotherapists’ perceptions of problematic musculoskeletal soft tissue disorders

Original article can be found at: http://www.ijtr.co.uk/ Copyright MA Healthcare Limited.Aims: Many common musculoskeletal disorders are resistant to existing management strategies,causing long-term pain and disability. While arthritic and spinal problems have been prioritized for research, several soft tissue disorders may be equally burdensome for individuals and difficult to treat successfully. dentifying those that are least responsive to reatment may help focus the limited resources available for research and treatment provision. This study aimed to rank the most problematic disorders, and identify contributory factors, to inform the debate on research and service priorities in the management of musculoskeletal disorders. Methods: The views of practising physiotherapists on the most problematic soft tissue disorders were sought using a postal questionnaire survey and telephone interviews. The questionnaire was sent to 193 experienced musculoskeletal physiotherapists working in National Health Service and private clinics in south-east England. Findings: The response rate was 48%. The top three problematic disorders were identifi ed as frozen shoulder, plantar fasciitis and tennis elbow. Subsequent interviews with 20 respondents indicated that inadequate differential diagnosis, triaging and differences in therapeutic practice may account for some of the observed variation in outcomes. Conclusions: A greater focus on these particular disorders and issues by both clinicians and the research community is warranted.Peer reviewe

Understanding the challenge of weight loss maintenance: A systematic review and synthesis of qualitative research on weight loss maintenance

This is the author accepted manuscript. The final version is available from Taylor & Francis via the DOI in this record.Behaviour change interventions can be effective in helping people to lose weight, but weight is often regained. Effective interventions are required to prevent this. We conducted a systematic review and synthesis of qualitative research on people's experiences of weight loss maintenance. We searched bibliographic databases for qualitative studies about the experience of currently or previously overweight adults trying to maintain weight loss. We thematically synthesised study findings to develop a model of weight loss maintenance. Twenty six studies from five countries with 710 participants were included. The model developed through our synthesis proposes that making the behaviour changes required for weight loss maintenance generates psychological "tension" due to the need to override existing habits, and incompatibility of the new behaviours with the fulfilment of psychological needs. Successful maintenance involves management or resolution of this tension. Management of tension can be achieved through self-regulation, renewing of motivation and managing external influences, although this can require constant effort. Resolution may be achieved through changing habits, finding non obesogenic methods for addressing needs, and potentially through change in self-concept. Implications for the development of weight loss maintenance interventions are explored.This report is independent research supported by the UK’s National Institute for Health Research (Career Development Fellowship CDF-2012-05-259) and the National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care of the South West Peninsula (PenCLAHRC). Dr R Garside’s time is partly financed by the European Regional Development Fund Programme and European Social Fund Convergence Programme for Cornwall and the Isles of Scilly. The views expressed are those of the authors and not necessarily those of EU, NIHR or the UK Department of Health

Intervention fidelity: developing an experience-based model for rehabilitation research

This is a freely-available open access publication. Please cite the published version which is available via the DOI link in this record.Background Intervention fidelity is concerned with the extent to which interventions are implemented as intended. Consideration of fidelity is essential if the conclusions of effectiveness studies are to be credible, but little attention has been given to it in the rehabilitation literature. We describe our experiences addressing fidelity in the development of a rehabilitation clinical trial, and consider how an existing model of fidelity may be employed in rehabilitation research. Methods We used a model and methods drawn from the psychology literature to investigate how fidelity might be maximised during the planning and development of a stroke rehabilitation trial. We considered fidelity in intervention design, provider training, and the behaviour of providers and participants. We also evaluated methods of assessing fidelity during a trial. Results We identified strategies to help address fidelity in our trial protocol, along with their potential strengths and limitations. We incorporated these strategies into a model of fidelity that is appropriate to the concepts and language of rehabilitation. Conclusion A range of strategies are appropriate to help maximise and measure fidelity in rehabilitation research. Based on our experiences, we propose a model of fidelity and provide recommendations to inform the growing literature of fidelity in this discipline.National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care (CLAHRC) for the South West Peninsul

Independently getting off the floor (IGO): a feasibility study of teaching people with stroke to get up after a fall

This is the author accepted manuscript. The final version is available from Mark Allen Healthcare via the DOI in this record.Background: Falls are common among stroke survivors but many are not taught how to get up again. A technique from Action for Rehabilitation following Neurological Injury (ARNI) addresses this problem. We investigated the feasibility and safety of teaching this technique to stroke survivors. Methods: Stroke survivors (mean 7.1 years post-stroke) with mild-to-moderate disability (mean modified Rankin Score 2.4), who could get up with assistance but not independently, received up to six sessions of training to independently get off the floor (IGO). The primary outcome was IGO success; safety and feasibility were investigated by participant and trainer interviews, biomechanical and video analysis and expert panel review. Findings: Six of the 10 participants achieved IGO and five of nine retained the skill two months post-training. One to six sessions (median 3) were needed to master IGO; one minor but no serious adverse events occurred. Expert reviewers indicated training involved an acceptable risk of falls and no concerns for knee and wrist positions. Conclusions: This feasibility study indicates IGO may be useful. IGO was taught to and safely used by selected stroke survivors. Further assessment of IGO has now been part of a pilot randomised controlled trial of ARNI based stroke rehabilitation.The study was part-funded by the Royal Devon and Exeter NHS Foundation Trust small research grants scheme. This paper presents independent research part-funded by the National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care South West Peninsula at the Royal Devon and Exeter NHS Foundation Trust

The dynamics of decision-making in weight loss and maintenance: a qualitative enquiry

This is the final version. Available on open access from BMC via the DOI in this recordBackground . Behavioural approaches to weight loss are often initially successful but less so in the longer term, as some people maintain the necessary behaviour changes while others do not. This study aimed to derive possible explanations for this using a qualitative approach with a view to improving intervention effectiveness. Methods . Thirty-six participants in a development and feasibility study for a weight loss and maintenance intervention (called SkiM) were interviewed three times over 18 months regarding their experiences before, during and after the intervention. Data were analysed thematically. The accounts of those who were more and less successful in terms of longer term weight loss were compared, and a conceptual model linking the main analytic themes was developed. Results. Five interpretative themes were generated: encountering and managing key situations; the impact of emotion; the source of control; personal values; and acquiring knowledge and skills. These themes were linked through a model of decision-making during key situations. In this model, behavioural decisions emerge from a dynamic interplay between several drivers: emotional state and needs, perceived control, personal values, the individual’s knowledge and skills, and their existing habits. The individual’s response in key situations generates experiential learning that caninfluence decisional dynamics in similar situations in future. These dynamics appeared to differ between participants, and between those who were more and less successful in weight management. Conclusions. Our analysis and model of decision-making during weight-management have implications for the development and delivery of behavioural weight management interventions. By helping individuals to identify the drivers of their decision-making in key situations, and equipping them to manage these drivers, programmes may enhance their capacity to sustain the behaviour changes needed for long-term weight loss.National Institute for Health Research (NIHR

Shared decision-making between older people with multimorbidity and GPs: focus group study

This is the author accepted manuscript. The final version is available from the Royal College of General Practitioners via the DOI in this record. Background: Shared decision-making, utilising the expertise of both patient and clinician, is a key feature of good-quality patient care. Multimorbidity can complicate shared decision-making, yet few studies have explored this dynamic for older patients with multimorbidity in general practice. Aim: To explore factors influencing shared decision-making from the perspectives of older patients with multimorbidity and GPs, to inform improvements in personalised care. Design & setting: Qualitative study. General practices (rural and urban) in Devon, England. Method: Four focus groups, two with patients (aged 65+ with multimorbidity) and two with GPs. Data were coded inductively by two researchers applying thematic analysis. Results: Patient acknowledgement of clinician medicolegal vulnerability in the context of multimorbidity, and their recognition of this as a barrier to shared decision-making, is a new finding. Medicolegal vulnerability was a unifying theme for other reported barriers to shared decision-making. These included expectations for GPs to follow clinical guidelines, challenges encountered in applying guidelines and in communicating clinical uncertainty, and limited clinician self-efficacy for shared decision-making. Increasing consultation duration and improving continuity were viewed as facilitators. Conclusion: Clinician perceptions of medicolegal vulnerability are recognised by both patients and GPs as a barrier to shared decision-making and should be addressed to optimise delivery of personalised care. Greater awareness of multimorbidity guidelines is needed. Educating clinicians in the communication of uncertainty should be a core component of shared decision-making training. The incorrect perception that most clinicians already effectively facilitate shared decision-making should be addressed to improve the uptake of personalised care interventions.National Institute for Health Research (NIHR

Motivators for uptake and maintenance of exercise: perceptions of long-term stroke survivors and implications for design of exercise programmes.

PURPOSE: Exercise-after-stroke programmes are increasingly being provided to encourage more physical exercise among stroke survivors, but little is known about what motivates people with stroke to participate in them. This research aimed to identify factors that motivate long-term stroke survivors to exercise, and the implications for programme design. METHODS: In two separate studies, focus groups and individual interviews were used to investigate the views of long-term stroke survivors on exercise and participating in exercise programmes. Their data were analysed thematically, and the findings of the studies were synthesised. RESULTS: Eleven stroke survivors and two partners took part in two focus groups; six other stroke survivors (one with a partner) were interviewed individually. Factors reported to influence motivation were the psychological benefits of exercise, a desire to move away from a medicalised approach to exercise, beliefs about stroke recovery, and on-going support to sustain commitment. A number of potential implications of these themes for exercise programme design were identified. CONCLUSIONS: A range of personal beliefs and attitudes and external factors may affect the motivation to exercise, and these vary between individuals. Addressing these factors in the design of exercise programmes for long-term stroke survivors may enhance their appeal and so encourage greater engagement in exercise. IMPLICATIONS FOR REHABILITATION: Exercise programmes may be more attractive to long-term stroke survivors if the psychological well-being benefits of participation are emphasised in their promotion. Some participants will be more attracted by programmes that are de-medicalised, for example, by being located away from clinical settings, and led by or involving suitably-trained non-clinicians. Programmes offered in different formats may attract stroke survivors with different beliefs about the value of exercise in stroke recovery. Programmes should provide explicit support strategies for on-going engagement in exercise.This paper presents independent research funded by the National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care (CLAHRC) for the South West Peninsula. The views expressed in this publication are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health in England. The authors report no other declarations of interest

Community-based Rehabilitation Training after stroke: Protocol of a pilot randomised controlled trial (ReTrain)

Introduction: The Rehabilitation Training (ReTrain) intervention aims to improve functional mobility, adherence to poststroke exercise guidelines and quality of life for people after stroke. A definitive randomised controlled trial (RCT) is required to assess the clinical and cost-effectiveness of ReTrain, which is based on Action for Rehabilitation from Neurological Injury (ARNI). The purpose of this pilot study is to assess the feasibility of such a definitive trial and inform its design. Methods and analysis: A 2-group, assessor-blinded, randomised controlled external pilot trial with parallel mixed-methods process evaluation and economic evaluation. 48 participants discharged from clinical rehabilitation despite residual physical disability will be individually randomised 1:1 to ReTrain (25 sessions) or control (exercise advice booklet). Outcome assessment at baseline, 6 and 9 months include Rivermead Mobility Index; Timed Up and Go Test; modified Patient-Specific Functional Scale; 7-day accelerometry; Stroke Self-efficacy Questionnaire, exercise diary, Fatigue Assessment Scale, exercise beliefs and self-efficacy questionnaires, SF-12, EQ-5D-5L, Stroke Quality of Life, Carer Burden Index and Service Receipt Inventory. Feasibility, acceptability and process outcomes include recruitment and retention rates; with measurement burden and trial experiences being explored in qualitative interviews (20 participants, 3 intervention providers). Analyses include descriptive statistics, with 95% CI where appropriate; qualitative themes; intervention fidelity from videos and session checklists; rehearsal of health economic analysis. Ethics and dissemination: National Health Service (NHS) National Research Ethics Service approval granted in April 2015; recruitment started in June. Preliminary studies suggested low risk of serious adverse events; however (minor) falls, transitory muscle soreness and high levels of postexercise fatigue are expected. Outputs include pilot data to inform whether to proceed to a definitive RCT and support a funding application; finalised Trainer and Intervention Delivery manuals for multicentre replication of ReTrain; presentations at conferences, public involvement events; internationally recognised peer-reviewed journal publications, open access sources and media releases

Comparing international postgraduate training and healthcare context with the UK to streamline overseas GP recruitment: four case studies.

This is the final published version, also available from Royal College of General Practitioners via the DOI in this record.BACKGROUND: There are ambitious overseas recruitment targets to alleviate current GP shortages in the UK. GP training in European Economic Area (EEA) countries is recognised by the General Medical Council (GMC) as equivalent UK training; non-EEA GPs must obtain a Certificate of Eligibility for General Practice Registration (CEGPR), demonstrating equivalence to UK-trained GPs. The CEGPR may be a barrier to recruiting GPs from non-EEA countries. It is important to facilitate the most streamlined route into UK general practice while maintaining registration standards and patient safety. AIM: To apply a previously published mapping methodology to four non-EEA countries: South Africa, US, Canada, and New Zealand. DESIGN & SETTING: Desk-based research was undertaken. This was supplemented with stakeholder interviews. METHOD: The method consisted of: (1) a rapid review of 13 non-EEA countries using a structured mapping framework, and publicly available website content and country-based informant interviews; (2) mapping of five 'domains' of comparison between four overseas countries and the UK (healthcare context, training pathway, curriculum, assessment, and continuing professional development (CPD) and revalidation). Mapping of the domains involved desk-based research. A red, amber, or green (RAG) rating was applied to indicate the degree of alignment with the UK. RESULTS: All four countries were rated 'green'. Areas of differences that should be considered by regulatory authorities when designing streamlined CEGPR processes for these countries include: healthcare context (South Africa and US), CPD and revalidation (US, Canada, and South Africa), and assessments (New Zealand). CONCLUSION: Mapping these four non-EEA countries to the UK provides evidence of utility of the systematic method for comparing GP training between countries, and may support the UK's ambitions to recruit more GPs to alleviate UK GP workforce pressures.National Institute for Health Research (NIHR

Physical activity, sleep, and fatigue in community dwelling Stroke Survivors

Stroke can lead to physiological and psychological impairments and impact individuals’ physical activity (PA), fatigue and sleep patterns. We analysed wrist-worn accelerometry data and the Fatigue Assessment Scale from 41 stroke survivors following a physical rehabilitation programme, to examine relationships between PA levels, fatigue and sleep. Validated acceleration thresholds were used to quantify time spent in each PA intensity/sleep category. Stroke survivors performed less moderate to vigorous PA (MVPA) in 10 minute bouts than the National Stroke guidelines recommend. Regression analysis revealed associations at baseline between light PA and fatigue (p = 0.02) and MVPA and sleep efficiency (p = 0.04). Light PA was positively associated with fatigue at 6 months (p = 0.03), whilst sleep efficiency and fatigue were associated at 9 months (p = 0.02). No other effects were shown at baseline, 6 or 9 months. The magnitude of these associations were small and are unlikely to be clinically meaningful. Larger trials need to examine the efficacy and utility of accelerometry to assess PA and sleep in stroke survivorsStroke Association for funding this research (TSA – 2014-03) and the National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care South West Peninsula at the Royal Devon and Exeter NHS Foundation Trus