Australian Physical Activity Clinical Practice Guideline for people with moderate to severe traumatic brain injury: Technical Report

Background In 2020, the World Health Organization (WHO) released updated physical activity and sedentary behaviour guidelines, which for the first-time included a guideline for people living with disability. The disability guideline is based on evidence from the general population and eight common health conditions causing disability, but did not include people with traumatic brain injury (TBI), nor did it consider the rehabilitation phase of recovery from injury. In 2019, the Australian federal government launched the Traumatic Brain Injury Mission. The Mission was tasked with providing $50 million over 10 years under the Medical Research Future Fund (MRFF) to support research. The goal of the Mission is to better predict recovery outcomes after a TBI, identify the most effective care and treatments, and reduce barriers to support people to live their best possible life after TBI. In 2021, our team was funded through the MRFF TBI Mission to develop an Australian Physical Activity Clinical Practice Guideline for people living with moderate to severe TBI (msTBI). The overarching project to guide the development of the guideline was called BRIDGES (BRain Injury: Developing GuidElineS for physical activities). Objective To develop an Australian clinical practice guideline to support the clinical decision-making of health professionals working with people with msTBI and increase uptake of safe and beneficial physical activity by people living with msTBI. Methods The overarching BRIDGES project was guided by the Exploration Preparation Implementation Sustainment (EPIS) framework. We used a Grading of Recommendations Assessment, Development and Evaluation (GRADE) ADOLOPMENT approach to determine whether to ‘adapt’ or ‘adopt’ the WHO guideline or develop de novo recommendations. We established guideline leadership and development groups, conducted a rapid systematic review to identify direct evidence in TBI, and reviewed guidelines in other relevant health conditions (i.e., stroke, cerebral palsy) to identify indirect evidence. To further inform guideline development and implementation considerations, we conducted an audit of brain injury services in Australia and qualitative consultations with key stakeholders, including people with msTBI. Results Direct evidence for the prescription of physical activity for people with msTBI is limited. The clinical practice guideline developed incorporates 10 de novo evidence-based recommendations with additional good practice points and precautionary practice points to guide clinical decision-making. The physical activity recommended is aerobic exercise, strength training, mobility training, sport and physical recreation, and promotion of physical activity. The physical activity is recommended for children, adolescents, adults, and older adults across the continuum of rehabilitation. Conclusion While there remain evidence gaps that require further research, and further work on how the guideline can be implemented into clinical practice is needed, physical activity interventions tailored to the individual’s goals and needs should be standard clinical practice for health professionals working with people with msTBI in Australian rehabilitation, community, home, and school (for children and adolescents) settings

Current practice of physical activity counselling within physiotherapy usual care and influences on its use : a cross-sectional survey

Physical activity counselling has demonstrated effectiveness at increasing physical activity when delivered in healthcare, but is not routinely practised. This study aimed to determine (1) current use of physical activity counselling by physiotherapists working within publicly funded hospitals; and (2) influences on this behaviour. A cross‐sectional survey of physiotherapists was conducted across five hospitals within a local health district in Sydney, Australia. The survey investigated physiotherapists’ frequency of incorporating 15 different elements of physical activity counselling into their usual healthcare interactions, and 53 potential influences on their behaviour framed by the COM‐B (Capability, Opportunity, Motivation‐Behaviour) model. The sample comprised 84 physiotherapists (79% female, 48% 90% indicating their patients lacked financial and transport opportunities. These findings confirm that physical activity counselling is not routinely incorporated in physiotherapy practice and help to identify implementation strategies to build clinicians’ opportunities and capabilities to deliver physical activity counselling

Physical activity preferences of people living with brain injury : Formative qualitative research to develop a discrete choice experiment

Background and Objective The World Health Organization physical activity guidelines for people living with disability do not consider the needs of people living with moderate-to-severe traumatic brain injury. This paper describes the qualitative co-development of a discrete choice experiment survey to inform the adaption of these guidelines by identifying the physical activity preferences of people living with moderate-to-severe traumatic brain injury in Australia. Methods The research team comprised researchers, people with lived experience of traumatic brain injury and health professionals with expertise in traumatic brain injury. We followed a four-stage process: (1) identification of key constructs and initial expression of attributes, (2) critique and refinement of attributes, (3) prioritisation of attributes and refinement of levels and (4) testing and refining language, format and comprehensibility. Data collection included deliberative dialogue, focus groups and think-aloud interviews with 22 purposively sampled people living with moderate-to-severe traumatic brain injury. Strategies were used to support inclusive participation. Analysis employed qualitative description and framework methods. Results This formative process resulted in discarding, merging, renaming and reconceptualising attributes and levels. Attributes were reduced from an initial list of 17 to six: (1) Type of activity, (2) Out-of-pocket cost, (3) Travel time, (4) Who with, (5) Facilitated by and (6) Accessibility of setting. Confusing terminology and cumbersome features of the survey instrument were also revised. Challenges included purposive recruitment, reducing diverse stakeholder views to a few attributes, finding the right language and navigating the complexity of discrete choice experiment scenarios. Conclusions This formative co-development process significantly improved the relevance and comprehensibility of the discrete choice experiment survey tool. This process may be applicable in other discrete choice experiment studies

Digitally enabled aged care and neurological rehabilitation to enhance outcomes with Activity and MObility UsiNg Technology (AMOUNT) in Australia: A randomised controlled trial

Background: Digitally enabled rehabilitation may lead to better outcomes but has not been tested in large pragmatic trials. We aimed to evaluate a tailored prescription of affordable digital devices in addition to usual care for people with mobility limitations admitted to aged care and neurological rehabilitation. Methods and findings: We conducted a pragmatic, outcome-assessor-blinded, parallel-group randomised trial in 3 Australian hospitals in Sydney and Adelaide recruiting adults 18 to 101 years old with mobility limitations undertaking aged care and neurological inpatient rehabilitation. Both the intervention and control groups received usual multidisciplinary inpatient and post-hospital rehabilitation care as determined by the treating rehabilitation clinicians. In addition to usual care, the intervention group used devices to target mobility and physical activity problems, individually prescribed by a physiotherapist according to an intervention protocol, including virtual reality video games, activity monitors, and handheld computer devices for 6 months in hospital and at home. Co-primary outcomes were mobility (performance-based Short Physical Performance Battery [SPPB]; continuous version; range 0 to 3; higher score indicates better mobility) and upright time as a proxy measure of physical activity (proportion of the day upright measured with activPAL) at 6 months. The dataset was analysed using intention-to-treat principles. The trial was prospectively registered with the Australian New Zealand Clinical Trials Registry (ACTRN12614000936628). Between 22 September 2014 and 10 November 2016, 300 patients (mean age 74 years, SD 14; 50% female; 54% neurological condition causing activity limitation) were randomly assigned to intervention (n = 149) or control (n = 151) using a secure online database (REDCap) to achieve allocation concealment. Six-month assessments were completed by 258 participants (129 intervention, 129 control). Intervention participants received on average 12 (SD 11) supervised inpatient sessions using 4 (SD 1) different devices and 15 (SD 5) physiotherapy contacts supporting device use after hospital discharge. Changes in mobility scores were higher in the intervention group compared to the control group from baseline (SPPB [continuous, 0–3] mean [SD]: intervention group, 1.5 [0.7]; control group, 1.5 [0.8]) to 6 months (SPPB [continuous, 0–3] mean [SD]: intervention group, 2.3 [0.6]; control group, 2.1 [0.8]; mean between-group difference 0.2 points, 95% CI 0.1 to 0.3; p = 0.006). However, there was no evidence of a difference between groups for upright time at 6 months (mean [SD] proportion of the day spent upright at 6 months: intervention group, 18.2 [9.8]; control group, 18.4 [10.2]; mean between-group difference −0.2, 95% CI −2.7 to 2.3; p = 0.87). Scores were higher in the intervention group compared to the control group across most secondary mobility outcomes, but there was no evidence of a difference between groups for most other secondary outcomes including self-reported balance confidence and quality of life. No adverse events were reported in the intervention group. Thirteen participants died while in the trial (intervention group: 9; control group: 4) due to unrelated causes, and there was no evidence of a difference between groups in fall rates (unadjusted incidence rate ratio 1.19, 95% CI 0.78 to 1.83; p = 0.43). Study limitations include 15%–19% loss to follow-up at 6 months on the co-primary outcomes, as anticipated; the number of secondary outcome measures in our trial, which may increase the risk of a type I error; and potential low statistical power to demonstrate significant between-group differences on important secondary patient-reported outcomes. Conclusions: In this study, we observed improved mobility in people with a wide range of health conditions making use of digitally enabled rehabilitation, whereas time spent upright was not impacted. Trial registration: The trial was prospectively registered with the Australian New Zealand Clinical Trials Register; ACTRN1261400093662

Physical activity coaching for adults with mobility limitations: protocol for the ComeBACK pragmatic hybrid effectiveness-implementation type 1 randomised controlled trial

INTRODUCTION: Mobility limitation is common and often results from neurological and musculoskeletal health conditions, ageing and/or physical inactivity. In consultation with consumers, clinicians and policymakers, we have developed two affordable and scalable intervention packages designed to enhance physical activity for adults with self-reported mobility limitations. Both are based on behaviour change theories and involve tailored advice from physiotherapists. METHODS AND ANALYSIS: This pragmatic hybrid effectiveness-implementation type 1 randomised control trial (n=600) will be undertaken among adults with self-reported mobility limitations. It aims to estimate the effects on physical activity of: (1) an enhanced 6-month intervention package (one face-to-face physiotherapy assessment, tailored physical activity plan, physical activity phone coaching from a physiotherapist, informational/motivational resources and activity monitors) compared with a less intensive 6-month intervention package (single session of tailored phone advice from a physiotherapist, tailored physical activity plan, unidirectional text messages, informational/motivational resources); (2) the enhanced intervention package compared with no intervention (6-month waiting list control group); and (3) the less intensive intervention package compared with no intervention (waiting list control group). The primary outcome will be average steps per day, measured with the StepWatch Activity Monitor over a 1-week period, 6 months after randomisation. Secondary outcomes include other physical activity measures, measures of health and functioning, individualised mobility goal attainment, mental well-being, quality of life, rate of falls, health utilisation and intervention evaluation. The hybrid effectiveness-implementation design (type 1) will be used to enable the collection of secondary implementation outcomes at the same time as the primary effectiveness outcome. An economic analysis will estimate the cost-effectiveness and cost-utility of the interventions compared with no intervention and to each other. ETHICS AND DISSEMINATION: Ethical approval has been obtained by Sydney Local Health District, Royal Prince Alfred Zone. Dissemination will be via publications, conferences, newsletters, talks and meetings with health managers. TRIAL REGISTRATION NUMBER: ACTRN12618001983291

Market-dependent production set

A country’s production possibility frontier or PPF is defined as the boundary of its economy’s production set in the net output space for a given technology and fixed quantities of primary factors of production. In general equilibrium theory, exogenous changes in technology or primary-factor supplies alter equilibrium prices; however, government-policy induced domestic relative commodity price changes do not alter the shape of an economy’s production set. We show that, under international capital mobility, which is empirically significant, the shape of a country’s production set does, in fact, depend on market forces and this shape can be manipulated by government policy

Australian Physical Activity Clinical Practice Guideline for people with moderate to severe traumatic brain injury: Administrative Report

Background In 2020, the World Health Organization (WHO) released updated physical activity and sedentary behaviour guidelines, which for the first-time included a guideline for people living with disability. The disability guideline is based on evidence from the general population and eight common health conditions causing disability, but did not include people with traumatic brain injury (TBI), nor did it consider the rehabilitation phase of recovery from injury. In 2019, the Australian federal government launched the Traumatic Brain Injury Mission. The Mission was tasked with providing $50 million over 10 years under the Medical Research Future Fund (MRFF) to support research. The goal of the Mission is to better predict recovery outcomes after a TBI, identify the most effective care and treatments, and reduce barriers to support people to live their best possible life after TBI. In 2021, our team was funded through the MRFF TBI Mission to develop an Australian Physical Activity Clinical Practice Guideline for people living with moderate to severe TBI (msTBI). The overarching project to guide the development of the guideline was called BRIDGES (BRain Injury: Developing GuidElineS for physical activities). Objective To develop an Australian clinical practice guideline to support the clinical decision-making of health professionals working with people with msTBI and increase uptake of safe and beneficial physical activity by people living with msTBI. Methods The overarching BRIDGES project was guided by the Exploration Preparation Implementation Sustainment (EPIS) framework. We used a Grading of Recommendations Assessment, Development and Evaluation (GRADE) ADOLOPMENT approach to determine whether to ‘adapt’ or ‘adopt’ the WHO guideline or develop de novo recommendations. We established guideline leadership and development groups, conducted a rapid systematic review to identify direct evidence in TBI, and reviewed guidelines in other relevant health conditions (i.e., stroke, cerebral palsy) to identify indirect evidence. To further inform guideline development and implementation considerations, we conducted an audit of brain injury services in Australia and qualitative consultations with key stakeholders, including people with msTBI. Results Direct evidence for the prescription of physical activity for people with msTBI is limited. The clinical practice guideline developed incorporates 10 de novo evidence-based recommendations with additional good practice points and precautionary practice points to guide clinical decision-making. The physical activity recommended is aerobic exercise, strength training, mobility training, sport and physical recreation, and promotion of physical activity. The physical activity is recommended for children, adolescents, adults, and older adults across the continuum of rehabilitation. Conclusion While there remain evidence gaps that require further research, and further work on how the guideline can be implemented into clinical practice is needed, physical activity interventions tailored to the individual’s goals and needs should be standard clinical practice for health professionals working with people with msTBI in Australian rehabilitation, community, home, and school (for children and adolescents) settings

A novel approach to the issue of physical inactivity in older age

Objective: Well-designed exercise can prevent falls in older people but previous research indicates that promoting general physical activity may increase falls. This study aimed to evaluate uptake and adherence to a physical activity promotion and fall prevention intervention among community-dwelling people aged 60+ years. Methods: This was a process evaluation of intervention group data from an ongoing randomised controlled trial. Participants were 38 Australian community-dwelling older people assigned to intervention group who had completed 3 months of a physical activity and fall prevention intervention. Study measures included baseline daily step count assessed by Actigraph accelerometers, 12 week follow-up step count assessed by Fitbit pedometers and rating of participant engagement with the health coaching intervention. Results: 35 participants remained in the study at week 12 and were analysed. Mean daily steps significantly increased in week 12 compared with steps at baseline (change in mean = 1101 steps, 95% CI: 285–1917, p = 0.01). Health coaching engagement was rated as high for 19 people (54%), medium for 12 (34%) and low for 4 people (12%). All participants used the Fitbit to provide feedback about daily activity. Conclusion: The excellent intervention compliance and promising physical activity results demonstrate the acceptability and feasibility of this novel intervention