Combining self-help and professional help to minimize barriers to physical activity in persons with multiple sclerosis: a trial of the "Blue Prescription" approach in New Zealand

Flipping the ICF: Exploring the Interplay of Theory and the Lived Experience to Reconsider Physical Activity in Community-Dwelling People With Multiple Sclerosis

People with multiple sclerosis (MS) report lower physical activity levels and are at a risk of becoming sedentary. As such, they are at an increased risk of developing secondary health conditions associated with inactivity. This is of major public health concern. Attempts to improve the physical activity levels in people with MS remain a challenge for health professionals. One key reason might be the lack of understanding about the meanings people with MS ascribe to exercise and physical activity. This paper draws on the key findings of a three-phased interconnected mixed methods sequential explanatory study to examine the meanings of exercise and physical activity from the perspectives of people with MS and health professionals. Phase 1 used a four-round Delphi questionnaire to scope and determine the consensus of priorities for exercise and physical activity and the reasons why people with MS (N = 101) engaged in these activities. Phase 2 used face-to-face semistructured interviews of people with MS (N = 16) to explore the meanings ascribed to exercise and physical activity. Phase 3 explored the perceptions of physiotherapists (N = 14) about exercise and physical activity using three focus groups. Using the International Classification of Functioning, Disability, and Health as a theoretical framework to underpin this study, the authors discuss the key factors, for example, emphasis on the contextual factors, that drive decision making around exercise and physical activity participation in people with MS and explore the clinical implications to health professionals.

Shifting mindsets: a realist synthesis of evidence from self-management support training

CONTEXT

Accompanying the growing expectation of patient self-management is the need to ensure health care professionals (HCPs) have the required attitudes and skills to provide effective self-management support (SMS). Results from existing training interventions for HCPs in SMS have been mixed and the evidence base is weaker for certain settings, including supporting people with progressive neurological conditions (PNCs). We set out to understand how training operates, and to identify barriers and facilitators to training designed to support shifts in attitudes amongst HCPs.

METHODS

We undertook a realist literature synthesis focused on: (i) the influence of how HCPs, teams and organisations view and adopt self-management; and (ii) how SMS needs to be tailored for people with PNCs. A traditional database search strategy was used alongside citation tracking, grey literature searching and stakeholder recommendations. We supplemented PNC-specific literature with data from other long-term conditions. Key informant interviews and stakeholder advisory group meetings informed the synthesis process. Realist context-mechanism-outcome configurations were generated and mapped onto the stages described in Mezirow's Transformative Learning Theory.

RESULTS

Forty-four original articles were included (19 relating to PNCs), from which seven refined theories were developed. The theories identified important training elements (evidence provision, building skills and confidence, facilitating reflection and generating empathy). The significant influence of workplace factors as possible barriers or facilitators was highlighted. Embracing SMS often required challenging traditional professional role boundaries.

CONCLUSION

The integration of SMS into routine care is not an automatic outcome from training. A transformative learning process is often required to trigger the necessary mindset shift. Training should focus on how individual HCPs define and value SMS and how their work context (patient group and organisational constraints) influences this process. Proactively addressing potential contextual barriers may facilitate implementation. These findings could be applied to other types of training designed to shift attitudes amongst HCPs.

From Disease to Health: Physical Therapy Health Promotion Practices for Secondary Prevention in Adult and Pediatric Neurologic Populations

BACKGROUND AND PURPOSE

Over the last decade there has been a substantial increase in efforts to better understand how targeted physical activity and exercise interventions can be used to minimize secondary consequences arising from neurological damage in both adult and pediatric populations. This article offers an overview of contemporary research that addresses mediators of functional and neuroplastic adaptations associated with physical activity and exercise. We emphasize the important role that physical therapists can play to increase participation and improve well-being in adults and children with neurological disorders. We further highlight potential strategies to foster translation of evidence-based findings for use by clinicians and consumers.

SUMMARY OF KEY POINTS

Engagement in physical activity can serve as a powerful promoter of health and well-being in adults and youth with neurologic disease, and has the potential to alter the course of disease processes. Physical therapists can play a key role in promoting fitness and wellness by encouraging active living, providing early diagnosis of disease and prescribing targeted activity interventions to improve fitness and participation, and helping individuals overcome personal and environmental barriers to an active lifestyle.

RECOMMENDATIONS FOR CLINICAL PRACTICE

Physical therapists must adopt a model of rehabilitation that emphasizes secondary prevention in adults and youth with neurologic diseases. Physical therapists have a unique role in developing forward-thinking approaches in using innovative health and wellness strategies to promote positive changes in activity and exercise behaviors.

Participant experiences and perceptions of physical activity-enhancing interventions for people with physical impairments and mobility limitations: a meta-synthesis of qualitative research evidence

Disabled people face multiple personal, environmental and social barriers that interfere with leading a physically active lifestyle. Thus, there is an urgent need for behaviour change interventions to increase physical activity (PA) by specifically addressing the situations of disabled people, and barriers to participation. This original meta-synthesis of qualitative research was undertaken to explore participants' experiences and perceptions of PA-enhancing interventions for adults with physical impairments resulting in mobility limitations. Published articles were identified through a rigorous systematic search. Based on the inclusion/exclusion criteria, 10 articles were included for review. Following a critical appraisal of the articles, methods of thematic synthesis were drawn upon to generate overarching concepts through interpretation and conceptual synthesis. Seven interrelated concepts were constructed representing both components and outcomes of the interventions. These were (i) Diversity of interventions; (ii) Importance of communication; (iii) Need for social support; (iv) Behavioural strategies; (v) Gaining knowledge; (vi) Re-framing thoughts about exercise and the self and (vii) Health and well-being. The results revealed that a combination of informational, social and behavioural interventions is perceived as crucial for PA initiation and maintenance. Furthermore, key elements of effective intervention design and implications for policies and practices to increase PA participation are proposed.

A New Framework and Practice Center for Adapting, Translating, and Scaling Evidence-Based Health/Wellness Programs for People With Disabilities

Supporting the transition of people with newly acquired and existing disability from rehabilitation into community-based health/wellness programs, services, and venues requires rehabilitation professionals to build evidence by capturing successful strategies at the local level, finding innovative ways to translate successful practices to other communities, and ultimately to upgrade and maintain their applicability and currency for future scale-up. This article describes a knowledge-to-practice framework housed in a national resource and practice center that will support therapists and other rehabilitation professionals in building and maintaining a database of successful health/wellness guidelines, recommendations, and adaptations to promote community health inclusion for people with disabilities. A framework was developed in the National Center on Health, Physical Activity and Disability (NCHPAD) to systematically build and advance the evidence base of health/wellness programs, practices, and services applicable to people with disabilities. N-KATS (NCHPAD Knowledge Adaptation, Translation, and Scale-up) has 4 sequencing strategies: strategy 1-new evidence- and practice-based knowledge is collected and adapted for the local context (ie, community); strategy 2-customized resources are effectively disseminated to key stakeholders including rehabilitation professionals with appropriate training tools; strategy 3-NCHPAD staff serve as facilitators assisting key stakeholders in implementing recommendations; strategy 4-successful elements of practice (eg, guideline, recommendation, adaptation) are archived and scaled to other rehabilitation providers. The N-KATS framework supports the role of rehabilitation professionals as knowledge brokers, facilitators, and users in a collaborative, dynamic structure that will grow and be sustained over time through the NCHPAD.Video abstract available for additional insights from the authors (see Video, Supplemental Digital Content 1, http://links.lww.com/JNPT/A130).

Development and Delivery of a Physical Activity Intervention for People With Huntington Disease: Facilitating Translation to Clinical Practice

Supplemental Digital Content is Available in the Text.

Background and Purpose:

We studied the development and delivery of a 14-week complex physical activity intervention for people with Huntington disease, where detailed information about the intervention was fully embedded in the trial design process.

Methods:

Intervention Development: The intervention was developed through a series of focus groups. The findings from the focus groups informed the development of a logic model for the physical activity intervention that was broadly consistent with the framework of self-determination theory. Intervention Delivery: Key components underpinning the delivery of the intervention were implemented including a defined coach training program and intervention fidelity assessment methods. Training of coaches (physical therapists, occupational therapists, research nurses, and exercise trainers) was delivered via group and 1:1 training sessions using a detailed coach's manual, and with ongoing support via video calls, and e-mail communication as needed. Detailed documentation was provided to determine costs of intervention development and coach training.

Results:

Intervention delivery coaches at 8 sites across the United Kingdom participated in the face-to-face training. Self-report checklists completed by each of the coaches indicated that all components of the intervention were delivered in accordance with the protocol. Mean (standard deviation) intervention fidelity scores (n = 15), as measured using a purpose-developed rating scale, was 11 (2.4) (out of 16 possible points). Coaches' perceptions of intervention fidelity were similarly high. The total cost of developing the intervention and providing training was £30,773 ($47,042 USD).

Discussion and Conclusions:

An important consideration in promoting translation of clinical research into practice is the ability to convey the detailed components of how the intervention was delivered to facilitate replication if the results are favorable. This report presents an illustrative example of a physical activity intervention, including the development and the training required to deliver it. This approach has the potential to facilitate reproducibility, evidence synthesis, and implementation in clinical practice.

Video Abstract available for more insights from the authors (see Supplemental Digital Content 1, http://links.lww.com/JNPT/A122).

Blue Prescription: A single-subject design intervention to enable physical activity for people with stroke

Background/Aims:

Adherence to long-term physical activity is low in stroke survivors despite evidence supporting the benefits of regular physical activity on health and wellbeing. The aims of this single-subject design study were to: i) determine whether Blue Prescription, a physiotherapy approach to increase physical activity, enabled adults with chronic stroke living in the community to engage in a physical activity of their choice for three months; ii) explore the benefits of the Blue Prescription intervention on self-reported quality of life, physical function and self-efficacy.

Methods:

A multiple-participant, two-phase (baseline followed by treatment) single-subject design study was repeated with adults (n=5) with chronic stroke. The time of baseline testing, follow-up outcome measurement and Blue Prescription visits were randomly assigned to each participant. Due to randomisation, the baseline phase spanned four to six weeks. The intervention phase had a duration of three months. Engagement in physical activity was recorded in a physical activity diary. Secondary outcome measures used included the European Quality of Life Scale, Stroke Impact Scale and Stroke Self-Efficacy Questionnaire, which were completed at 15 random intervals over four and a half months.

Results:

All five participants maintained engagement in their chosen activity for three months. Participant 2 mostly showed significant improvements in the secondary outcome measures (p<0.05), while participant 4 showed a significant decline in the European Quality of Life Scale (p<0.05). No other significant results were found, although observable trends in secondary outcome measure scores were present.

Conclusions:

Blue Prescription appears feasible for engaging chronic stroke survivors in physical activity, although its effects on quality of life, physical function and self-efficacy are variable.

Attitudes and barriers to exercise in adults with type 1 diabetes (T1DM) and how best to address them: a qualitative study

Background

Regular physical activity has recognised health benefits for people with T1DM. However a significant proportion of them do not undertake the recommended levels of activity. Whilst questionnaire-based studies have examined barriers to exercise in people with T1DM, a formal qualitative analysis of these barriers has not been undertaken. Our aims were to explore attitudes, barriers and facilitators to exercise in patients with T1DM.

Methodology

A purposeful sample of long standing T1DM patients were invited to participate in this qualitative study. Twenty-six adults were interviewed using a semi-structured interview schedule to determine their level of exercise and barriers to initiation and maintenance of an exercise programme.

Principal findings

Six main barriers to exercise were identified: lack of time and work related factors; access to facilities; lack of motivation; embarrassment and body image; weather; and diabetes specific barriers (low levels of knowledge about managing diabetes and its complications around exercise). Four motivators to exercise were identified: physical benefits from exercise; improvements in body image; enjoyment and the social interaction of exercising at gym or in groups. Three facilitators to exercise were identified: free or reduced admission to gyms and pools, help with time management, and advice and encouragement around managing diabetes for exercise.

Significance

Many of the barriers to exercise in people with T1DM are shared with the non-diabetic population. The primary difference is the requirement for education about the effect of exercise on diabetes control and its complications. There was a preference for support to be given on a one to one basis rather than in a group environment. This suggests that with the addition of the above educational requirements, one to one techniques that have been successful in increasing activity in patients with other chronic disease and the general public should be successful in increasing activity in patients with T1DM.