Health care communication issues in multiple sclerosis: an interpretive description

Resilience Across the Life Course for Women Experiencing Intimate Partner Violence

This study employed a life course perspective to explore the resilience of Canadian women of various ages who had experienced intimate partner violence (IPV). Interpretive description was used to analyze 22 in-depth, semi-structured interview transcripts with women who ranged in age from >19 to 60+ years. Results revealed that developmental age affected service accessibility and effectiveness, historical age shaped abuse normalization, and social age presented barriers and facilitators to women's resilience. This study highlighted the central role of resilience for women of all ages who have experienced IPV and emphasized the need for accessible, effective, and supportive services.

Accommodating Students with Disabilities: Fieldwork Educators' Experiences

Background. Fieldwork is an essential part of experiential learning in occupational therapy education. Fieldwork educators identify limits on reasonable accommodation and difficulty implementing disability-related accommodations. Student occupational therapists with disabilities report discrimination from within the profession, including inflexible fieldwork environments. Purpose. To understand the experiences of occupational therapy fieldwork educators in Canada in accommodating students with disabilities and to develop action-oriented practice recommendations. Method. In this interpretive description study, we interviewed 11 fieldwork educators about their experiences accommodating students with disabilities. Interviews were recorded, transcribed, and analyzed using a constant comparative approach. Findings. Educators emphasized a meta-theme of "Learning" when asked about disability-related accommodations. Three subthemes about student learning emerged: 1. Educators focused on "Student Learning in Preparation for Professional Practice" rather than their fieldwork setting only; 2. Educators were "Using Occupational Therapy Skills for Student Learning" in fieldwork; and 3. Educators recognized that their professional and personal "Context Influences Student Learning." Conclusion. Fieldwork educators can work with students to align their accommodations with required learning outcomes for professional practice and use their occupational therapy skills to assist with implementation. Fieldwork educators require time and other supports to work effectively with all students.

Knowledge exchange sessions on primary health care research findings in public libraries: A qualitative study with citizens in Quebec

Little is known about knowledge transfer with the public. We explored how citizens, physicians, and communication specialists understand knowledge transfer in public spaces such as libraries. The initial study aimed at evaluating the scaling up of a program on disseminating research findings on potentially inappropriate medication. Twenty-two citizen workshops were offered by 16 physicians and facilitated by 6 communication specialists to 322 citizens in libraries during spring 2019. We did secondary analysis using the recorded workshop discussions to explore the type of knowledge participants used. Participants described four kinds of knowledge: biomedical, sociocultural beliefs, value-based reasoning, and institutional knowledge. Biomedical knowledge included scientific evidence, research methods, clinical guidelines, and access to research outcomes. Participants discussed beliefs in scientific progress, innovative clinical practices, and doctors' behaviours. Participants discussed values related to reliability, transparency, respect for patient autonomy and participation in decision-making. All categories of participants used these four kinds of knowledge. However, their descriptions varied particularly for biomedical knowledge which was described by physician-speakers and communication specialists-facilitators as scientific evidence, epidemiological and clinical practice guidelines, and pathophysiological theories. Communication specialists-facilitators also described scientific journalistic sources and scientific journalistic reports as proxies of scientific evidence. Citizens described biomedical knowledge in terms of knowledge to make informed decisions. These findings offer insights for future scientific knowledge exchange interventions with the public.

Exploring impairments and allied health professional utilisation in people with myasthenia gravis: A cross-sectional study

This study aimed to explore how people with myasthenia gravis experience impairments in vision, dizziness, hearing, and fatigue, and how these relate to balance confidence, community participation, and health-related quality of life. Additionally, this study investigated the utilisation and perception of the allied health role in managing these impairments in the Australian context. Visual and hearing impairments, along with fatigue, were found to be correlated with health-related quality of life and community participation to varying degrees, while visual impairment and dizziness were correlated with balance confidence. Perception and utilisation of allied health professionals was variable; common barriers to better utilisation included participant perception of clinicians having poor knowledge around myasthenia gravis, previous poor experiences with clinicians, uncertainty about the clinicians' role, and lack of awareness that symptoms were associated with myasthenia gravis. Further research exploring clinicians' knowledge of myasthenia gravis is recommended, along with education for people with the disease about symptoms associated and how to appropriately access care.

Patient and Provider Recommendations for Improved Telemedicine User Experience in Primary Care: A Multi-Center Qualitative Study

OBJECTIVE

The purpose of this study was to explore telemedicine use and obtain actionable recommendations to improve telemedicine user experience from a diverse group of patients and providers.

METHODS

We interviewed adult patients and primary care providers (PCPs) across three National Patient-Centered Clinical Research Network (PCORnet) sites in New York City, North Carolina, and Florida. Both patients and providers could participate via phone or videoconferencing; patients could complete the interview in English or Spanish. Spanish interviews were conducted by a member of the research team who spoke Spanish fluently. Interviews were audio-recorded, transcribed verbatim, and when necessary, professionally translated.

RESULTS

We interviewed 21 PCPs and 65 patients between March and October 2021. We found that patients' and providers' perspectives on ways to improve the telemedicine experience focused on three recommendation themes: (1) expectations of care provided via telemedicine, (2) innovations to support usability, and (3) alleviation of physician burden. Key recommendations were related to expectations regarding (1) care provided, for example, adding educational content for the patients, and clarity about long-term payment models; (2) support innovation to improve telemedicine usability, for example, providing patients with remote monitoring devices, integrating in-home testing and nursing evaluation; (3) and reduce physician burden, for example, virtual rooming, reimbursement of time spent outside of the telemedicine encounter.

DISCUSSION

Primary care patients and providers see merit in telemedicine. However, both groups recommended novel ways to improve the quality of care and user experience. Findings from this article suggest that policymakers would be best served by addressing current gaps in patient digital literacy by creating technical support strategies, and gaps in telemedicine reimbursement to present an equitable form of payment.

Consumer involvement in research - parent perceptions of partnership in cerebral palsy research: a qualitative study

PURPOSE

Identify perceptions of parents and caregivers of children with cerebral palsy about being consumer research partners and identify strategies to inform involvement of parents in cerebral palsy research.

MATERIALS AND METHODS

Twenty-two parents in New South Wales and Victoria (Australia) participated in this qualitative study. Seven interviews and three focus groups were completed. Interpretive description guided data analysis. Methodological rigor was enhanced through involving two consumer investigators in the research team, member checking, and multiple researchers completing data analysis and theme generation.

RESULTS

Participants identified a range of factors that may influence their involvement in research partner roles. Main topics emerging from the data included "Research Is Better with Parents" and "Parents Benefit from Being Research Partners." A third, "Parents as Research Partners," contained the themes "Flexible Involvement," "Starting Partnerships," and "Building and Sustaining Partnerships."

CONCLUSION

This study has provided a rich insight into how parents perceive and describe engaging as research partners. Parent-identified guidance will inform future partnerships aiming to enhance the quality of cerebral palsy research and outcomes for people with cerebral palsy and their families. The involvement of consumer investigators in this study was considered valuable for enhancing the quality and applicability of the research.IMPLICATIONS FOR REHABILITATIONParents believed that parent partnership in research has benefits for the research and for the consumers involved.Parents provided guidance about the importance of starting, building and sustaining relationships in involving parents as research partners.Understanding the parent context, investing in relationships and acknowledgement of, and recognition for, contributions were considered important for building and sustaining effective partnerships.Flexible approaches to supporting parents as research partners was considered necessary for effective partnership.

Implementing an exercise oncology model to reach rural and remote individuals living with and beyond cancer: a hybrid effectiveness-implementation protocol for project EXCEL (EXercise for Cancer to Enhance Living Well)

INTRODUCTION

Individuals living with and beyond cancer from rural and remote areas lack accessibility to supportive cancer care resources compared with those in urban areas. Exercise is an evidence-based intervention that is a safe and effective supportive cancer care resource, improving physical fitness and function, well-being and quality of life. Thus, it is imperative that exercise oncology programs are accessible for all individuals living with cancer, regardless of geographical location. To improve accessibility to exercise oncology programs, we have designed the EXercise for Cancer to Enhance Living Well (EXCEL) study.

METHODS AND ANALYSIS

EXCEL is a hybrid effectiveness-implementation study. Exercise-based oncology knowledge from clinical exercise physiologists supports healthcare professionals and community-based qualified exercise professionals, facilitating exercise oncology education, referrals and programming. Recruitment began in September 2020 and will continue for 5 years with the goal to enroll ~1500 individuals from rural and remote areas. All tumour groups are eligible, and participants must be 18 years or older. Participants take part in a 12-week multimodal progressive exercise intervention currently being delivered online. The reach, effectiveness, adoption, implementation, and maintenance (RE-AIM) framework is used to determine the impact of EXCEL at participant and institutional levels. Physical activity, functional fitness and patient-reported outcomes are assessed at baseline and 12-week time points of the EXCEL exercise intervention.

ETHICS AND DISSEMINATION

The study was approved by the Health Research Ethics Board of Alberta. Our team will disseminate EXCEL information through quarterly newsletters to stakeholders, including participants, qualified exercise professionals, healthcare professionals and community networks. Ongoing outreach includes community presentations (eg, support groups, fitness companies) that provide study updates and exercise resources. Our team will publish manuscripts and present at conferences on EXCEL's ongoing implementation efforts across the 5-year study.

TRIAL REGISTRATION NUMBER

NCT04478851.

Cut-off evaluation of intrathecal oligoclonal bands of IgM in relapsing-remitting multiple sclerosis; a retrospective study

BACKGROUND

Multiple sclerosis (MS) is the most common demyelinating disease and characterized by immunological changes. Oligoclonal bands of IgG in CSF not seen in corresponding serum have been used for many years as part of the diagnostic criteria. However, considerably less is known about the role of IgM, despite several studies showing marked changes to IgM metabolism in MS. Bands of oligoclonal IgM (o-IgM) are more difficult to determine than oligoclonal IgG, thus limiting their study, and there is no agreement as to whether o-IgM in CSF should be part of the clinical work-up of MS. Nevertheless, there is a possibility that such bands might provide a prognostic marker if a cut-off could be established.

MATERIALS AND METHODS

In this pilot study, paired samples of CSF and serum from 37 patients with relapsing-remitting MS (RRMS) and 57 controls with no subsequent signs of neurological disease were analysed for total IgM, and bands of o-IgM were visualised by isoelectric focusing and western blot. Patient records were used to compare mean changes in Expanded Disability Status Scale (EDSS) over a maximum of 17 years.

RESULTS

None of the controls displayed extra o-IgM in CSF compared to corresponding serum, whereas additional o-IgM band(s) were seen in CSF in most patient samples (70%). After five years of disease, there was a significant difference in the EDSS between patients with no extra o-IgM compared to patients with at least one extra o-IgM band. This difference increased over time. If a cut-off of two or more extra bands of o-IgM in CSF was applied, this difference was not found.

CONCLUSION

These exploratory data suggest that o-IgM support the prognostic potential for RRMS, and though tentative, the occurrence of any bands of o-IgM restricted to CSF seems to result in poorer prognosis. Despite the small size of the groups, the data infer that the absence of CSF-restricted o-IgM is good news for the patient. The results need to be reproduced in a more comprehensive study.

Communication between persons with multiple sclerosis and their health care providers: A scoping review

OBJECTIVES

This study undertakes a scoping review of research about communication between persons with MS and their health care providers.

DESIGN

PubMed, PsycInfo, Communication Source, Socindex, Sociological Abstracts, Cinahl, and Proquest Dissertations and Theses were used to identify studies since each database's inception. Research team members engaged in study selection, coding for communication issues, and data extraction for descriptive information.

RESULTS

Of the 419 empirical articles identified, 175 were included. Codes represented all elements of ecological and pathway models, emphasizing emerging technologies for facilitating communication, uncertainty and anxiety for persons with MS, and communication issues surrounding diagnosis, information seeking, and decision making.

CONCLUSION

This review synthesizes and organizes influences on communication, communication processes, and health outcomes of communication for persons with MS and their providers. Findings extend the ecological model with illness context and the pathway model with communication breakdowns and provider outcomes.

PRACTICE IMPLICATIONS

Health care providers should consider the complexity of communication when interacting with persons with MS, including the larger context in which it occurs, communication processes and their purposes, and short-term and long-term consequences of interactions. Ecological and pathway models can be frameworks for developing educational materials, as they succinctly capture key communication issues and outcomes.

Riding on resilience: impacts of the COVID-19 pandemic on women experiencing intimate partner violence

The COVID-19 pandemic and resultant public health measures, although helpful in reducing the spread of the disease, have disproportionately impacted women experiencing intimate partner violence (IPV). Despite these adverse circumstances, women continue to show resilience. Although difficult to define, resilience can be conceptualized as a dynamic process in which psychosocial and environmental factors interact to enable an individual to survive, grow, and thrive despite exposure to adversity. This research identifies facilitators and gaps in supports to promoting resilience among urban and rural women experiencing intimate partner violence (IPV) during the COVID-19 pandemic, via an online survey (n = 95) and interviews (n = 19). T-tests, Wilcoxon rank sum tests, and interpretive description were utilized for analyses. Almost 41% of participants experienced an increase in abuse during COVID-19, and resilience significantly decreased during COVID-19 (t(44) = 2.91, p = 0.006). Qualitatively, four parent themes (coercive control, social services, resilience, and future) and seven sub-themes emerged. Changes are needed in accessibility and delivery of support services for women experiencing IPV during COVID-19, and future pandemics.

“I wanna live and not think about the future” what place for advance care planning for people living with severe multiple sclerosis and their families? A qualitative study

Background

Little is known about how people with multiple sclerosis (MS) and their families comprehend advance care planning (ACP) and its relevance in their lives.

Aim

To explore under what situations, with whom, how, and why do people with MS and their families engage in ACP.

Methods

We conducted a qualitative study comprising interviews with people living with MS and their families followed by an ethical discussion group with five health professionals representing specialties working with people affected by MS and their families. Twenty-seven people with MS and 17 family members were interviewed between June 2019 and March 2020. Interviews and the ethical discussion group were audio-recorded and transcribed verbatim. Data were analysed using the framework approach.

Results

Participants’ narratives focused on three major themes: (i) planning for an uncertain future; (ii) perceived obstacles to engaging in ACP that included uncertainty concerning MS disease progression, negative previous experiences of ACP discussions and prioritising symptom management over future planning; (iii) Preferences for engagement in ACP included a trusting relationship with a health professional and that information then be shared across services. Health professionals’ accounts from the ethical discussion group departed from viewing ACP as a formal document to that of an ongoing process of seeking preferences and values. They voiced similar concerns to people with MS about uncertainty and when to initiate ACP-related discussions. Some shared concerns of their lack of confidence when having these discussions.

Conclusion

These findings support the need for a whole system strategic approach where information about the potential benefits of ACP in all its forms can be shared with people with MS. Moreover, they highlight the need for health professionals to be skilled and trained in engaging in ACP discussions and where information is contemporaneously and seamlessly shared across services.

ACE-Neuro: A tailored exercise oncology program for neuro-oncology patients – Study protocol

Background

Methods

Conclusion

•

Neuro-oncology patients require access to tailored exercise oncology programs.

•

The feasibility of a tailored neuro-oncology exercise program is being examined.

•

Patients are referred and triaged via the electronic medical record.

•

Intervention includes tailored exercise, an activity tracker, and health coaching.

•

This work supports the implementation of exercise within neuro-oncology care.

Managing communication changes in persons with multiple sclerosis: Findings from qualitative focus groups

BACKGROUND

There is growing recognition that communication can be affected in multiple sclerosis (MS) and can negatively impact relationships, employment and psychological well-being. Some persons with MS (PwMS) implement strategies to facilitate their communication; however, some do not. Most PwMS who report communication changes do not engage with speech-language pathology (SLP) services. This raises concerns that a large portion of communication changes associated with MS go under-recognized and unmanaged. Little is known about what PwMS want and need to facilitate effective communication.

AIM

To explore what PwMS want and need to better manage their communication changes.

METHODS & PROCEDURES

Three focus groups were conducted online using Zoom, with a total of 12 PwMS. Participants were an opportunistic sample of PwMS within Australia recruited via advertisements distributed to various MS organizations and clinics. Data were transcribed verbatim and analysed using thematic content analysis to provide a qualitative analysis of the data.

OUTCOMES & RESULTS

Two main themes emerged: (1) accessible knowledge and a holistic approach; and (2) partnerships. Specifically, the identified wants and needs of participants included: (1) assessment; (2) information; (3) raising awareness; (4) support groups; (5) a whole-person approach to intervention; (6) geographically and economically accessible and navigable services; (7) effective patient-physician interactions; and (8) a multidisciplinary team-based approach (e.g., SLP, psychology, neuropsychology, occupational therapy).

CONCLUSIONS & IMPLICATIONS

This study identified a wide range of unmet wants and needs of PwMS related to communication changes. Participants wanted improved collaborative partnerships with healthcare professionals to better manage their communication changes. For example, healthcare professionals could ask PwMS about potential communication changes, provide education and make appropriate referrals. Education and information provision could focus on communication changes in MS, factors that trigger or exacerbate communication changes, impacts, self-management strategies, and available supports and services. Specific implications for clinical practice and future research are suggested in this paper, including ideas for patient education materials and content, suggestions for communication-specific screening and information that could be shared in patient-physician interactions, the development of guidelines to systematically screen, assess, manage and monitor communication changes in MS, and the design of evidence-based communication interventions for this clinical population. The results from this study can be used to guide the design of supports and services to help PwMS better manage communication changes, with the aim to reduce the negative impacts.

WHAT THIS PAPER ADDS

What is already known on this subject PwMS can experience communication changes across a range of domains, including speech, voice, fluency, expressive and receptive language, and cognitive-linguistic functions. These changes can have profound and far-reaching negative impacts on educational and vocational outcomes, social participation, relationships, psychological well-being, and quality of life. Most PwMS who report communication changes do not engage with SLP services. There has been little research exploring what PwMS want and need to help manage their communication changes. What this paper adds to the existing knowledge This research is the first study of its kind that sets out specifically to explore what PwMS want and need to better manage their communication changes. This study increases our understanding of, and provides valuable insights into, the specific types of supports and services PwMS desire to access, and the partnerships and kinds of interactions PwMS dream of having with healthcare professionals to manage these changes. This information can facilitate the development of future interventions to manage communication changes in MS. What are the potential or actual clinical implications of this work? PwMS wanted healthcare professionals to ask about potential communication changes, provide education and make appropriate referrals. When providing education and information on communication changes in MS, healthcare professionals should focus on covering symptoms, triggers, impacts, self-management strategies, and available supports and services. There is a timely need to develop guidelines and interventions to manage communication changes in MS to reduce their negative impacts.

Training physicians in providing complex information to patients with multiple sclerosis: a randomised controlled trial

OBJECTIVE

To evaluate the effect of a specific communication training for neurologists on how to provide complex information about treatment options to patients with multiple sclerosis (MS).

DESIGN

Single-centre, single-blind, randomised controlled trial.

SETTING

One university hospital in Norway.

PARTICIPANTS

Thirty-four patients with early-stage MS.

INTERVENTION

A 3-hour training for neurologists on how to provide complex information about MS escalation therapy.

MAIN OUTCOME MEASURES

Patient recall rate, measured with a reliable counting system of provided and recalled information about drugs.

SECONDARY OUTCOME MEASURES

Number of information units provided by the physicians. Effects on patient involvement through questionnaires.

METHODS

Patients with MS were instructed to imagine a disease development and were randomised and blinded to meet a physician to receive information on escalation therapy, before or after the physician had participated in a 3-hour training on how to provide complex information. Consultations and immediate patient recall interviews were video-recorded and transcribed verbatim.

RESULTS

Patient recall rate was 0.37 (SD=0.10) pre-intervention and 0.39 (SD=0.10) post-intervention. The effect of the intervention on recall rate predicted with a general linear model covariate was not significant (coefficient parameter 0.07 (SE 0.04, 95% CI (-0.01 to 0.15)), p=0.099).The physicians tended to provide significantly fewer information units after the training, with an average of 91.0 (SD=30.3) pre-intervention and 76.5 (SD=17.4) post-intervention; coefficient parameter -0.09 (SE 0.02, 95% CI (-0.13 to -0.05)), p<0.001. There was a significant negative association between the amount of provided information and the recall rate (coefficient parameter -0.29 (SE 0.05, 95% CI (-0.39 to -0.18)), p<0.001). We found no significant effects on patient involvement using the Control Preference Scale, Collaborate or Four Habits Patient Questionnaire.

CONCLUSION

A brief course for physicians on providing complex information reduced the amount of information provided, but did not improve patient recall rate.

TRIAL REGISTRATION NUMBER

ISRCTN42739508.

Women’s experiences of navigating chronic pain within the context of living with an episodic disability

Objectives:

Of the 6.2 million Canadians aged 15 years or older who live with disability, 61% have disabilities that are not static or continuous. These dynamic conditions are known as episodic disabilities and many disproportionately experienced by women. Chronic pain is also a common feature associated with many episodic disabilities. The purpose of this article is to explore the experience of chronic pain for women living with episodic disabilities.

Methods:

This qualitative study draws on the tenets of interpretive description. Thirty women, with one or more episodic disabilities and chronic pain, participated in a semi-structured interview and answered questions about their chronic pain levels, using Von Korff et al.’s graded chronic pain scale.

Results:

Women experienced gendered treatment within the healthcare system and reported that they were frequently dismissed by their healthcare providers, most often physicians. Healthcare professionals’ practices around pain assessment were another common challenge for women. Women who were able to access financial support from government disability programs were more likely to access allied health professionals. Many of the holistic strategies that women researched and used to treat chronic pain were self-enacted. While diet, exercise, and other self-care activities are general health promotion strategies for all, they were seen as essential aspects of living that helped women have control over chronic pain and modifying the course of their episodic disability.

Conclusion:

Living with chronic pain and an episodic disability is complex. The findings of this study present the impact that gendered treatment in the healthcare system has on women who live with an episodic disability and experience chronic pain. It is evident that the current system did not meet the needs of the women in our study and system changes could result in better experiences, more disclosure of alternative therapies, and increase women’s agency in their care.

An exploratory study regarding communication facilitators and barriers reported by a cohort of multiple sclerosis (MS) community members from the international massive open online course 'Understanding MS'

BACKGROUND

Effective communication is essential for high-quality multiple sclerosis (MS)-related healthcare, but significant knowledge and practice gaps remain in this area. The aim of this study was to explore facilitators and barriers of communication about MS reported by members of the MS community.

METHODS

We conducted an exploratory mixed method study analysing self-reported facilitators and barriers to communication among MS community members participating in a free international online course about MS (called Understanding MS) who commented on an optional discussion board. We quantitatively compared commenters with course participants who did not comment and, among commenters, compared health information consumers (people with MS, caregivers) and suppliers (healthcare providers, service providers, researchers) using chi square and t-tests. We evaluated free text discussion board responses for emergent themes, comparing and contrasting consumer and supplier responses.

RESULTS

We found that the sociodemographic characteristics of commenters (n = 262) were similar to course participants overall including age, sex and MS community role. However, among commenters, consumers (n = 152) were about 9 years older than suppliers (n = 57) on average (mean age consumers 52.9 years; suppliers 44.0 years p<0.001), and were less likely to have a university degree (p = 0.004) or live in Australia (the course host country representing almost 60% of the cohort; p<0.001). Nonetheless, consumers and suppliers listed similar facilitators for communication about MS: honesty, kindness/empathy/compassion, openness, and effective listening. Consumers further prioritized clarity and patience. Consumers were also more likely to list barriers to communication, commonly listing the following barriers: encountering a lack of knowledge about MS, the invisible symptoms of MS, uncertainty about the appropriate amount of communication, and concern about being perceived as complaining and/or burdening others. Finally, consumers also discussed communication as a means to educate others about MS.

CONCLUSIONS

Effective communication remains a challenge in the MS community, particularly between health information suppliers and health information consumers. The results of this exploratory study highlight areas that should be considered when developing communication strategies for MS community members. A larger confirmatory study of MS health information consumers and suppliers that uses focus groups and individual interviews could be conducted to further explore these emerging themes.

Tissue Transglutaminase Expression Associates With Progression of Multiple Sclerosis

Objective

The clinical course of multiple sclerosis (MS) is variable and largely unpredictable pointing to an urgent need for markers to monitor disease activity and progression. Recent evidence revealed that tissue transglutaminase (TG2) is altered in patient-derived monocytes. We hypothesize that blood cell–derived TG2 messenger RNA (mRNA) can potentially be used as biomarker in patients with MS.

Methods

In peripheral blood mononuclear cells (PBMCs) from 151 healthy controls and 161 patients with MS, TG2 mRNA was measured and correlated with clinical and MRI parameters of disease activity (annualized relapse rate, gadolinium-enhanced lesions, and T2 lesion volume) and disease progression (Expanded Disability Status Scale [EDSS], normalized brain volume, and hypointense T1 lesion volume).

Results

PBMC-derived TG2 mRNA levels were significantly associated with disease progression, i.e., worsening of the EDSS over 2 years of follow-up, normalized brain volume, and normalized gray and white matter volume in the total MS patient group at baseline. Of these, in patients with relapsing-remitting MS, TG2 expression was significantly associated with worsening of the EDSS scores over 2 years of follow-up. In the patients with primary progressive (PP) MS, TG2 mRNA levels were significantly associated with EDSS, normalized brain volume, and normalized gray and white matter volume at baseline. In addition, TG2 mRNA associated with T1 hypointense lesion volume in the patients with PP MS at baseline.

Conclusion

PBMC-derived TG2 mRNA levels hold promise as biomarker for disease progression in patients with MS.

Classification of Evidence

This study provides Class II evidence that in patients with MS, PBMC-derived TG2 mRNA levels are associated with disease progression.

Perspectives of children and adolescents with cerebral palsy about involvement as research partners: a qualitative study

PURPOSE

Children and adolescents with cerebral palsy have diverse needs and often engage with healthcare services, including paediatric rehabilitation. Partnering with these children and adolescents on research projects to inform practice has the potential to ensure services continue to remain relevant and appropriate. This study aimed to identify what children and adolescents with cerebral palsy suggest are effective ways for researchers to involve them as partners in research.

MATERIALS AND METHODS

This qualitative study was guided by interpretive description. Children and adolescents with cerebral palsy between 8 and 18 years participated in semi-structured, activity-based focus groups or interviews. Verbatim transcripts were coded and analysed using thematic analysis. One member of the research team was a young woman with cerebral palsy.

RESULTS

Seventeen children and adolescents with cerebral palsy from NSW and Victoria (Australia) were involved. Participants were between 8 and 18 years (mean = 12 years), male (n = 11) and female (n = 6). Analysis identified four nested themes: "insider knowledge", "reasons for involvement", "roles in research" and "facilitating partnership".

CONCLUSION

This study identified perspectives of children and adolescents on their involvement as research partners, and considerations for researchers to facilitate involvement of children and adolescents with cerebral palsy as partners in research.IMPLICATIONS FOR REHABILITATIONThe commitment in healthcare to client-centred practice requires that consumers, including children and young people with cerebral palsy, have opportunities to influence the direction of research which impacts them.Children and young people with cerebral palsy are interested in research partnerships and motivated to be involved in various areas of research.Effective research partnerships with younger populations can be facilitated by researchers acknowledging a child or young person's expertise, and employing strategies relating to open communication, flexibility and support.

Identifying Barriers to and Facilitators of Health Service Access Encountered by Individuals with Multiple Sclerosis

Background

The symptoms of multiple sclerosis (MS) can be diverse, complex, and progressive, creating a need for frequent and long-standing health care services. The purpose of this scoping review was to identify the barriers people with MS encounter when attempting to access multidisciplinary health services and the reported facilitators for better access to health services.

Methods

The MEDLINE, Embase, and CINAHL databases were searched, without date or geographic restrictions, using the following terms: multiple sclerosis, health services accessibility, health care access, health care delivery, and delivery of health care. After screening based on exclusion criteria, 23 articles were included in the final review.

Results

Five main themes were identified as barriers and facilitators to accessing health services: 1) information (information available to people with MS, health care provider knowledge of and familiarity with MS), 2) interactions (interactions between health care providers and people with MS, social networks and support of people with MS, collaboration among health care providers), 3) beliefs and skills (personal values and beliefs, perceived time to travel to and attend appointments, and self-assessment of symptoms and needs of people with MS), 4) practical considerations (wait times, physical barriers, affordability of services), and 5) nature of MS (complexity and unpredictability of disease symptoms).

Conclusions

People with MS and their health care providers may benefit from structured and comprehensive MS-specific education to address barriers to accessing health care services. The education can ultimately facilitate the process of addressing unmet health care needs and contribute to a greater quality of life for people with MS.

A comparison of standard occupational therapy versus early enhanced occupation-based therapy in a medical/surgical intensive care unit: study protocol for a single site feasibility trial (EFFORT-ICU)

BACKGROUND

Admissions to intensive care units (ICUs) are increasing due to an ageing population, and rising incidence of cardiac and respiratory disease. With advances in medical care, more patients are surviving an initial stay in critical care; however, they can experience ongoing health and cognitive limitations that may influence return to baseline function up to a year post-admission. Recent research has focused on the introduction of early rehabilitation within the ICU to reduce long-term physical and cognitive complications. The aim of this study is to explore the feasibility and impact of providing early enhanced occupation-based therapy, including cognitive stimulation and activities of daily living, to patients in intensive care.

METHODS

This study involves a single site randomised-controlled feasibility trial comparing standard occupational therapy care to an early enhanced occupation-based therapy. Thirty mechanically ventilated ICU patients will be recruited and randomly allocated to the intervention or control group. The primary outcome measure is the Functional Independence Measure (FIM), and secondary measures include the Modified Barthel Index (MBI), Montreal Cognitive Assessment (MoCA), grip strength, Hospital Anxiety and Depression Scale (HADS) and Short-Form 36 Health survey (SF-36). Measures will be collected by a blind assessor at discharge from intensive care, hospital discharge and a 90-day follow-up. Daily outcome measures including the Glasgow Coma Scale (GCS), Richmond Agitation and Sedation Scale (RASS) and Confusion Assessment Measure for intensive care units (CAM-ICU) will be taken prior to treatment. Participants in the intervention group will receive daily a maximum of up to 60-min sessions with an occupational therapist involving cognitive and functional activities such as self-care and grooming. At the follow-up, intervention group participants will be interviewed to gain user perspectives of the intervention. Feasibility data including recruitment and retention rates will be summarised descriptively. Parametric tests will compare outcomes between groups. Interview data will be thematically analysed.

DISCUSSION

This trial will provide information about the feasibility of investigating how occupational therapy interventions in ICU influence longer term outcomes. It seeks to inform the design of a phase III multicentre trial of occupational therapy in critical care general medical intensive care units.

TRIAL REGISTRATION

Australia New Zealand Clinical Trials Registry (ANZCTR): ACTRN12618000374268 ; prospectively registered on 13 March 2018/ https://www.anzctr.org.au Trial funding: Metro South Health Research Support Scheme Postgraduate Scholarship.

A realist review of advance care planning for people with multiple sclerosis and their families

Background

Advance care planning (ACP) is reported to improve the quality of outcomes of care among those with life-limiting conditions. However, uptake is low among people living with multiple sclerosis (MS) and little is known about why or how people with MS engage in this process of decision-making.

Aims

To develop and refine an initial theory on engagement in ACP for people with MS and to identify ways to improve its uptake for those who desire it.

Methods

Realist review following published protocol and reporting following Realist and Meta-narrative Evidence Synthesis: Evolving Standards (RAMESES) guidelines. A multi-disciplinary team searched MEDLINE, PsychInfo, CINAHL, Scopus, Web of Science, Embase, Google Scholar in addition to other sources from inception to August 2019. Quantitative or qualitative studies, case reports, and opinion or discussion articles related to ACP and/or end of life discussions in the context of MS were included, as well as one article on physical disability and one on motor neuron disease, that contributed important contextual information. Researchers independently screened abstracts and extracted data from full-text articles. Using abductive and retroductive analysis, each article was examined for evidence to support or refute ‘context, mechanism, and outcome’ (CMO) hypotheses, using the Integrated Behaviour Model to guide theory development. Quality was assessed according to methodological rigour and relevance of evidence. Those studies providing rich descriptions were synthesised using a realist matrix to identify commonalities across CMO configurations.

Results

Of the 4,034 articles identified, 33 articles were included in the synthesis that supported six CMO hypotheses that identified contexts and mechanisms underpinning engagement in ACP for people with MS and included: acceptance of their situation, prior experiences, confidence, empowerment, fear (of being a burden, of death and of dying) and the desire for autonomy. Acceptance of self as a person with a life-limiting illness was imperative as it enabled people with MS to see ACP as pertinent to them. We identified the context of MS—its long, uncertain disease trajectory with periods of stability punctuated by crisis—inhibited triggering of mechanisms. Similarly, the absence of skills and confidence in advanced communication skills among health professionals prevented possibilities for ACP discussions taking place.

Conclusion

Although mechanisms are inhibited by the context of MS, health professionals can facilitate greater uptake of ACP among those people with MS who want it by developing their skills in communication, building trusting relationships, sharing accurate prognostic information and sensitively discussing death and dying.

Giving and receiving a diagnosis of a progressive neurological condition: A scoping review of doctors' and patients' perspectives

OBJECTIVE

Delivering a life changing diagnosis can be a distressing experience for patients and a challenging task for professionals. Diagnosis delivery can be especially difficult for individuals with neurodegenerative diseases such as motor neurone disease (MND), multiple sclerosis (MS) and Parkinson's disease (PD). This review aims to scope the literature on doctors' and patients' perspectives on diagnosis delivery for these conditions in order to enhance our understanding in this area and identify potential research gaps.

METHODS

A scoping review methodology was used, and data were summarised using content analysis.

RESULTS

47 studies fulfilled the inclusion criteria. Studies showed that although patients were generally satisfied with diagnosis delivery, a considerable proportion was still dissatisfied with aspects of the consultation, especially the information and time provided and the doctor's approach. Only six studies addressed doctors' perspectives, which focused more on doctors' practice.

CONCLUSION

There was a significant research gap in professionals' perspectives. The review also found that although basic standards of good practice were being met, a significant proportion of patients were dissatisfied with diagnosis communication.

PRACTICE IMPLICATIONS

Professionals delivering such diagnoses need to assess and respond to patients' information needs, provide time for questions and maintain an empathic attitude.

Is it worth it?: The experiences of persons with multiple sclerosis as they access health care to manage their condition

Background

People with multiple sclerosis (MS) require complex care throughout life. Canadians with MS are high users of health‐care services, yet still report unmet health‐care needs and low satisfaction with services received.

Objective

This study aimed to investigate the health‐care access experiences of Ontarians with MS as they manage their condition.

Design and Participants

Interpretive description guided data collection and analysis. Forty‐eight people living across seven communities participated. Thirty‐eight participated in one of five focus groups; the remaining 10 participated in an individual semi‐structured interview.

Results

Participants described the experience of accessing care as a decisional process, guided by a form of cost‐benefit analysis. The process determined whether seeking conventional health‐care services ‘is worth it’. Most participants felt that the energy and resources required to access the health‐care system outweighed their expected outcomes, based on past experiences. Participants who did not see the benefit of care seeking turned to self‐treatment, use of complementary and alternative services, and engaged in patterns of health‐care avoidance until a crisis arose.

Discussion and Conclusion

Findings suggest that a renewed effort to promote patient‐centred care and a biopsychosocial approach may improve the health‐care access experiences of persons with MS and reduce service avoidance.

Evaluation of a Conceptual Model Regarding Exercise Promotion Through the Patient-Provider Interaction in Multiple Sclerosis: Health Care Provider Perspectives

Nearly 80% of persons with multiple sclerosis (MS) do not engage in sufficient amounts of exercise for managing symptoms and improving quality of life. We have addressed this problem by developing a systematic line of qualitative research targeting the patient-provider interaction for promotion of exercise within comprehensive MS care. This research resulted in a conceptual model that guides health care providers in promoting exercise among persons with MS. The current study involves a final evaluation of the model based on semistructured interviews with 28 MS health care providers. Providers perceived that the model was a strong conceptualization of practice that reflected the MS illness course and supported exercise behavior change, but more steps were required to translate the model from concept into practice, including improved clarity of the model, and the development of practice models. The evaluation yielded a final conceptual model for exercise promotion in MS through the patient-provider interaction.

The unresolved role of the neurologist in providing dietary advice to people with multiple sclerosis

BACKGROUND

People with MS often make dietary changes after diagnosis with the aim of slowing disease progression. Although people with MS commonly use the internet for information on diet and MS, neurologists are their preferred source of information. However, little is known about what dietary advice is provided by neurologists.

OBJECTIVES

To explore the perceptions of neurologists about diet and MS, and to identify the type of dietary advice they provide to their patients with MS.

METHODS

In this exploratory qualitative study, 11 semi-structured interviews were conducted with neurologists in Western Australia. Audio files were transcribed verbatim, and transcripts were thematically analysed using a general inductive approach.

RESULTS

Four themes emerged: 1) juggling the evidence on the role of diet in MS; 2) acknowledging the risks and benefits of specific diets; 3) distancing from the diet 'gurus'; and 4) the unresolved role of the neurologist in providing dietary advice.

CONCLUSION

Neurologists could meet their patients' expectations by providing evidence-based dietary advice, such as promoting the benefits of diets that adhere to national dietary guidelines, and being prepared to explain potential risks of restrictive diets. Information about healthy eating needs to be targeted to people with MS.

"I Don't Like to Make a Big Thing out of It": A Qualitative Interview-Based Study Exploring Factors Affecting Whether Young People Tell or Do Not Tell Their Friends about Their IBD

Inflammatory Bowel Disease (IBD) describes a group of conditions that includes Crohn's disease and ulcerative colitis. Unlike some chronic conditions, to a greater or lesser extent, IBD is hidden from or invisible to others which enables concealment of the condition, especially when stigma is associated with the condition. Concealment or nondisclosure allows a means of identity management. Disclosure of a chronic condition is not a single event, and it is dependent on many factors. There is little literature that specifically addresses stigma and/or disclosure in relation to children and young people with IBD. An in-depth qualitative study was undertaken, framed by Interpretive Description and using interviews, friendship maps, and photographs within a participatory framework. Public and patient involvement and engagement (PPIE) was undertaken throughout (inception to dissemination) the study. Young people aged 14-25 years with IBD who had participated in the survey phase of the larger study self-selected to participate in interviews that focused broadly on friendship and feelings of social connectedness. Data were analysed using an iterative, interpretive approach. Preliminary themes were developed and these were explored further, and then tentative theoretical connections about friendship were developed. One superordinate theme focused on disclosure. Thirty-one young people (16 males, 15 females, mean age 18.7 years; 24 Crohn's, 7 colitis) participated in the interviews (of these, five created friendship maps and six utilised photographs). Three discrete, but interlinked, themes were generated, revealing young people's experiences of disclosure: to tell or not to tell; controlling the flow: the who, when, what, and how of telling; and reactions and responses to telling: anticipated and actual. Decisions about telling friends about having IBD are challenging for many young people. Having control over disclosure is not always possible, and the potential consequences can feel risky. However, most young people had positive experiences of disclosure and gained support from friends and romantic partners. Most young people downplayed the seriousness of their IBD, revealing some facets of their condition, aiming to sustain their self-identity. Only one young person had been given professional support to disclose. Provision of support and opportunities to discuss whether, when, who, and how to tell friends and what the risks and benefits may be is something that could be woven into an ongoing and wider person-centred dialogue between young people and health professionals within routine clinic visits.

Knowledge Is Power, but Is Ignorance Bliss? Optimising Conversations About Disease Progression in Multiple Sclerosis

Communication about multiple sclerosis (MS) disease progression between healthcare professionals (HCPs) and people with MS (PwMS) has historically been considered difficult, and attention to improving it has been neglected. However, a growing number of studies have shown that this is a key area to get right, since negative experiences can affect patient satisfaction, treatment adherence, and clinical outcomes. This article reports on a symposium at the European Charcot Foundation, 2018, led by a panel of leading clinicians and patient experts from MS in the 21st Century, who debated the benefits, drawbacks, and challenges of communicating about disease progression, for both HCPs and PwMS, and potential ways to optimise these discussions. PwMS' preferences and priorities regarding conversations about disease progression vary widely. While the majority want to have these conversations, some will be reluctant and/or emotionally unready. Communication therefore needs to be personalised, and HCPs should always be prepared to have such conversations in an appropriate and sensitive manner. Clinical information can be opaque for PwMS, so HCPs also need to use language that is clear, easily understandable, and patient-friendly. MS in the 21st Century is in the process of developing several resources and programmes to help improve disease progression communication between HCPs and PwMS. FUNDING: Merck KGaA, Darmstadt, Germany. Plain language summary available for this article.

Experiences of adjustment to secondary progressive multiple sclerosis: a meta-ethnographic systematic review

PURPOSE

To provide an overview of the experiences and needs of patients adjusting to life after receiving a diagnosis of secondary progressive multiple sclerosis (SPMS).

METHOD

We conducted a meta-ethnographic synthesis of qualitative studies on the experiences of transition to SPMS, based on a systematic literature search of CINAHL, PsycINFO, Embase, MEDLINE, and Web of Science. Identified studies were quality-appraised using a critical appraisal checklist, and individual findings synthesised inductively.

RESULTS

The synthesis included 12 articles with 144 people with SPMS. Adjusting to SPMS transition encompassed a variety of reactions and coping strategies. Successful adjustment was associated with accepting and adapting coping strategies, and availability of social support and relationships. Clinical services increased uncertainty around adjustment where patients felt clinicians were not transparent with them about their changing diagnosis.

CONCLUSIONS

People adjust to SPMS in different ways, with the success of adjustment influenced by a patient's primary coping mechanism. Coping mechanisms are determined by pre-existing individual differences, alongside engagement with, and quality of, social support networks and activities. Services should ensure that people are provided with informational support about their illness progression, and emotional support concerning coping strategies, social networks, and physical activity, as these are key determinants of successful adjustment.IMPLICATIONS FOR REHABILITATIONAdjusting to secondary progressive multiple sclerosis is a difficult and stressful time for patients.Coping strategies patients use, their support network and their activity levels are key determinants of successful adjustment.Clinicians should be open with patients about their assessment of their changing diagnosis, rather than trying to avoid upsetting the patient by withholding information.Clinical services should be proactive in supporting patients during adjustment with learning positive coping strategies, and maintaining or increasing social relationships and activity levels.

Intrathecal IgM as a Prognostic Marker in Multiple Sclerosis

One of the great challenges related to multiple sclerosis (MS) research is the identification of markers of prognosis and treatment response. In the last couple of decades, an association between intrathecally produced immunoglobulin M (IgM) and a more severe course of the disease has been suggested. Therefore, the objective of this literature review was to gather and review evidence from studies on intrathecally produced IgM as a prognostic marker of clinically isolated syndrome (CIS) converting to clinically definite MS (CDMS), the prognosis of MS and treatment response in patients with MS. This was accomplished through a systematic literature search of the PubMed database, which resulted in 719 hits that were then systematically assessed with well-defined inclusion and exclusion criteria. This process resulted in 29 relevant research articles. The combined evidence from the current literature suggests that intrathecal IgM is a negative prognostic marker that identifies patients with CIS who have a higher risk of converting to CDMS and patients with relapsing-remitting MS (RRMS) with a higher risk of a more aggressive disease course. However, a few studies, some with large studied populations, have reported conflicting results regarding MS prognosis. Further research is needed to establish a more accurate estimate of the effect of intrathecal IgM on the disease course of MS. Further research is also necessary to evaluate the potential prognostic value of intrathecal IgM in treatment response.

An interpretative phenomenological analysis of dignity in people with multiple sclerosis

BACKGROUND

Dignity is a fundamental concept in healthcare. The symptoms of multiple sclerosis have a negative effect on dignity. Understanding of lived experience of dignity in people with multiple sclerosis is crucial to support dignity in practice.

RESEARCH AIM

The aim was to explore the sense of dignity experienced by people with multiple sclerosis.

RESEARCH DESIGN AND PARTICIPANTS

An interpretative phenomenological analysis design was adopted, using data collected through face-to-face interviews with 14 participants.

ETHICAL CONSIDERATIONS

The study was approved by the faculty Ethical Committee (No. EC 1828/2016).

FINDINGS

Four interconnected superordinate themes emerged from analysis: Loss of a fully-fledged life: Violating the dignity-of-self; To accept and fight: Promoting the dignity-of-self; Contempt and rudeness: Indignity-in-relation; and Those who know and see, help: Promoting dignity-in-relation. The loss of former fully-fledged life has a dramatic impact on integrity and impaired dignity-of-self. Accepting illness and changed identity impaired by multiple sclerosis was the step that the participants considered to be important for reacquiring the sense of dignity. The participants encountered misunderstandings, prejudices, embarrassment, insensitive remarks, labelling, unwillingness and impersonal treatment as indignities. Acceptance of their condition, needed support, the feeling of being part of a group, sensitivity and the sharing of problems had a positive effect on their dignity.

DISCUSSION

Continual changes in functional ability threaten an individual's identity and were experienced as violations of dignity. Based on this, participant's dignity-of-self was not a moral, but much more existential value. Acceptance of changed identity and fighting spirit were important for restoring their dignity-of-self. The misunderstandings, prejudices and unwillingness had a negative impact on their dignity-in-relation. On the other side, support from others in fighting promoted their dignity-in-relation.

CONCLUSION

Dignity is manifested as a complex phenomenon of lived experience of people with multiple sclerosis and also an umbrella concept for providing good quality of person-centred care.

Understanding the therapeutic alliance in stroke rehabilitation

PURPOSE

The quality of the therapeutic alliance between a client and their clinician is thought to play an important role in healthcare but there is limited research about this concept in stroke rehabilitation. This study explored the core components of a therapeutic alliance and the factors perceived to impact on its development in a stroke rehabilitation unit.

METHODS

Interpretive description methodology was used to gather and synthesise participants' experiences of their therapeutic relationships. Ten individual client interviews and one clinician focus group were conducted. Data was were analysed using conventional content analysis.

RESULTS

A therapeutic alliance appeared to consist of three overlapping core components: a personal connection, a professional collaboration, and family collaboration. Clients valued these components to different degrees and priorities could change over time. Alliance breakdowns were perceived to stem from a clinician's incorrect assumptions about their client's relationship preferences or lack of responsiveness to their needs. Recovery of the alliance seemed to depend on the strength of the pre-existing relationship and steps taken to repair it.

CONCLUSIONS

Establishing and maintaining a therapeutic alliance appears to be an individualised and complex process. A clinician's ability to use their personal attributes therapeutically, and professional skills flexibly, appeared integral to relationship quality.IMPLICATIONS FOR REHABILITATIONDeveloping therapeutic relationships requires a person-centred and sometimes family/whānau-centred approach.The judicious use of self-disclosure may achieve emotional proximity and yet maintain professional boundaries.Maintaining relationship health requires a proactive approach to detect and manage relationship disruptions.

Coping but not allowing the coping to be everything: Resilience in informal dementia care

Health and social sciences literature recognises the significance of psychological resilience in relation to stressful life events. Providing ongoing care for a friend or relative with dementia can be inherently stressful. The aims of this qualitative study were to: (a) explore discrepancies and congruency between definitions of resilience in the academic literature and carers own conceptualisations; (b) assess differences and similarities in conceptualisations of resilience between carers with high, medium and low resilience scores; (c) compare carers' perceived level of resilience with the level of resilience when measured on a standardised tool. Participants were recruited from an earlier study examining levels of resilience and well-being in UK carers of people with dementia. A subset of carers were identified using theoretical sampling, to ensure a diversity of participant characteristics and caring experience. Thirteen carers took part in semi-structured interviews between September and October 2017. Interpretative description was used to elicit findings relevant to clinical practice. We found carers' definitions were concordant with clinical and academic definitions described in the literature. However, they extended the concept and placed greater value on the role of self-compassion. Carers recognised that the appearance of resilience may have negative consequences in terms of securing support from others. Scores on the Brief Resilient Coping Scale did not always match carers' own perceptions of their level of resilience. Additionally, service providers' offers of support did not always reflect carers' priorities. Aligning these two areas would better enable carers and providers to work together to identify resources to support resilience.

Family caregiving for persons with advanced heart failure: An integrative review

Objective

The unique needs of caregivers of those with advanced heart failure (HF) are not effectively being met, and reports of physical and mental health challenges are common. The objective is to identify the current state of the literature related to family caregivers of persons with advanced HF, ascertain gaps that require further exploration, and provide preliminary practice recommendations based on the results.

Method

Systematic review of quantitative and qualitative literature. A search of CINAHL, Medline, EMBASE, and PubMed identified 24 articles that met inclusion criteria. Data were analyzed using the constant comparison method and coded. Thematic analysis was used to develop themes.

Result

Sixteen qualitative and seven quantitative studies met inclusion criteria. Analysis of these studies identified six key areas: (1) undertaking a journey in a state of flux, (2) gaining strength, (3) forgetting oneself along the way, (4) seeking out sources of support, (5) preparing for end of life, and (6) finding closure.

Significance of results

The healthcare system currently struggles to meet the care demands of patients with chronic conditions such as advanced HF; as such, informal caregivers are undertaking key roles in the management of symptoms and promotion of the health of those with advanced HF. When caregivers are not adequately prepared for their role, both patient and caregiver well-being is compromised; therefore, a deeper understanding of the caregiving experience could assist in identifying the cause of caregiver anxiety and result in the development of strategies to minimize its effects. Overall, this review will also contribute to improving the current practice when working with caregivers of persons with advanced HF and serve as a basis for development of evidence informed interventions in the future.

The neurologist's role in disabling multiple sclerosis: A qualitative study of patient and care provider perspectives

BACKGROUND

Patients with advanced, disabling multiple sclerosis (MS) have few effective treatment options. Little is known about the role that patients and their care providers want their neurologist to fill in this situation.

OBJECTIVE

To better understand the role that patients with disabling MS and their care providers want their neurologist to have in their care.

METHODS

In this exploratory qualitative study, we conducted semi-structured interviews with 29 participants (19 patients with severe disability due to MS and 10 care providers). Interview transcripts were analyzed using inductive thematic analysis.

RESULTS

Participants identified three main roles for their neurologist: a source of hope for therapeutic advances, an educator about the disease and its management, and a source of support.

CONCLUSION

Despite sustaining a level of disability that may be refractory to standard medical therapy, patients with disabling MS and care providers continue to value certain roles of their neurologist. The neurologist's role as a source of hope and support in particular has not received enough attention in the literature.

Multiple challenges for people after transitioning to secondary progressive multiple sclerosis: a qualitative study

OBJECTIVES

Transitioning to secondary progressive multiple sclerosis (SPMS) is demanding for both patients and healthcare professionals. The particular challenges and the ways patients cope are poorly understood. The present study examines what challenges people face when diagnosed with SPMS by exploring experiences of people who have transitioned recently (up to 5 years).

DESIGN

Semistructured qualitative interviews at two time points a year apart. Interviews were analysed using inductive thematic analysis.

SETTING

UK.

PARTICIPANTS

We interviewed 21 people at baseline and 17 participated in the follow-up interviews.

RESULTS

The majority of participants reported expecting to transition to SPMS, and the diagnosis did not make much difference to them. Participants described increasing emotional and physical challenges after transitioning to SPMS and between the first and second interviews. Planning, using distractions and maintaining social roles helped participants cope with the increased challenges. The same coping strategies were used between the two interviews. Participants felt there was not much left to do regarding the management of their symptoms. A key theme was the sense of abandonment from healthcare services after transitioning to SPMS.

CONCLUSIONS

After transitioning to SPMS, people are faced with multiple challenges. Participants described a lack of directions for symptoms management and lack of support from the healthcare system. An integrated multidisciplinary healthcare approach is crucial at the progressive stage of the disease to alleviate feelings of helplessness and promote symptom management.

Motivators and Deterrents to Diet Change in Low Socio-Economic Pakistani Patients With Cardiovascular Disease

This study explores factors that affect the people of low socioeconomic status regarding food choices after diagnosis with cardiovascular disease. Qualitative approach was used to identify the important factors associated with dietary changes as a result of their disease. Twenty-four participants were interviewed from two cardiac facilities in Karachi, the largest metropolitan city of Pakistan. Data were analyzed to identify the themes using the interpretative description approach. While most participants understood the need for dietary changes, few were able to follow recommended diets. Their food choices were primarily influenced by financial constraints as well as cultural, familial, and religious values and practices. The challenge for health care providers lies in understanding the economical, sociocultural, and religious factors that influence behavioral changes which, in turn, affect dietary choices. It is apparent that cardiovascular risk and disease outcomes for the people of low socioeconomic status are likely to escalate. Thus, it is necessary to address the sociocultural, religious, and behavioral factors affecting dietary choices. Achieving this imperative requires an intersectorial, multilevel intervention for the prevention of cardiovascular diseases in people of low socioeconomic status.

Understanding treatment decisions from the perspective of people with relapsing remitting multiple Sclerosis: A critical interpretive synthesis

BACKGROUND

Multiple Sclerosis (MS) is a chronic inflammatory demyelinating disorder of the central nervous system that mainly affects young adults. While there is no cure for MS, disease modifying treatments (DMTs) reduce the relapse rate and partial accrual of disability. More effective DMTs may have higher risks including life-threatening infections or secondary autoimmunity. The complexity and novelty of available treatments cause challenges for clinicians when prescribing treatments and for people with MS (PwMS) when deciding what trade-offs they are willing and ready to make.

OBJECTIVE

To explore the experience of people with relapsing remitting MS (PwRRMS) and their perspectives in choosing treatments.

METHODS

Critical interpretive synthesis was employed to review and synthesis the published literature. Eighty-three publications were selected in a multi-step systematic process.

RESULTS

Findings are presented in four interrelated areas: the influence of the clinical evidence-base in decision making; the meaning of DMT efficacy for PwRRMS; the influence of models of decision-making and information acquisition practices in PwRRMS; and the importance of psychosocial dimensions in DMT decision making. Synthesis of the findings revealed that alongside medical and individual reasoning, contextual circumstances play an important role in making treatment decisions.

CONCLUSION

This review identifies and explains the importance of diverse contextual circumstances (clinical, social, psychological) that are important for PwRRMS when making treatment decisions. The findings demonstrate the importance of eliciting, understanding and addressing such contextual factors.

Defining Empowerment and Supporting Engagement Using Patient Views From the Citizen Health Information Portal: Qualitative Study

Background

The increasing presence of technology in health care has created new opportunities for patient engagement and with this, an intensified exploration of patient empowerment within the digital health context. While the use of technology, such as patient portals, has been positively received, a clear linkage between digital health solutions, patient empowerment, and health outcomes remains elusive.

Objective

The primary objective of this research was to explore the views of participants enrolled in an electronic health record portal access trial regarding the resultant influence of this technology on their feelings of patient empowerment.

Methods

The exploration of patient empowerment within a digital health context was done with participants in a tethered patient portal trial using interpretive description. Interpretive description is a qualitative methodology developed to pragmatically address clinical health questions. Patient demographics, self-reported health status, and self-identified technology adaptation contributed to the assessment of empowerment in this qualitative approach.

Results

This research produced a view of patient empowerment within the digital health context summarized in two overarching categories: (1) Being Heard and (2) Moving Forward. In each of these, two subcategories further delineate the aspects of empowerment, as viewed by these participants: Knowing More and Seeing What They See under Being Heard, and Owning Future Steps and Promoting Future Care under Moving Forward. This work also highlighted an ongoing interconnectedness between the concepts of patient empowerment, engagement, and activation and the need to further articulate the unique aspects of each of these.

Conclusions

The results of this study contribute needed patient voice to the ongoing evolution of the concept of patient empowerment. In order to move toward more concrete and accurate measure of patient empowerment and engagement in digital health, there must be further consideration of what patients themselves identify as essential aspects of these complex concepts. This research has revealed relational and informational elements as two key areas of focus in the ongoing evolution of patient empowerment operationalization and measure.

Our disease: a qualitative meta-synthesis of the experiences of spousal/partner caregivers of people with multiple sclerosis

PURPOSE

To provide a unique and conceptually comprehensive account of the lived experiences of caregiving spouses/partners of people with multiple sclerosis, which can be used to better enable health professionals to provide appropriate support services.

METHOD

A systematic review of qualitative studies reporting the experiences of caregiving spouses/partners was conducted. Relevant articles were identified and analysed using a meta-ethnographic synthesis.

RESULTS

Twenty studies met eligibility criteria, of which 18 were included in the final meta-synthesis. Six major concepts were identified: Acceptance and Appreciation, Commitment, Becoming the Carer, Living with Loss, Shifting Sands and Setbacks with Services. A model of carer experience is presented as a line of argument to synthesise the findings. Suggestions are made regarding the types of supportive interventions that might be effective for spousal carers.

CONCLUSION

The findings increase our understanding about the experiences of partners caring for people with multiple sclerosis. Spousal carers can adapt to the challenges associated with change and loss, and have the potential to develop appreciation, acceptance and hope. Services need to be sensitive to the fluctuating demands placed upon carers and be flexible in their support.

Caught in a no-win situation: discussions about CCSVI between persons with multiple sclerosis and their neurologists - a qualitative study

Background

In recent years, shared decision making (SDM) has been promoted as a model to guide interactions between persons with MS and their neurologists to reach mutually satisfying decisions about disease management – generally about deciding treatment courses of prevailing disease modifying therapies. In 2009, Dr. Paolo Zamboni introduced the world to his hypothesis of Chronic Cerebrospinal Venous Insufficiency (CCSVI) as a cause of MS and proposed venous angioplasty (‘liberation therapy’) as a potential therapy. This study explores the discussions that took place between persons with MS (PwMS) and their neurologists about CCSVI against the backdrop of the recent calls for the use of SDM to guide clinical conversations.

Methods

In 2012, study researchers conducted focus groups with PwMS (n = 69) in Winnipeg, Canada. Interviews with key informants were also carried out with 15 participants across Canada who were stakeholders in the MS community: advocacy organizations, MS clinicians (i.e. neurologists, nurses), clinical researchers, and government health policy makers.

Results

PwMS reported a variety of experiences when attempting to discuss CCSVI with their neurologist. Some found that there was little effort to engage in desired discussions or were dissatisfied with critical or cautious stances of their neurologist. This led to communication breakdowns, broken relationships, and decisions to autonomously access alternative opinions or liberation therapy. Other participants were appreciative when clinicians engaged them in discussions and were more receptive to more critical appraisals of the evidence. Key informants reported that they too had heard of neurologists who refused to discuss CCSVI with patients and that neurology as a whole had been particularly vilified for their response to the hypothesis. Clinicians indicated that they had shared information as best they could but recommended against seeking liberation therapy. They noted that being respectful of patient emotions, values, and hope were also key to maintaining good relationships.

Conclusions

While CCSVI proved a challenging context to carry out patient-physician discussions and brought numerous tensions to the surface, following the approach of SDM can minimize the potential for unfortunate outcomes as much as possible because it is based on principles of respect and more two-way communication.

Electronic supplementary material

The online version of this article (10.1186/s12883-017-0954-7) contains supplementary material, which is available to authorized users.

Managing the transition (ManTra): a resource for persons with secondary progressive multiple sclerosis and their health professionals: protocol for a mixed-methods study in Italy

INTRODUCTION

15 years after clinical onset, about 50% of patients with relapsing-remitting multiple sclerosis convert to secondary progressive multiple sclerosis (SPMS). Notwithstanding the importance of this transition, knowledge of the experiences and needs of patients and carers is fragmentary, and targeted interventions are not available. Managing the Transition to SPMS (ManTra) is a mixed methodology project to develop and test a user-led resource for newly diagnosed patients with SPMS. Here, we describe the developmental phase, consisting of a literature review and a new research study involving key stakeholders, in which we construct the resource.

METHODS AND ANALYSIS

Round 1: The literature review and study will be conducted in parallel. The latter will identify patient needs using a qualitative approach consisting of: personal semistructured interviews with >15 recently diagnosed patients with SPMS; three focus group meetings (one with significant others of patients, one with neurologists and one with other health professionals caring for patients with SPMS). An online survey (>200 recently diagnosed Italian patients with SPMS) will follow to verify needs in a larger independent sample. An expert panel will outline a set of candidate resources/interventions that aim to satisfy the needs thus identified. Round 2: Consensus on the final resource will be obtained in a 1-day meeting of recently diagnosed patients with SPMS, significant others, health professionals and other stakeholders, using the nominal group technique. The expert panel will refine the resource, identify the outcome measures to assess its efficacy and ascertain the most suitable comparator (ManTra Phase 2, not part of this protocol).

ETHICS AND DISSEMINATION

The study protocol was approved by the ethics committees of each of the involved centres: Foundation IRCCS Neurological Institute C Besta, Milan ; G D'Annunzio University of Chieti-Pescara and the Aldo Moro University of Bari. The results will be published in peer-reviewed journals, presented at conferences and a lay summary sent to participants.

Experts' opinion on manual wheelchair adjustments for adults with diabetes

Diabetes is a global health concern that can lead to mobility limitations necessitating a wheelchair. However, there are currently no guidelines for wheelchair adjustments tailored to the diabetic population.

PURPOSE

To describe relevant manual wheelchair adjustments for adults with diabetes, and to explore how these adjustments apply to populations living in less-resourced countries.

METHODS

Semi-structured interviews were conducted with 13 wheelchair experts from five different countries working with adult with diabetes. Interviews were analyzed using the constant comparison method.

RESULTS

The most frequently mentioned wheelchair adjustments were related to neuropathies, skin integrity, decreased strength and amputations. Air cushions were preferred for managing seat sores. Lightweight wheelchairs could be advantageous for people with decreased strength and endurance. In less-resourced settings, wheelchair adjustment decisions prioritized durability and low maintenance.

DISCUSSION

The recommendation of lightweight wheelchairs for adults with diabetes may be limited by the lack of adjustment possibilities compared to regular weight wheelchairs. In less-resourced settings, prioritizing durability and low maintenance may limit prevention and management of conditions associated to diabetes.

CONCLUSION

This study represents a first step towards the development of guidelines for manual wheelchair adjustments specifically tailored to adults with diabetes, in a global health context. Implications of rehabilitation When prescribing manual wheelchairs to persons with diabetes, expert clinicians agree that skin integrity, neuropathies and decreased strength are their primary concerns. Compromises are often necessary when adjusting a wheelchair for a person with diabetes, due to the complexity of their symptoms: same modification can be indicated for one symptom but contraindicated for another. Diabetes prevalence is high in less-resourced settings. There is a need for increased availability of affordable wheelchair equipment that is durable, reliable and adapted to persons with diabetes.

Identifying preferred format and source of exercise information in persons with multiple sclerosis that can be delivered by health-care providers

Background

There is increasing recognition of the benefits of exercise in individuals with multiple sclerosis (MS), yet the MS population does not engage in sufficient amounts of exercise to accrue health benefits. There has been little qualitative inquiry to establish the preferred format and source for receiving exercise information from health‐care providers among persons with MS.

Objective

We sought to identify the desired and preferred format and source of exercise information for persons with MS that can be delivered through health‐care providers.

Setting and participants

Participants were adults with MS who had mild or moderate disability and participated in a range of exercise levels. All participants lived in the Midwest of the United States.

Methods

Fifty semi‐structured interviews were conducted and analysed using thematic analysis.

Results

Two themes emerged, (i) approach for receiving exercise promotion and (ii) ideal person for promoting exercise. Persons with MS want to receive exercise information through in‐person consultations with health‐care providers, print media and electronic media. Persons with MS want to receive exercise promotion from health‐care providers with expertise in MS (ie neurologists) and with expertise in exercise (eg physical therapists).

Conclusions

These data support the importance of understanding how to provide exercise information to persons with MS and identifying that health‐care providers including neurologists and physical therapists should be involved in exercise promotion.