Caitlin McArthur

“I do not have time. Is there a handout I can use?”: combining physicians’ needs and behavior change theory to put physical activity evidence into practice

SummaryGuidelines for physical activity exist and following them would improve health. Physicians can advise patients on physical activity. We found barriers related to physicians’ knowledge, a lack of tools and of physician incentives, and competing demands for limited time with a patient. We discuss interventions that could reduce these barriers.IntroductionUptake of physical activity (PA) guidelines would improve health and reduce mortality in older adults. However, physicians face barriers in guideline implementation, particularly when faced with needing to tailor recommendations in the presence of chronic disease. We performed a behavioral analysis of physician barriers to PA guideline implementation and to identify interventions. The Too Fit To Fracture physical activity recommendations were used as an example of disease-specific PA guidelines.MethodsFocus groups and semi-structured interviews were conducted with physicians and nurse practitioners in Ontario, stratified by type of physician, geographic area, and urban/rural, and transcribed verbatim. Two researchers coded data and identified emerging themes. Using the behavior change wheel framework, themes were categorized into capability, opportunity and motivation, and interventions were identified.ResultsFifty-nine family physicians, specialists, and nurse practitioners participated. Barriers were as follows: Capability–lack of exercise knowledge or where to refer; Opportunity–pragmatic tools, fit within existing workflow, available programs that meet patients’ needs, physical activity literacy and cultural practices; Motivation–lack of incentives, not in their scope of practice or professional identity, competing priorities, outcome expectancies. Interventions selected: education, environmental restructuring, enablement, persuasion. Policy categories: communications/marketing, service provision, guidelines.ConclusionsKey barriers to PA guideline implementation among physicians include knowledge on where to refer or what to say, access to pragmatic programs or resources, and things that influence motivation, such as competing priorities or lack of incentives. Future work will report on the development and evaluation of knowledge translation interventions informed by the barriers.

Who Receives Rehabilitation in Canadian Long-Term Care Facilities? A Cross-Sectional Study

PURPOSE To describe the proportion of residents receiving occupational therapy (OT) and physical therapy (PT) and the factors associated with receiving PT in long-term care (LTC) facilities across five provinces and one territory in Canada. METHODS Using a population-based, retrospective analysis of cross-sectional data, the proportion of LTC facility residents in each province or territory receiving three different amounts (time and frequency) of PT, OT, or both before July 1, 2013, was calculated according to the Resource Utilization Groups-III rehabilitation classifications. Twenty-three variables from the Resident Assessment Instrument 2.0, such as age and cognition, were examined as correlates; those significant at p<0.01 were included in a multivariate logistic regression. RESULTS Between 63.7% and 88.6% of residents did not receive any PT or OT; 0.8%-12.6% received both PT and OT; 5.8%-29.5% received an unspecified amount of PT; 1.9%-7.0% received 45 minutes or more of PT 3 days or more per week; and fewer than 1% received 150 minutes or more of PT on 5 or more days per week. Province, age, cognitive status, depression, clinical status, fracture, multiple sclerosis, and self-rated potential for improvement were associated with PT irrespective of time intensity. CONCLUSIONS The proportion of LTC residents receiving rehabilitation services varies across Canada and appears to be associated with physical impairments and the potential for improvement; older residents with cognitive impairment or mood disorders are less likely to receive rehabilitation services. Future recommendations should consider what is driving the patterns of service use, determine whether the resources available are appropriate, and address the most appropriate goals for residents in LTC.

Scoping review of physical rehabilitation interventions in long-term care: protocol for tools, models of delivery, outcomes and quality indicators

Introduction A growing number of medically complex older adults reside in long-term care (LTC) and often require physical rehabilitation (PR). While PR is effective at maintaining or improving a patients physical function, the breadth of PR interventions evaluated in LTC, which outcomes or quality indicators (QI) can be used to evaluate PR, and what tools or models can be used to determine eligibility for PR services remain unknown. Methods and analysis A scoping review will be conducted to address the following research questions: (1) What types of PR have been evaluated for efficacy or effectiveness in LTC? (2) Which outcomes or QIs have been used when evaluating PR interventions in LTC, and how can this inform evaluation of PR using existing QIs in the Canadian context? (3) What tools or models exist or have been validated for decision-making in the allocation of PR resources in LTC? We will conduct a comprehensive literature search in MEDLINE, EMBASE, CINAHL, Cochrane Database of Systematic Reviews, Physiotherapy Evidence Database (PEDro) and Occupational Therapy Systematic Evaluation of Evidence database (OTseeker) and a structured grey literature search. Two team members will screen articles and abstract the data. The results will be displayed according to the research question they address. Data abstracted regarding outcomes and QIs will be mapped onto existing, publicly reported QIs used in Ontario, Canada. Ethics and dissemination The scoping review will synthesise the characteristics of PR interventions described in the literature, the outcomes used to evaluate them and tools to determine eligibility for services. The review will be the first step in formally identifying what outcomes and QIs have been used to evaluate PR in LTC, and will be used to inform a stakeholder consensus process exploring the same question. The scoping review may also identify knowledge gaps. The results will be disseminated via publication and presentation at conferences, in addition to a 1-day stakeholder meeting.

Measuring the implementation of a group- based Lifestyle-integrated Functional Exercise (Mi-LiFE) intervention delivered in primary care for older adults aged 75 years or older: a pilot feasibility study protocol

BackgroundDeclines in function and quality of life, and an increased risk of cardiovascular events, falls, and fractures occur with aging and may be amenable to exercise intervention. Primary care is an ideal setting for identifying older adults in need of exercise intervention. However, a cost-effective, generalizable model of chronic disease management using exercise in a real-world setting remains elusive. Our objective is to measure the feasibility, potential effectiveness, and implementation of an evidence-based Lifestyle-integrated Functional strength and balance Exercise (LiFE) intervention adapted as a group-based format (Mi-LiFE) for primary care to promote increased physical activity levels in older adults aged 75 years or older. We hypothesize that the intervention will be feasible without modification if ≥30 individuals are recruited over 6 months, ≥75 % of our sample is retained, and ≥50 % of our sample complete exercises ≥3 days per week.Methods/designA pre-post pilot study design will be used to evaluate feasibility, potential effectiveness, and implementation outcomes over a 6-month period in physically inactive older adults ≥75 years recruited from a local family health team practice. The reach, effectiveness, adoption, implementation, and maintenance (RE-AIM) framework will be applied to evaluate the public health effects of the intervention including outcomes both at the individual and organizational levels. A physical therapist will teach participants how to integrate strength and balance activities into their daily lives over one individual and four group-based sessions, and two phone calls. Assessments will be completed at baseline and 6 months. Feasibility outcomes include recruitment over 6 months, retention at follow-up, and adherence measured by activity diaries. Change in patient-centered and implementation outcomes that will be evaluated include physical activity levels using accelerometers and International Physical Activity Questionnaire, physical performance using short physical performance battery, quality of life using EQ5D questionnaire, falls and harms using daily calendar diaries and self-report, fidelity using descriptive feedback, barriers and facilitators to implementation using thematic content analysis, and process outcomes.DiscussionThe feasibility and implementation of the Mi-LiFE intervention in primary care for older adults will be evaluated, as well as the effects of the intervention on secondary outcomes. If the intervention appears feasible, we will use the resultant information to design a larger trial.Trial registrationClinicalTrials.gov: NCTO2266225

“Left to my own devices, I don’t know”: using theory and patient-reported barriers to move from physical activity recommendations to practice

SummaryKnowledge exchange with community-dwelling individuals across Ontario revealed barriers to implementation of physical activity recommendations that reflected capability, opportunity, and motivation; barriers unique to individuals with osteoporosis include fear of fracturing, trust in providers, and knowledge of exercise terminology. Using the Behaviour Change Wheel, we identified interventions (training, education, modeling) and policy categories (communication/marketing, guidelines, service provision).IntroductionPhysical activity recommendations exist for individuals with osteoporosis; however, to change behavior, we must address barriers and facilitators to their implementation. The purposes of this project are (1) to identify barriers to and facilitators of uptake of disease-specific physical activity recommendations (2) to use the findings to identify behavior change strategies using the Behaviour Change Wheel (BCW).MethodsFocus groups and semi-structured interviews were conducted with community-dwelling individuals attending osteoporosis-related programs or education sessions in Ontario. They were stratified by geographic area, urban/rural, and gender, and transcribed verbatim. Two researchers coded data and identified emerging themes. Using the Behaviour Change Wheel framework, themes were categorized into capability, opportunity, and motivation, and interventions were identified.ResultsTwo hundred forty community-dwelling individuals across Ontario participated (mean ± SD age = 72 ± 8.28). Barriers were as follows: capability: disease-related symptoms hinder exercise and physical activity participation, lack of exercise-related knowledge, low exercise self-efficacy; opportunity: access to exercise programs that meet needs and preferences, limited resources and time, physical activity norms and preferences; motivation: incentives to exercise, fear of fracturing, trust in exercise providers. Interventions selected were training, education, and modeling. Policy categories selected were communication/marketing, guidelines, and service provision.ConclusionsBarriers unique to individuals with osteoporosis included the following: lack of knowledge on key exercise concepts, fear of fracturing, and trust in providers. Behavior change techniques may need tailoring to gender, age, or presence of comorbid conditions.

What Are the Circumstances of Falls and Fractures in Long-Term Care?

RÉSUMÉ: Cette étude prospective d’observation rend compte des circonstances qui ont conduit à des chutes des résidents dans des établissements de soins de longue durée (SLD) et les caractéristiques des résidents qui ont subi des fractures suite à une chute. Le personnel a enregistré l’emplacement de la chute, le moment de la journée, l’activité dans laquelle un participant a été engagé avant l’incident et si une blessure a été soutenue. Les statistiques descriptives ont été utilisées pour décrire les chutes, et un modèle linéaire généralisé a été utilisé pour déterminer les différences entre les circonstances. Parmi les 101 résidents SLD qui ont participé, 41 pour cent ont eu au moins une chute. Les résidents étaient beaucoup plus susceptibles d’être tombés dans la chambre et tout en marchant. Parmi les 17 chutes entraînant des fractures, la plupart se sont produites dans la chambre à coucher et la salle de bains, tôt le matin; la plupart des résidents qui ont subi des fractures étaient des femmes ayant une déficience cognitive. Pour surveiller les chutes globalement, la surveillance ambulatoire, qui évite les problèmes de confidentialité dans les chambres à coucher ou les salles de bains, peuvent être nécessaires. Les interventions devraient cibler la marche à pied ou l’organisation de la chambre. This prospective, observational study characterizes the circumstances that led to falls in long-term care (LTC) residents and describes the characteristics of residents who fractured following a fall. Staff recorded the location of the fall, time of day, activity the participant was doing prior, and if an injury occurred. Descriptive statistics were used to describe the falls, and a generalized linear model was used to determine differences between the circumstances. Of the 101 LTC residents who participated, 41 per cent experienced at least one fall. Residents were significantly more likely to have fallen in the bedroom and while walking. Of the 17 falls resulting in fractures, most occurred in the bedroom and bathroom, during the early morning; most residents who fractured were female with cognitive impairment. To monitor falls comprehensively, ambulatory monitoring that avoids privacy issues in bedrooms or bathrooms may be needed. Interventions should target walking or the bedroom setting.

ABLE: An Arts-Based, Interactive Physical Therapy Platform for Seniors with Dementia and Frailty.

ABLE is a gesture-based interactive platform that transforms physical therapy into game play or art creation – for example, virtual painting or digital music creation. ABLE targets older adults with dementia and fragility, employing art and gaming to encourage playful, physical interactions with family members, peers and care providers. The project aims to forge synergy between physical interaction and creative engagement to produce a range of positive effects; the platform aims to reduce boredom, agitation and social isolation while enhancing physiological, affective and cognitive health. Our interdisciplinary team of medical and health scientists, computer scientists, humanities scholars and artists together contribute the aptitudes required to develop ABLE with attention to the specific needs of these users, to design wearable biometric sensors for data capture, and to develop the app in a consumer-friendly interface appropriate for independent use in residences and homes. We are also developing ABLE with physical therapists, to create a menu of scalable physical therapy exercises designed to enhance strength, balance, and agility for variable populations with frailty and dementia presenting with low to severe impairments. As well, we are co-developing the platform with a range of participants (hospital patients, supported housing residents and home residents) to ensure that the experiences are pleasurable and encourage sustained use of over time. Offering a host of physiological, affective and social engagement benefits, ABLE aims to assist older adults, as they age, to stay mobile, active, and engaged with community and the people they love.

Osteoporosis exercise knowledge and education in medicine and nursing: response to comments by Nguyen

Dear Editor, We thank Dr. Nguyen [1] for commenting on our article [2]. We agree that we need to target both patients and health care providers to increase the translation of physical activity guidelines for osteoporosis into practice. Our key message was not to remove responsibility for exercise prescription from physicians or nurse practitioners, nor to emphasize handouts over online resources. However, our approach to developing knowledge translation tools is theory-guided, and therefore the first step is to identify barriers to implementation, and then use behaviour change theory to select and tailor interventions to address those barriers [3, 4]. The purpose of the paper Dr. Nguyen commented on was to take that step; we identified education, environmental restructuring, enablement and persuasion as intervention functions and communications/marketing, service provision and guidelines as policy categories. The next step is to select, tailor and implement the interventions and monitor knowledge use. We agree with Dr. Nguyen that the professional competencies of physicians and nurses should include basic knowledge on prescription of safe and effective physical activity, tailored to patient needs—changing professional competencies would be a form of education, one of the intervention functions identified above. The steps we have taken toward enhancing uptake of Too Fit To Fracture recommendations through education include development of guidelines [5, 6] and communications/marketing, including presentations at 52 continuing education events, conferences and Grand Rounds, including the 2017 combined meeting of the International Society for Clinical Densitometry and National Osteoporosis Foundation, Clinical Osteoporosis (http://clinicalosteoporosis.org/). Other events include meeting with family health teams and family practice residents and dialogues with associations such as the Association of Family Health Teams of Ontario. There are calls to action and initiatives in support of integrating training on exercise into medical school curricula [7, 8]. The Exercise is Medicine Initiative (http://exerciseismedicine.org/) has continuing education opportunities on exercise prescription for health care providers. In addition, we have developed materials on exercise for a family medicine training program and accredited osteoporosis e-module and have received feedback that our physical activity recommendations are being used in the training of medical school students and physiotherapists. A free e-module, designed for health care providers, on exercise for older adults is in development. Therefore, the Too Fit To Fracture recommendations are being translated to current and future health care providers through education, service provision and guidelines. We also agree that we need to move beyond handouts. We included the handout as an example at the request of a reviewer of our manuscript. We intend to document the development * L. Giangregorio lmgiangr@uwaterloo.ca

A Scoping Review of Physical Rehabilitation in Long-Term Care: Interventions, Outcomes, Tools

RÉSUMÉ: Les résidents en soins de longue durée (SLD) ont souvent besoin de soins en réadaptation pour maintenir ou améliorer leur état physique fonctionnel. L’objectif de cet examen de portée était de décrire l’envergure des publications concernant la réadaptation physique en SLD jusqu’à ce jour, avec une emphase sur les types d’interventions en réadaptation qui ont été évaluées, ainsi que sur les mesures de résultats utilisées et les outils déterminant l’admissibilité au service. Une recherche structurée a été réalisée dans six bases de données sous licence et dans la littérature grise. Deux analystes ont identifié 381 articles qui ont été triés en utilisant un formulaire qui avait préalablement été testé dans un essai pilote, et les données de ces articles ont été extraites. La plupart des interventions avaient été réalisées et évaluées au niveau des résidents, et consistaient fréquemment en des programmes d’exercices à plusieurs composantes dispensés par du personnel de recherche et des physiothérapeutes. Les mesures les plus couramment rapportées étaient basées sur la performance, les activités de la vie quotidienne et l’humeur. Une lacune importante a été identifiée concernant les connaissances sur la réadaptation en lien avec des objectifs qui soient pertinents pour les résidents, tels que la qualité de vie. Dans les études à venir, il serait important que les caractéristiques des résidents en SLD soit représentatives de la complexité de l’état de santé de cette population; la durée de leur séjour devrait aussi être incluse et différenciée. Les études d’intervention devraient aussi explorer des méthodes de prestation de soins qui soient réalistes et soutenables. Le développement d’outils pour favoriser une meilleure détermination de l’admissibilité aux services est aussi nécessaire pour assurer l’égalité en matière de soins en réadaptation dans l’ensemble du secteur des SLD. ABSTRACT: Residents in long-term care (LTC) often require physical rehabilitation (PR) to maintain/improve physical function. This scoping review described the breadth of literature regarding PR in LTC to date, synthesizing PR interventions that have been evaluated, outcomes used, and tools for determining service eligibility. A structured search, conducted in six licensed databases and grey literature, identified 381 articles for inclusion. Most interventions were delivered and evaluated at the resident level and typically were multicomponent exercise programs. Performance-based measures, activities of daily living, and mood were the most frequently reported outcomes. A key knowledge gap was PR in relation to goals, such as quality of life. Future studies should reflect medically complex residents who live in LTC, and length of residents’ stay should be differentiated. Intervention studies should also explore realistic delivery methods; moreover, tool development for determining service eligibility is necessary to ensure equality in rehabilitative care across the LTC sector.