Caroline Stretton

Determinants of physical health in frail older people: the importance of self-efficacy

Objective: There is continued uncertainty regarding the strength of association between performance-based and self-report measures of physical functioning, and of their relationship to self-efficacy and health-related quality of life (HRQoL). This study assessed the inter-relationships between such measures, and the predictors of ‘physical’ aspects of HRQoL in frail older patients. Design: We used statistical models to determine the predictors of ‘physical’ HRQoL, according to the physical component summary score and the physical functioning domain of the 36-item short form (SF-36) questionnaire. Setting: Patients were recruited from hospitals in Australia and New Zealand and followed up in their homes. Subjects: Two hundred and forty-three frail older patients. Main measures: Physical functioning was assessed using three performance-based measures (Timed Up and Go Test, gait speed and the Berg Balance Scale) and five self-report measures, including the modified falls self-efficacy scale, at three and six months after registration. Results: A moderate association (r=0.48=0.55) was found between each of the performance-based and self-report measures, including the SF-36 physical component summary score. Multiple linear regression analyses showed that the performance-based measures and falls self-efficacy predicted 33% of the SF-36 physical component summary score. Falls self-efficacy was the single highest predictor of both the SF-36 physical component summary score and SF-36 physical functioning domain. A curvilinear relationship was found between the SF-36 physical functioning domain and two variables: falls self-efficacy and the Berg Balance Scale. Conclusions: Although performance-based and self-report measures provide complementary but distinct measures of physical function, psychosocial factors such as self-efficacy have a strong influence on the HRQoL of frail older people.

Does clinic-measured gait speed differ from gait speed measured in the community in people with stroke?

Objective: To compare the extent to which gait speed measured in the clinic setting differs from that measured in the community. Design: Participants completed the 10-m walk test at a self-selected speed in a clinic setting. Following this they completed a 300-m community-based walking circuit that covered a variety of environmental conditions. Gait velocity was sampled at different points in the circuit. The same circuit and sampling points were used for all participants. Clinic gait velocity was compared to gait velocity measured on five occasions during the community-based circuit. Setting: Physiotherapy clinic and local shopping mall. Participants: Twenty-eight chronic stroke patients who regularly accessed the community divided into two groups based on their gait velocity in the clinic. Main outcome measures: Walking velocity. Results: Spearman rank correlation coefficient indicated that there was a strong correlation between the total time taken to walk the 300-m course and the clinic-based gait velocity (r=-0.88, P<0.0001). A linear mixed model with repeated measures analysis revealed significant interaction between community measures for group A versus group B (F4,26=4.49, P=0.0068) and significant differences across community conditions (F4,26=7.12, P=0.0005). Conclusion: The clinic-based 10-m walk test is able to predict walking velocity in a community setting in chronic stroke patients who score 0.8 m/s or faster. However, for those who score less than 0.8 m/s in the clinic test, gait velocity in the community may be overestimated.

Are physiotherapists comfortable with person-centred practice? An autoethnographic insight.

Abstract Purpose: This study aimed to understand our shared conflicting response and discomfort to person-centred rehabilitation within the context of our physiotherapy rehabilitation culture by reflecting on our own experiences as research physiotherapists and clinicians. Method: This study used autoethnographical methods to explore the personal and professional experiences of two physiotherapists in neurological rehabilitation. Data were collected through ten written reflections and five joint discussions. The data were analysed collaboratively through focused conversations and writing. We looked for patterns in our data and the literature to triangulate our findings. Joint narratives were structured based on three headings: Where we have come from, Challenges to our position and Where we are now. Results: The four main topics of discussion were goal setting, hope, the physiotherapy paradigm and person-centred practice. Physiotherapy practice is typically underpinned by a biomechanical discourse, which separates the mind and the body. This paradigm limits our ability to manage aspects of person-centred practice, such as valuing patient preferences, fostering hope, managing expectation and building a positive therapeutic relationship. Conclusion: Awareness of existing influences on theory and practice is necessary to move the physiotherapy profession towards a greater degree of understanding and application of the principles of person-centred practice. Implications for Rehabilitation Physiotherapists need to recognise that our clinical practice is currently dominated by a biomechanical perspective, which limits our adoption of person-centred practice. Our usual way of working as an expert focuses on our own perspective that makes it difficult to work in a person-centred way. Strategies to incorporate a more person-centred approach include using communication strategies that help us actively seek patients’ perspectives.

Activity coaching to improve walking is liked by rehabilitation patients but physiotherapists have concerns: a qualitative study

QUESTION Does activity coaching add value to physiotherapy from the perspective of physiotherapists and patients in neurological rehabilitation? Is the use of activity coaching to promote walking and physical activity considered feasible by these physiotherapists and patients? DESIGN Qualitative study using interviews. PARTICIPANTS Five pairs of physiotherapists and their patients with neurological conditions. INTERVENTION A research physiotherapist trained in health coaching delivered an activity coaching intervention. This was provided in addition to standard physiotherapy. The treating physiotherapists observed the activity coaching session undertaken by their patients. RESULTS Observing the coaching interview was valuable for the treating physiotherapists in that it provided a way to refocus, step back, gain insight, and facilitate more active involvement for their patients in the rehabilitation process. Similarly patients valued the opportunity to focus on what was important and put into action their rehabilitation goals. Contrasting perceptions were evident, which limits the practical usefulness of this intervention due to the concerns voiced by some of the physiotherapists. CONCLUSION The activity coaching was perceived as providing a valuable addition to standard practice and was acceptable to patients but the mixed responses of physiotherapists limit the feasibility of this approach. Use of strategies and specific training for physiotherapists may be needed before approaches like activity coaching can be adopted successfully.

Interventions to improve real-world walking after stroke: a systematic review and meta-analysis

Objective: This study aimed to determine the effectiveness of current interventions to improve real-world walking for people with stroke and specifically whether benefits are sustained. Data sources: EBSCO Megafile, AMED, Cochrane, Scopus, PEDRO, OTSeeker and Psychbite databases were searched to identify relevant studies. Review methods: Proximity searching with keywords such as ambulat*, walk*, gait, mobility*, activit* was used. Randomized controlled trials that used measures of real-world walking were included. Two reviewers independently assessed methodological quality using the Cochrane Risk of Bias Tool and extracted the data. Results: Nine studies fitting the inclusion criteria were identified, most of high quality. A positive effect overall was found indicating a small effect of interventions on real-world walking (SMD 0.29 (0.17, 0.41)). Five studies provided follow-up data at >3–6 months, which demonstrated sustained benefits (SMD 0.32 (0.16, 0.48)). Subgroup analysis revealed studies using exercise alone were not effective (SMD 0.19 (–0.11, 0.49)), but those incorporating behavioural change techniques (SMD 0.27 (0.12, 0.41)) were. Conclusions: A small but significant effect was found for current interventions and benefits can be sustained. Interventions that include behaviour change techniques appear more effective at improving real-world walking habits than exercise alone.