Felicity C. Blackstock

Motivational interviewing to increase physical activity in people with chronic health conditions: a systematic review and meta-analysis

Objective: A systematic review and meta-analysis of randomized controlled trials to determine if motivational interviewing leads to increased physical activity, cardiorespiratory fitness or functional exercise capacity in people with chronic health conditions. Data sources: Seven electronic databases (MEDLINE, PsychINFO, EMBASE, AMED, CINHAL, SPORTDiscus and the Cochrane Central Register of Controlled trials) were searched from inception until January 2014. Trial selection: Two reviewers independently examined publications for inclusion. Trials were included if participants were adults (>18 years), had a chronic health condition, used motivational interviewing as the intervention and examined physical activity, cardiorespiratory fitness or functional exercise capacity. Data extraction: Two reviewers independently extracted data. Risk of bias within trials was assessed using the Physiotherapy Evidence Database Scale. Data synthesis: Meta-analyses were conducted with standardized mean differences and 95% confidence intervals (CIs) were calculated. The Grades of Recommendation, Assessment, Development and Evaluation approach was used to evaluate the quality of the evidence. Results: Eleven publications (of ten trials) were included. There was moderate level evidence that motivational interviewing had a small effect in increasing physical activity levels in people with chronic health conditions relative to comparison groups (standardized mean differences = 0.19, 95% CI 0.06 to 0.32, p = 0.004). Sensitivity analysis based on trials that confirmed treatment fidelity produced a larger effect. No conclusive evidence was observed for cardiorespiratory fitness or functional exercise capacity. Conclusion: The addition of motivational interviewing to usual care may lead to modest improvements in physical activity for people with chronic health conditions.

Can simulation replace part of clinical time? Two parallel randomised controlled trials

Medical Education 2012

Simulation can contribute a part of cardiorespiratory physiotherapy clinical education: Two randomized trials

Introduction Simulated learning environments (SLEs) are used worldwide in health professional education, including physiotherapy, to train certain attributes and skills. To date, no randomized controlled trial (RCT) has evaluated whether education in SLEs can partly replace time in the clinical environment for physiotherapy cardiorespiratory practice. Methods Two independent single-blind multi-institutional RCTs were conducted in parallel using a noninferiority design. Participants were volunteer physiotherapy students (RCT 1, n = 176; RCT 2, n = 173) entering acute care cardiorespiratory physiotherapy clinical placements. Two SLE models were investigated as follows: RCT 1, 1 week in SLE before 3 weeks of clinical immersion; RCT 2, 2 weeks of interspersed SLE/clinical immersion (equivalent to 1 SLE week) within the 4-week clinical placement. Students in each RCT were stratified on academic grade and randomly allocated to an SLE plus clinical immersion or clinical immersion control group. The primary outcome was competency to practice measured in 2 clinical examinations using the Assessment of Physiotherapy Practice. Secondary outcomes were student perception of experience and clinical educator and patient rating of student performance. Results There were no significant differences in student competency between the SLE and control groups in either RCT, although students in the interspersed group (RCT 2) achieved a higher score in 5 of 7 Assessment of Physiotherapy Practice standards (all P < 0.05). Students rated the SLE experience positively. Clinical educators and patients reported comparability between groups. Conclusions An SLE can replace clinical time in cardiorespiratory physiotherapy practice. Part education in the SLE satisfied clinical competency requirements, and all stakeholders were satisfied.

High-fidelity patient simulation in physiotherapy education.

Over the last 30 years, the medical profession has been following in the foot steps of the aviation industry by developing equipment and teaching styles to recreate, or simulate, patient scenarios for educational purposes. One of the first mannequins in simulation education was the cardiopulmonary resuscitation mannequin, used with nurses and medical professionals for basic life support training since the 1970s. The popularity and positive learning outcomes noted from the use of such an education tool stimulated the medical profession to develop a vast assortment of simulators, ranging from simple part task trainers through to technologically advanced medium-to high-fidelity human patient simulators. ‘Part task trainers’ refers to modelled segments of the body, eg, the pelvis or knee, designed to teach specific skills such as intra-articular injection, scopic surgical procedures, or pelvic examinations. ‘Mediumto high-fidelity human patient simulators’ are full body mannequins that mimic precisely physiological responses to medical intervention such as drug administration or invasive procedures. The high-fidelity mannequin is linked to a computer system that drives physical changes in the mannequin such as respiratory rate, and opening of eyes, as well as physiological responses displayed on the ‘patient’ monitor such as heart rate, blood pressure, and oxygenation. This technology allows medical educators to simulate patient cases and provide students with the opportunity to refine practice away from real patients, in a safe and

Chest physiotherapy for patients admitted to hospital with an acute exacerbation of chronic obstructive pulmonary disease (COPD): a systematic review

OBJECTIVES To examine the effectiveness of chest physiotherapy for patients admitted to hospital with an acute exacerbation of chronic obstructive pulmonary disease (COPD). DATA SOURCE CINAHL, MEDLINE, Embase, Cochrane, Expanded Academic Index, Clinical Evidence, PEDro, Pubmed, Web of Knowledge and Proquest were searched from the earliest available time to September 2007, using the key elements of COPD, acute exacerbation and chest physiotherapy interventions. REVIEW METHODS To be included, trials had to investigate patients during admission to hospital with an acute exacerbation of COPD, and to evaluate at least one physiotherapy intervention. Two reviewers independently applied the inclusion criteria, and assessed trial quality using the PEDro scale. Results were expressed as standardised mean differences and analysed qualitatively with a best-evidence synthesis. RESULTS Thirteen trials were identified. There was moderate evidence that intermittent positive pressure ventilation and positive expiratory pressure were effective in improving sputum expectoration. In addition, there was moderate evidence that walking programmes led to benefits in arterial blood gases, lung function, dyspnoea and quality of life. No evidence was found supporting the use of any other chest physiotherapy techniques to change lung function, arterial blood gases, perceived level of dyspnoea or quality of life. CONCLUSIONS Chest physiotherapy techniques such as intermittent positive pressure ventilation and positive expiratory pressure may benefit patients with COPD requiring assistance with sputum clearance, while walking programmes may have wider benefits for patients admitted with an exacerbation of COPD. Chest physiotherapy techniques other than percussion are safe for administration to this patient population.

Psychoeducational Rehabilitation for Health Behavior Change in Coronary Artery Disease: A SYSTEMATIC REVIEW OF CONTROLLED TRIALS

PURPOSE: Psychoeducation is a recommended component of cardiac rehabilitation, but to date, evidence from high quality trials examining behavior change has not been synthesized. The primary aim of this systematic review was to examine the effectiveness of psychoeducation on behavior change in adults with coronary artery disease participating in cardiac rehabilitation; and to identify if changes in health behavior had an effect on modifiable physiological risk factors. METHODS: A search of electronic databases was conducted for randomized controlled trials involving adults with a primary diagnosis of myocardial infarction, coronary artery bypass graft surgery, percutaneous coronary intervention, stable angina, or coronary artery disease defined by angiography. Trials comparing psychoeducational programs to exercise only, standard cardiac rehabilitation or medical care were included. Primary outcomes were smoking status, physical activity, dietary habits, supplemental oxygen, or medication use. Included trials were assessed for quality with the PEDro scale, and data synthesized descriptively or with meta-analysis. RESULTS: Six randomized controlled trials and 1 quasiexperimental trial were included, a total of 536 participants. A meta-analysis from 213 participants showed psychoeducational interventions produced a significant positive effect on physical activity levels over the medium term (6–12 months) when compared with exercise and risk factor education, (&dgr; = .62, 95% CI 0.3–0.94). However, there was limited positive evidence for change in smoking and dietary behavior. No effect was found on physiological risk factors. CONCLUSIONS: Psychoeducational interventions produce a significant positive effect on physical activity levels and potentially on dietary habits and smoking. Strategies such as goal setting, problem solving, self-monitoring, and role modeling appear to be influential in this change.

Early Rehabilitation Exercise Program for Inpatients During an Acute Exacerbation of Chronic Obstructive Pulmonary Disease: A RANDOMIZED CONTROLLED TRIAL.

PURPOSE: To determine whether an early rehabilitation program was safe and feasible for patients during an acute exacerbation of chronic obstructive pulmonary disease (COPD). METHODS: In this phase 1 randomized controlled trial, patients with an acute exacerbation of COPD admitted to the hospital were randomly allocated to a low-intensity exercise group, a moderate- to high-intensity exercise group, or a control group, who received routine physical therapy. In addition to routine physical therapy, patients in the exercise group had to participate in an exercise program. The program consisted of twice-daily aerobic and resistance exercise sessions. Primary outcomes were the number and classification of adverse events and program adherence. RESULTS: In 174 exercise sessions, there was 1 serious adverse event of arrhythmia in the low-intensity exercise group that resolved within 1 hour. There were 12 other minor adverse events involving 5 patients with no significant differences between groups. Patients completed an average of 80% of their scheduled sessions with no significant between-group differences. The exercise groups improved significantly in walking distance; however, no significant between-group differences were observed. CONCLUSIONS: There was preliminary evidence that it was safe and feasible to implement an exercise program for patients during an acute exacerbation of COPD. Additional studies with larger sample sizes are required to accurately evaluate program effectiveness.

Comparable improvements achieved in chronic obstructive pulmonary disease through pulmonary rehabilitation with and without a structured educational intervention: A randomized controlled trial

Pulmonary rehabilitation is beneficial for people with chronic obstructive pulmonary disease (COPD) and typically includes exercise and disease‐specific education components. However, the benefits directly attributable to the education component remain unclear. This trial sought to determine whether the addition of education to exercise training resulted in greater improvements in health outcomes than pulmonary rehabilitation where education has been omitted.

Simulated Patients in Physical Therapy Education: Systematic Review and Meta-Analysis

Background Traditional models of physical therapy clinical education are experiencing unprecedented pressures. Simulation-based education with simulated (standardized) patients (SPs) is one alternative that has significant potential value, and implementation is increasing globally. However, no review evaluating the effects of SPs on professional (entry-level) physical therapy education is available. Purpose The purpose of this study was to synthesize and critically appraise the findings of empirical studies evaluating the contribution of SPs to entry-level physical therapy education, compared with no SP interaction or an alternative education strategy, on any outcome relevant to learning. Data Sources A systematic search was conducted of Ovid MEDLINE, PubMed, AMED, ERIC, and CINAHL Plus databases and reference lists of included articles, relevant reviews, and gray literature up to May 2015. Study Selection Articles reporting quantitative or qualitative data evaluating the contribution of SPs to entry-level physical therapy education were included. Data Extraction Two reviewers independently extracted study characteristics, intervention details, and quantitative and qualitative evaluation data from the 14 articles that met the eligibility criteria. Data Synthesis Pooled random-effects meta-analysis indicated that replacing up to 25% of authentic patient–based physical therapist practice with SP-based education results in comparable competency (mean difference=1.55/100; 95% confidence interval=−1.08, 4.18; P=.25). Thematic analysis of qualitative data indicated that students value learning with SPs. Limitations Assumptions were made to enable pooling of data, and the search strategy was limited to English. Conclusion Simulated patients appear to have an effect comparable to that of alternative educational strategies on development of physical therapy clinical practice competencies and serve a valuable role in entry-level physical therapy education. However, available research lacks the rigor required for confidence in findings. Given the potential advantages for students, high-quality studies that include an economic analysis should be conducted.

Motivational interviewing increases physical activity and self-efficacy in people living in the community after hip fracture: A randomized controlled trial

Objective: To investigate if motivational interviewing improved physical activity, self-efficacy, quality of life, mobility and mental health in people living in the community after hip fracture. Design: Single-blind randomized controlled trial. Setting: Community. Participants: A total of 30 adults after hip fracture who had been discharged from rehabilitation to independent living in the community and allocated to a control group (n = 14) or an intervention group (n = 16). Intervention: All participants received usual care. The intervention group also received eight weekly sessions of motivational interviewing as additional input, with the control group having no additional matching input. Main outcomes: The primary outcome was physical activity levels as measured by an accelerometer (steps taken per day, time spent walking per day, and time spent sitting or lying each day). Secondary outcomes included self-efficacy (confidence about walking and not falling), health-related quality of life, mobility and mental health. Results: Relative to usual care, the motivational interviewing group took significantly more steps per day (mean = 1237 steps, 95% confidence interval (CI) 12 to 2463), walked for longer per day (mean = 14.4 minutes, 95% CI 0.6 to 28.8), had improved self-efficacy evidenced by being more confident about walking (mean = 1.6 units out of 10, 95% CI 0.3 to 2.9) and not falling (mean = 1.1 units out of 10, 95% CI 0.3 to 1.9) and improved health-related quality of life and mental health. Conclusion: This study provides preliminary evidence that motivational interviewing can result in clinically meaningful improvements in physical activity and psychosocial outcomes for people recovering from hip fracture.