Hannah Ml Young

The development and pilot testing of the Self-management Programme of Activity, Coping and Education for Chronic Obstructive Pulmonary Disease (SPACE for COPD)

Purpose There is no independent standardized self-management approach available for chronic obstructive pulmonary disease (COPD). The aim of this project was to develop and test a novel self-management manual for individuals with COPD. Patients Participants with a confirmed diagnosis of COPD were recruited from primary care. Methods A novel self-management manual was developed with health care professionals and patients. Five focus groups were conducted with individuals with COPD (N = 24) during development to confirm and enhance the content of the prototype manual. The Self-management Programme of Activity, Coping and Education for Chronic Obstructive Pulmonary Disease (SPACE for COPD) manual was developed as the focus of a comprehensive self-management approach facilitated by health care professionals. Preference for delivery was initial face-to-face consultation with telephone follow-up. The SPACE for COPD manual was piloted with 37 participants in primary care. Outcome measures included the Self-Report Chronic Respiratory Questionnaire, Incremental Shuttle Walk Test, and Endurance Shuttle Walking Test (ESWT); measurements were taken at baseline and 6 weeks. Results The pilot study observed statistically significant improvements for the dyspnea domain of the Self-Report Chronic Respiratory Questionnaire and ESWT. Dyspnea showed a mean change of 0.67 (95% confidence interval 0.23–1.11, P = 0.005). ESWT score increased by 302.25 seconds (95% confidence interval 161.47–443.03, P < 0.001). Conclusion This article describes the development and delivery of a novel self-management approach for COPD. The program, incorporating the SPACE for COPD manual, appears to provoke important changes in exercise capacity and breathlessness for individuals with COPD managed in primary care.

Motivations and barriers to exercise in chronic kidney disease: a qualitative study

BACKGROUND Exercise has the potential to modulate a number of complications associated with chronic kidney disease (CKD). However, typically, CKD patients lead very sedentary lifestyles, the reasons for which are not fully known. The aim of this qualitative study was to gain an understanding of the motivators, barriers and beliefs held by CKD patients regarding exercise. METHODS We conducted 3 focus groups and 22 semi-structured interviews. Data were collected from nephrology outpatient clinics in the United Kingdom. A total of 36 individuals with CKD stages 1-5 not requiring renal replacement therapy, aged 26-83 years participated in this study. This manuscript outlines the findings from patients with CKD stages 3-5. Focus groups and interviews were transcribed verbatim and analysed thematically. RESULTS Positive attitudes to exercise reflected autonomous motivations including: exercising for health; enjoyment and social interaction. Family support and goal setting were seen as motivators for exercise and the accessibility of local facilities influenced activity levels. Barriers to exercise were poor health, fear of injury or aggravating their condition, a lack of guidance from healthcare professionals and a lack of facilities. CONCLUSIONS These findings are an important first stage in the development of a CKD-specific exercise behaviour change intervention. Interventions should operate at multiple levels, with a focus on improving patient autonomy and exercise self-efficacy, support networks and the physical environment (e.g. the accessibility of local facilities). In addition, strategies are required to ensure that the healthcare system is actively promoting and routinely supporting exercise for all patients with CKD.

Important, misunderstood, and challenging: a qualitative study of nurses’ and allied health professionals’ perceptions of implementing self-management for patients with COPD

Background In light of the growing burden of COPD, there is increasing focus on the role of self-management for this population. Currently, self-management varies widely. Little is known either about nurses’ and allied health professionals’ (AHPs’) understanding and provision of self-management in clinical practice. This study explores nurses’ and AHPs’ understanding and implementation of supported COPD self-management within routine clinical practice. Materials and methods Nurses and AHPs participated in face-to-face semistructured interviews to explore their understanding and provision of COPD self-management, as well as their perceptions of the challenges to providing such care. Purposive sampling was used to select participants from a range of professions working within primary, community, and secondary care settings. Three researchers independently analyzed each transcript using a thematic approach. Results A total of 14 participants were interviewed. Nurses and AHPs viewed self-management as an important aspect of COPD care, but often misunderstood what it involved, leading to variation in practice. A number of challenges to supporting self-management were identified, which related to lack of time, lack of insight regarding training needs, and assumptions regarding patients’ perceived self-management abilities. Conclusion Nurses and AHPs delivering self-management require clear guidance, training in the use of effective self-management skills, and education that challenges their preconceptions regarding patients. The design of health care services also needs to consider the practical barriers to COPD self-management support for the implementation of such interventions to be successful.

The impact of exercising during haemodialysis on blood pressure, markers of cardiac injury and systemic inflammation - preliminary results of a pilot study

Background/Aims: Patients requiring haemodialysis have cardiovascular and immune dysfunction. Little is known about the acute effects of exercise during haemodialysis. Exercise has numerous health benefits but in other populations has a profound impact upon blood pressure, inflammation and immune function; therefore having the potential to exacerbate cardiovascular and immune dysfunction in this vulnerable population. Methods: Fifteen patients took part in a randomised-crossover study investigating the effect of a 30-min bout of exercise during haemodialysis compared to resting haemodialysis. We assessed blood pressure, plasma markers of cardiac injury and systemic inflammation and neutrophil degranulation. Results: Exercise increased blood pressure immediately post-exercise; however, 1 hour after exercise blood pressure was lower than resting levels (106±22 vs. 117±25 mm Hg). No differences in h-FABP, cTnI, myoglobin or CKMB were observed between trial arms. Exercise did not alter circulating concentrations of IL-6, TNF-α or IL-1ra nor clearly suppress neutrophil function. Conclusions: This study demonstrates fluctuations in blood pressure during haemodialysis in response to exercise. However, since the fall in blood pressure occurred without evidence of cardiac injury, we regard it as a normal response to exercise superimposed onto the haemodynamic response to haemodialysis. Importantly, exercise did not exacerbate systemic inflammation or immune dysfunction; intradialytic exercise was well tolerated.

Patient and Staff Perceptions of Intradialytic Exercise before and after Implementation: A Qualitative Study

Introduction Despite guidance and evidence for the beneficial effects of intradialytic exercise (IDE), such programmes are rarely adopted within practice and little is known about how they may best be sustained. The Theoretical Domains Framework (TDF) was used to guide the understanding of the barriers and facilitators to initial and ongoing IDE participation and to understand how these are influential at each stage. Materials and Methods Focus groups explored patient (n=24) and staff (n=9) perceptions of IDE prior to the introduction of a programme and, six months later, face to face semi-structured interviews captured exercising patients (n=11) and staffs’ (n=8) actual experiences. Data were collected at private and NHS haemodialysis units within the UK. All data were audio-recorded, translated where necessary, transcribed verbatim and subject to framework analysis. Results IDE initiation can be facilitated by addressing the pre-existing beliefs about IDE through the influence of peers (for patients) and training (for staff). Participation was sustained through the observation of positive outcomes and through social influences such as teamwork and collaboration. Despite this, environment and resource limitations remained the greatest barrier perceived by both groups. Conclusions Novel methods of staff training and patient education should enhance engagement. Programmes that clearly highlight the benefits of IDE should be more successful in the longer term. The barrier of staff workload needs to be addressed through specific guidance that includes recommendations on staffing levels, roles, training and skill mix.

Regular exercise during haemodialysis promotes an anti-inflammatory leukocyte profile

Abstract Background Cardiovascular disease is the most common cause of mortality in haemodialysis (HD) patients and is highly predicted by markers of chronic inflammation. Regular exercise may have beneficial anti-inflammatory effects, but this is unclear in HD patients. This study assessed the effect of regular intradialytic exercise on soluble inflammatory factors and inflammatory leucocyte phenotypes. Methods Twenty-two HD patients from a centre where intradialytic cycling was offered thrice weekly and 16 HD patients receiving usual care volunteered. Exercising patients aimed to cycle for 30 min at rating of perceived exertion of ‘somewhat hard’. Baseline characteristics were compared with 16 healthy age-matched individuals. Physical function, soluble inflammatory markers and leucocyte phenotypes were assessed again after 6 months of regular exercise. Results Patients were less active than their healthy counterparts and had significant elevations in measures of inflammation [interleukin-6 (IL-6), C-reactive protein (CRP), tumour necrosis factor-α (TNF-α), intermediate and non-classical monocytes; all P < 0.001]. Six months of regular intradialytic exercise improved physical function (sit-to-stand 60). After 6 months, the proportion of intermediate monocytes in the exercising patients reduced compared with non-exercisers (7.58 ± 1.68% to 6.38 ± 1.81% versus 6.86 ± 1.45% to 7.88 ± 1.66%; P < 0.01). Numbers (but not proportion) of regulatory T cells decreased in the non-exercising patients only (P < 0.05). Training had no significant effect on circulating IL-6, CRP or TNF-α concentrations. Conclusions These findings suggest that regular intradialytic exercise is associated with an anti-inflammatory effect at a circulating cellular level but not in circulating cytokines. This may be protective against the increased risk of cardiovascular disease and mortality that is associated with chronic inflammation and elevated numbers of intermediate monocytes.

S24 A self-management programme of activity, coping and education (SPACE) for COPD: A randomised non-inferiority trial in a pulmonary rehabilitation population

Introduction Self-managed programmes for patients with COPD offer an alternative to conventional pulmonary rehabilitation (PR). Previously reported self management (SM) programmes either offer short education sessions or action plans or are long intensive programme with a high level of support which are more comprehensive than tradition UK PR programmes. There is limited data reported on self managed approaches to PR which offer minimal support for education, skills acquisition and exercise in comparison to PR in the UK. We have recently developed a SM programme for patients with COPD (SPACE for COPD) and have completed studies in primary care1. The demand for PR is high but the service is compromised by limited access and drop out rates. Therefore the aim of this study was to determine if SPACE for COPD is noninferior to (as good as) PR for patients with COPD over 7 weeks. Methods 287 patients (187 male: mean (SD) age 67 (9) yrs; FEV1 1.25 (0.55); BMI 27.63 (6.22) kg/m2) with COPD were consented and randomised to either SPACE for COPD or PR. Those who were assigned to the SPACE for COPD group received an introduction to the SPACE for COPD manual and 2 telephone calls at 2 and 4 weeks. Those assigned to PR received 14, 2 hour sessions of education and exercise over 7 weeks. The primary outcome was the Chronic Respiratory Questionnaire (CRQ) dyspnoea, with secondary measure of CRQ fatigue, emotion and mastery, Incremental Shuttle Walk Test (ISWT) and Endurance Shuttle Walk Test (ESWT). Measures were taken at baseline and 7 weeks. Within and between group differences were analysed using paired and unpaired t-tests respectively. Results Please see table 1. Abstract S24 Table 1. SPACE for COPDn=94 Pulmonary Rehabilitationn=84 Between group differences Baseline(SD) 7 weeks(SD) Change(95% CI) Baseline(SD) 7 weeks(SD) Change(95% CI) (95% CI) Dyspnoea 2.58(0.93) 3.11(1.23) 0.55(0.26 to 0.85)p=<0.001 2.42(0.91) 3.38(1.18) 0.87(0.61 to 1.13)p<0.001 -0.32(-0.71 to 0.08)p=0.113 Fatigue 3.42(1.19) 3.71(1.22) 0.13(-0.14 to 0.39)p=0.339 3.36(1.20) 4.09(1.49) 0.54(0.27 to 0.82)p<0.001 -0.41(-0.79 to 0.03)p=0.033 Emotion 4.41(1.24) 4.56(1.20) 0.005(-0.23 to 0.24)p=0.965 4.37(1.24) 4.92(1.03) 0.53(0.26 to 0.79)p<0.001 -0.52(-0.88 to 0.17)p=0.004 Mastery 4.50(1.40) 4.78(1.31) 0.15(-0.11 to 0.40)p=0.259 4.36(1.30) 4.94(1.19) 0.58(0.34 to 0.81)p<0.001 -0.43(-0.77 to 0.09)p=0.014 ISWT (metres) 260.24(147.91) 277.86 (145.59) 17.62(3.26 to 31.98)P=0.17 268.61(149.89) 310.13 (156.46) 41.52(23.91 to 59.12) -23.90(-46.33 to -1.47)p=0.038 ESWT (seconds) 231.42(231.00) 444.33(393.09) 212.91(139.49 to 286.34)P<0.001 189.14(96.25) 534.85 (395.38) 345.70(260.20 to 431.20)p<0.001 -132.78(-244.63 to -20.94)p=0.02 Conclusion SPACE for COPD can improve dyspnoea and endurance capacity over 7 weeks to a similar level to PR, although it remains unclear to its noniferiority to PR. The SPACE for COPD programme does offer a number of health benefits despite it involving limited support and could offer a suitable alternative to patients with COPD who would otherwise not attend conventional rehabilitation. References Mitchell-Wagg K et al. (2012). Thorax 67 (Suppl_2) A25–26.

Exercise during hemodialysis does not affect the phenotype or prothrombotic nature of microparticles but alters their proinflammatory function

Hemodialysis patients have dysfunctional immune systems, chronic inflammation and comorbidity‐associated risks of cardiovascular disease (CVD) and infection. Microparticles are biologically active nanovesicles shed from activated endothelial cells, immune cells, and platelets; they are elevated in hemodialysis patients and are associated with chronic inflammation and predictive of CVD mortality in this group. Exercise is advocated in hemodialysis to improve cardiovascular health yet acute exercise induces an increase in circulating microparticles in healthy populations. Therefore, this study aimed to assess acute effect of intradialytic exercise (IDE) on microparticle number and phenotype, and their ability to induce endothelial cell reactive oxygen species (ROS) in vitro. Eleven patients were studied during a routine hemodialysis session and one where they exercised in a randomized cross‐over design. Microparticle number increased during hemodialysis (2064–7071 microparticles/μL, P < 0.001) as did phosphatidylserine+ (P < 0.05), platelet‐derived (P < 0.01) and percentage procoagulant neutrophil‐derived microparticles (P < 0.05), but this was not affected by IDE. However, microparticles collected immediately and 60 min after IDE (but not later) induced greater ROS generation from cultured endothelial cells (P < 0.05), suggesting a transient proinflammatory event. In summary IDE does not further increase prothrombotic microparticle numbers that occurs during hemodialysis. However, given acute proinflammatory responses to exercise stimulate an adaptation toward a circulating anti‐inflammatory environment, microparticle‐induced transient increases of endothelial cell ROS in vitro with IDE may indicate the potential for a longer‐term anti‐inflammatory adaptive effect. These findings provide a crucial evidence base for future studies of microparticles responses to IDE in view of the exceptionally high risk of CVD in these patients.

Implementing a theory-based intradialytic exercise programme in practice: a quality improvement project

ABSTRACT Background Research evidence outlines the benefits of intradialytic exercise (IDE), yet implementation into practice has been slow, ostensibly due to a lack of patient and staff engagement. The aim of this quality improvement project was to improve patient outcomes via the introduction of an IDE programme, evaluate patient uptake and sustainability and enhance the engagement of routine haemodialysis (HD) staff with the delivery of the IDE programme. Methods We developed and refined an IDE programme, including interventions designed to increase patient and staff engagement that were based on the Theoretical Domains Framework (TDF), using a series of ‘Plan, Do, Study, Act’ (PDSA) cycles. The programme was introduced at two UK National Health Service HD units. Process measures included patient uptake, withdrawals, adherence and HD staff involvement. Outcome measures were patient-reported functional capacity, anxiety, depression and symptomology. All measures were collected over 12 months. Results A total of 95 patients were enrolled in the IDE programme; 64 (75%) were still participating at 3 months, decreasing to 41 (48%) at 12 months. Adherence was high (78%) at 3 months, decreasing to 63% by 12 months. The provision of IDE by HD staff accounted for a mean of 2 (5%) sessions per 3-month time point. Patients displayed significant improvements in functional ability (P = 0.01) and a reduction in depression (P = 0.02) over 12 months, but the effects seen were limited to those who completed the programme. Conclusions A theory-based IDE programme is feasible and leads to improvement in functional capacity and depression. Sustaining IDE over time is complicated by high levels of patient withdrawal from the programme. Significant change at an organizational level is required to enhance sustainability by increasing HD staff engagement or access to professional exercise support.

Effects of intradialytic cycling exercise on exercise capacity, quality of life, physical function and cardiovascular measures in adult haemodialysis patients: a systematic review and meta-analysis

Background Intradialytic cycling (IDC), delivered during haemodialysis (HD), has the potential to improve many health issues. This systematic review and meta-analysis examine the evidence on the effects of IDC on exercise capacity, quality of life (QoL), physical function and cardiovascular health. Methods Twenty-four databases were searched alongside Internet and hand searching, and consultation with experts. Eligibility criteria were cluster randomized, randomized and quasi-randomized controlled trials (RCTs) of IDC versus usual care in prevalent adult HD patients. Primary outcome measures were exercise capacity (VO2 peak and field tests) and QoL. Secondary measures were cardiac and physical function. Results Thirteen RCTs were eligible. Eight provided data for use in meta-analyses, which indicated no significant change in VO2 peak (mean difference, MD 1.19 mL/kg/min, 95% confidence interval -1.15 to 3.52, P = 0.3), physical (mean change, MC 1.97, -8.27 to 12.22, P = 0.7) or mental component (MC 3.37, -7.94 to 14.68, P = 0.6) summary scores of the Medical Outcomes Short Form 36, pulse wave velocity (MD -0.57 m/s, -1.55 to 0.41, P = 0.4), systolic (MD -2.28 mmHg, -14.46 to 9.90, P = 0.7) or diastolic blood pressure (MD 2.25 mmHg, -3.01 to 7.50, P = 0.4) following IDC. IDC, however, leads to an improvement in performance on the 6-min walk test (MD 87.84 m, 39.60-136.09, P = 0.0004). All included studies were considered to have high risk of bias. Conclusions There is insufficient evidence demonstrating whether cycling exercise during HD improves patient outcomes. High-quality, adequately powered RCTs of IDC are required.