Laura Desveaux

An International Comparison of Pulmonary Rehabilitation: A Systematic Review

Abstract Background: Despite the strong evidence base, the perception remains that the provision of pulmonary rehabilitation (PR) services are extremely limited. Imbalances in PR delivery give rise to unnecessary health costs and underserviced populations. We conducted a systematic review to characterize the international provision of PR, comparing its structure and delivery across countries, and gaining insight into the availability of PR in relation to geographical prevalence. Methods: Electronic databases were searched from inception to September 2013 using the key words “pulmonary rehabilitation” and “survey.” Two authors independently reviewed studies and assessed study quality. Data was extracted and double-checked to ensure accuracy. Results: The majority of programs (55–99%) were offered in an outpatient setting with the exception of Ireland, where the majority of programs were offered in the community (65%). Exercise was the primary component across all programs (77–100%), followed by education (74–100%). Physical therapists were the most common member of the PR team (49–100%). Functional walk tests were the most frequently used outcome measure, although the specific test utilized varied across countries. The current availability of PR services ≤1.2% of individuals with COPD. Conclusion: Components provided in PR are similar, irrespective of country, while patient outcome measures demonstrated variation across countries. Recent surveys report the use of community resources for the delivery of PR programs, although the majority are outpatient based. The small number of potential individuals enrolled in PR suggests that an international increase in access and capacity would improve quality of life and reduce healthcare utilization in this population.

Self-management following an acute exacerbation of COPD: a systematic review.

BACKGROUND Self-management (SM) reduces hospital admissions in patients with stable COPD. However, its role immediately post-acute exacerbation (AE) is unclear. The objectives of this review were to describe SM interventions delivered immediately following an AE of COPD (AECOPD) and to conduct a systematic review with meta-analysis of its impact on health-care utilization and health outcomes. METHODS Randomized controlled trials reporting on SM interventions delivered during hospitalization for an AECOPD or within 1 month of hospital discharge were included. Seven articles were identified. Data were extracted and assessed for quality by two researchers. RESULTS By definition, all interventions included action plans, education, and at least two SM skills. Nurses were responsible for providing all SM interventions. The delivery and follow-up periods varied widely. At 12 months, there were no significant differences between those who completed the SM intervention and control subjects in the number of patients readmitted to hospital (P = .38), or in health-related quality of life (P = .27). No effects were found on rate of mortality, depressive symptoms, primary care usage, or exercise capacity. Minimal effects were found on self-efficacy, anxiety symptoms, and health promoting behavior. SM was associated with positive effects on knowledge and management of an AECOPD. CONCLUSIONS SM interventions delivered immediately post-AE vary widely and outcome measures are inconsistent, making it difficult to draw strong recommendations regarding its effectiveness. The evaluation of SM interventions, delivered by trained health-care professionals to selected patients and which offer structured follow-up, appears necessary.

Community-based exercise programs as a strategy to optimize function in chronic disease: a systematic review.

Background:Chronic diseases are the leading cause of death and disability worldwide. Preliminary evidence suggests that community-based exercise (CBE) improves functional capacity (FC) and health-related quality of life (HRQL). Objective:To describe the structure and delivery of CBE programs for chronic disease populations and compare their impact on FC and HRQL to standard care. Research Design:Randomized trials examining CBE programs for individuals with stroke, chronic obstructive pulmonary disease, osteoarthritis, diabetes, and cardiovascular disease were identified. Quality was assessed using the Cochrane risk of bias tool. Meta-analyses were conducted using Review Manager 5.1. The protocol was registered on PROSPERO (CRD42012002786). Results:Sixteen studies (2198 individuals, mean age 66.8±4.9 y) were included to describe program structures, which were comparable in their design and components, irrespective of the chronic disease. Aerobic exercise and resistance training were the primary interventions in 85% of studies. Nine studies were included in the meta-analysis. The weighted mean difference for FC, evaluated using the 6-minute walk test, was 41.7 m (95% confidence interval [CI], 20.5–62.8). The standardized mean difference for all FC measures was 0.18 (95% CI, 0.05–0.3). The standardized mean difference for the physical component of HRQL measures was 0.21 (95% CI, 0.05–0.4) and 0.38 (95% CI, 0.04–0.7) for the total score. Conclusions:CBE programs across chronic disease populations have similar structures. These programs appear superior to standard care with respect to optimizing FC and HRQL in individuals with osteoarthritis; however, the effect beyond this population is unknown. Long-term sustainability of these programs remains to be established.

Yoga in the Management of Chronic Disease: A Systematic Review and Meta-analysis.

Background:Heart disease, stroke, and chronic obstructive pulmonary disease (COPD) are the leading causes of death and disability worldwide. Although individuals with these conditions have been reported to benefit from yoga, its effectiveness remains unclear. Objective:To perform a systematic review of the effectiveness of yoga on exercise capacity, health related quality of life (HRQL), and psychological well-being for individuals with chronic disease and describe the structure and delivery of programs. Research Design:We performed a systematic review of randomized controlled trials examining yoga programs for individuals with heart disease, stroke, and COPD compared with usual care. Quality was assessed using the Cochrane risk of bias tool. Meta-analyses were conducted using Review Manager 5.3. The protocol was registered on PROSPERO (CRD42014014589). Results:Ten studies (431 individuals, mean age 56±8 y) were included and were comparable in their design and components, irrespective of the chronic disease. The standardized mean difference for the mean change in exercise capacity was 2.69 (95% confidence interval, 1.39–3.99) and for HRQL it was 1.24 (95% confidence interval, −0.37 to 2.85). Symptoms of anxiety were reduced after yoga in individuals with stroke, although this was not observed in individuals with COPD. The effect of yoga on symptoms of depression varied across studies with no significant effects compared with usual care. Conclusions:Yoga programs have similar designs and components across chronic disease populations. Compared with usual care, yoga resulted in significant improvements in exercise capacity and a mean improvement in HRQL. Yoga programs may be a useful adjunct to formal rehabilitation programs.

Participant experiences of a community-based maintenance program post-pulmonary rehabilitation:

The aim of the present study was to describe the perspectives of individuals with chronic obstructive pulmonary disease (COPD) who participated in a minimally supervised maintenance exercise intervention and identify the barriers and facilitators associated with participation. The intervention was delivered in a community center and was designed to maintain exercise capacity and quality of life following discharge from pulmonary rehabilitation. This study utilized qualitative focus groups (FGs) involving individuals with COPD (n = 12) who had been attending the maintenance community program for at least 6 months. All individuals who met the inclusion criteria for the FGs consented to participate. Four themes were identified: (1) issues around attendance; (2) perceived benefits of the program; (3) perceived burdens of the program; and (4) recommendations for program improvement. Participants expressed more benefits than barriers, stating that their experience of improved function and quality of life facilitated their attendance. Barriers included exacerbations, fatigue, access to transportation, and weather. Participants endorsed the benefits of a community-based maintenance exercise program after pulmonary rehabilitation. Minimally supervised community-based programs with access to a case manager may provide a useful approach to enhancing adherence to exercise.

What Makes a Leader: Identifying the Strengths of Canadian Physical Therapists

ABSTRACT Purpose: To identify the personal strengths of Canadian physical therapists who hold leadership positions and compare them with the strengths of Canadian physical therapists who do not occupy positions of leadership. Methods: A quantitative, cross-sectional online survey was distributed to registered Canadian physical therapists. We used the Clifton StrengthsFinder to evaluate 34 characteristics and determine which characteristics described a participants strengths. Population demographics and leadership strengths were described via frequency distributions and percentages; chi-square analyses and Fishers exact tests were used to compare differences between groups. Results: Of 173 physical therapists who completed the survey, 108 occupied a position of leadership, and 65 did not. Those in the leader group had significantly more experience and achieved a higher level of education. Leaders most frequently exhibited the strengths of learner, achiever, responsibility, input, and strategic, whereas non-leaders most frequently displayed strengths of learner, achiever, input, relator, and harmony. Leaders were significantly more likely than non-leaders to possess the achiever strength. Gender, level of education, and years of experience did not significantly influence which strengths were present in the leadership profile. Conclusions: There is substantial overlap between leaders and non-leaders in terms of leadership profiles. Future research should investigate whether leadership strengths vary depending on the leadership position occupied and whether leadership development initiatives promote leadership strengths.

Leadership in Physical Therapy: Characteristics of Academics and Managers: A Brief Report

Purpose: To explore the characteristics of physical therapy leaders in academic and managerial roles. Methods: This quantitative, cross-sectional study used an online questionnaire administered via email to Canadian physical therapists recruited through the Canadian Physiotherapy Association and via additional emails targeted to academic and health care institutions. Individuals who met the inclusion criteria after completion of the questionnaire were asked to complete the Clifton StrengthsFinder, which was used to objectively assess the extent to which participants exhibited personality characteristics. We calculated frequencies for demographic characteristics and the 10 most prominent characteristics for participants in academic and managerial roles. Results: A total of 88 participants completed the questionnaire (52 managers, 36 academics). The most prevalent strengths among both academics and managers were the learner and achiever characteristics. Conclusions: Academics and managers in physical therapy share similar core characteristics, with slight variations in secondary characteristics.

Barriers to care in patients with diabetes and poor glycemic control—A cross-sectional survey

Aims To determine and quantify the prevalence of patient, provider and system level barriers to achieving diabetes care goals; and to examine whether barriers were different for people with poor glycemic control (HbA1c ≥ 10%; 86 mmol/mol) compared to fair glycemic control (7 to <8%; 53–64 mmol/mol). Methods We administered a survey by telephone to community-dwelling patients with diabetes, to examine patient-reported barriers and facilitators to care. We compared responses in individuals with HbA1c ≥ 10% (86 mmol/mol) against those with HbA1c between 7–8% (53–64 mmol/mol). We examined associations between HbA1c group and barriers to care, adjusting for sociodemographic factors and diabetes duration. Results The survey included 805 people with HbA1c ≥ 10% (86 mmol/mol), and 405 people with HbA1c 7–8% (53–64 mmol/mol). Participants with HbA1c ≥ 10% (86 mmol/mol) reported good access to care, however 20% of participants with HbA1c ≥ 10% (86 mmol/mol) felt that their care was not well-coordinated and 9.6% reported having an unmet health care need. In adjusted analysis, patients with HbA1c ≥10% (86 mmol/mol) were more likely to report lack of confidence and inadequate social support, compared to patients with HbA1c 7–8% (53–64 mmol/mol). They were also significantly more likely not to have drug insurance nor to have received recommended treatments because of cost. Conclusions These results reinforce the importance of an individualized, yet multi-faceted approach. Specific attention to financial barriers seems warranted. These findings can inform the development of programs and initiatives to overcome barriers to care, and improve diabetes care and outcomes.

A randomized wait-list control trial to evaluate the impact of a mobile application to improve self-management of individuals with type 2 diabetes: a study protocol

BackgroundManagement of diabetes through improved glycemic control and risk factor modification can help prevent long-term complications. Much diabetes management is self-management, in which healthcare providers play a supporting role. Well-designed e-Health solutions targeting behavior change can improve a range of measures, including glycemic control, perceived health, and a reduction in hospitalizations.MethodsThe primary objective of this study is to evaluate if a mobile application designed to improve self-management among patients with type 2 diabetes (T2DM) improves glycemic control compared to usual care. The secondary objectives are to determine the effects on patient experience and health system costs; evaluate how and why the intervention worked as observed; and gain insight into considerations for system-wide scale-up. This pragmatic, randomized, wait-list-control trial will recruit adult participants from three Diabetes Education Programs in Ontario, Canada. The primary outcome is glycemic control (measured by HbA1c). Secondary outcomes include patient-reported outcomes and patient-reported experience measures, health system utilization, and intervention usability. The primary outcome will be analyzed using an ANCOVA, with continuous secondary outcomes analyzed using Poisson regression. Direct observations will be conducted of the implementation and application-specific training sessions provided to each site. Semi-structured interviews will be conducted with participants, healthcare providers, organizational leaders, and system stakeholders as part of the embedded process evaluation. Thematic analysis will be applied to the qualitative data in order to describe the relationships between (a) key contextual factors, (b) the mechanisms by which they effect the implementation of the intervention, and (c) the impact on the outcomes of the intervention, according to the principles of Realist Evaluation.DiscussionThe use of mobile health and virtual tools is on the rise in health care, but the evidence of their effectiveness is mixed and their evaluation is often lacking key contextual data. Results from this study will provide much needed information about the clinical and cost-effectiveness of a mobile application to improve diabetes self-management. The process evaluation will provide valuable insight into the contextual factors that influence the application effectiveness, which will inform the potential for adoption and scale.Trial registrationClinicaltrials.gov NCT02813343. Registered on 24 June 2016 (retrospectively registered).Trial Sponsor: Ontario Telemedicine Network

Barriers to Physical Activity Following Rehabilitation: Perspectives of Older Adults with Chronic Disease

Nonadherence to exercise is a main cause of reduced function for older adults with chronic disease following completion of rehabilitation. This quantitative study used a questionnaire to evaluate the barriers and facilitators to community-based exercise following rehabilitation, from the perspectives of older adults with chronic diseases and their healthcare professionals (HCPs). Questionnaires were administered one-on-one to 83 older adults and 35 HCPs. Those with chronic disease perceived cost (43%), travel time (43%), and physical symptoms (39%) as primary barriers to program participation, with similar perceptions across all chronic conditions. Access to a case manager (82%), a supported transition following rehabilitation (78%), and a condition-specific program (78%) were the primary facilitators. Significant between group differences were found between HCPs and older adults with chronic disease across all barriers (p < .001), with a greater number of HCPs perceiving barriers to exercise participation. There were no between-group differences in the perception of factors that facilitate participation in exercise.