Liam Humphreys

Pragmatic intervention for increasing self-directed exercise behaviour and improving important health outcomes in people with multiple sclerosis: A randomised controlled trial

Background: Exercise programmes that can demonstrate evidence of long-lasting clinical effectiveness are needed for people with multiple sclerosis (PwMS). Objective: The objective of this study was to assess the effects of a practically implemented exercise programme on self-directed exercise behaviour and important health outcomes in PwMS to nine months of follow-up. Methods: We conducted a parallel-arm, randomised controlled trial: 120 PwMS (Expanded Disability Status Scale (EDSS) 1.0–6.5) randomised to a three-month exercise intervention plus usual care, or usual care only. Two supervised plus one home-exercise session (weeks 1–6) were followed by one supervised and two home-exercise sessions (weeks 7–12). Cognitive-behavioural techniques promoted long-term exercise behaviour change. Outcomes were blindly assessed at baseline and at three and nine months after randomisation. The primary outcome was self-reported exercise behaviour (Godin Leisure Time Exercise Questionnaire (GLTEQ)). Secondary outcomes included fatigue and health-related quality of life (HRQoL). Results: The intervention increased self-reported exercise (9.6 points; 95% CI: 2.0 to 17.3 points; p = 0.01) and improved fatigue (p < 0.0001) and many HRQoL domains (p ≤ 0.03) at three months. The improvements in emotional well-being (p = 0.01), social function (p = 0.004) and overall quality of life (p = 0.001) were sustained for nine months. Conclusion: This pragmatic approach to implementing exercise increases self-reported exercise behaviour, improves fatigue and leads to a sustained enhancement of HRQoL domains in PwMS.

Standing still in the street: Experiences, knowledge and beliefs of patients with intermittent claudication-A qualitative study

OBJECTIVES To explore the experiences of individuals living with intermittent claudication (IC) owing to peripheral artery disease (PAD), their knowledge about the condition, and their thoughts about being asked to walk more and an intervention to promote walking. METHODS We conducted five focus group sessions with 24 people (71% male; mean age, 71 years) diagnosed with IC with no prior lower extremity revascularization. RESULTS Two overriding themes emerged: uncertainty and lack of support/empathy. Participants expressed uncertainty about PAD and IC, how risk factors work, and whether lifestyle change, particularly walking, would help. They also expressed dissatisfaction with and lack of empathy from the medical professionals encountered, with feelings of being dismissed and left on their own. There was enthusiasm for an education program to support their self-management of the disease. CONCLUSIONS Addressing the knowledge gaps and uncertainty around the disease process and walking will be critical to providing impetus to behavior change. A structured education approach to address these issues seems to be desirable and acceptable to those living with PAD. PRACTICE IMPLICATIONS Those working with PAD patients should provide clear and consistent information about the disease process and specific information on walking, as well as support to enable and manage behavior change.

The development and pilot randomised controlled trial of a group education programme for promoting walking in people with intermittent claudication.

The aim of this study was to develop and pilot a group education programme for promoting walking in people with intermittent claudication. Patient focus groups (n=24) and literature reviews were conducted to inform the development of the education programme, which involves a three-hour group-based education workshop and follow-up telephone support. A pilot study was subsequently conducted in which 23 new patients (Rutherford category 1–3) were randomly assigned to usual care (control) or usual care plus the education programme. Outcomes were assessed at baseline and six weeks including daily steps (tri-axial accelerometer), walking capacity (six-minute walk test and Gardner treadmill test), and quality of life (Intermittent Claudication Questionnaire [ICQ]). Exit interviews were conducted to assess the acceptability and usefulness of the programme. Compared with controls, the intervention group had superior walking capacity and quality of life at six weeks. Mean differences in six-minute walk distance, treadmill maximum walking distance and ICQ score were 44.9 m (95% confidence interval [CI], 6.9 to 82.9), 173 m (95% CI, 23 to 322), and −10.6 (95% CI, −18.9 to −2.3), respectively. The daily step count did not differ between groups. The exit interviews indicated that participants valued attending the programme, that it gave them a greater understanding of their condition, and that they had been walking more for exercise since attending. The results suggest that the education programme is feasible, acceptable, and potentially useful for improving walking capacity and quality of life. A fully-powered trial exploring clinical and cost effectiveness is needed. TRIAL REGISTRATION NUMBER: ISRCTN06733130 (http://www.controlled-trials.com).

Validation of the English version of the Walking Estimated-Limitation Calculated by History (WELCH) questionnaire in patients with intermittent claudication

The Walking Estimated-Limitation Calculated by History (WELCH) questionnaire has recently been proposed as a valid and simple instrument for assessing walking limitation in patients with intermittent claudication. The aim of this study was to validate an English version of the WELCH questionnaire in an English native population. Thirty-nine patients (ankle–brachial index 0.59 ± 0.16, age 65 ± 11 years, 82% male) completed an English version of the WELCH questionnaire. Maximum walking distance was measured objectively using the Gardner–Skinner treadmill test and the 6-minute walk test. The median WELCH score was 24 (9–39). Maximum walking distances were 412 m (149–675 m) for the treadmill test and 381 ± 88 m for the 6-minute walking test. The Spearman’s correlation coefficient was ρ = 0.59 between the WELCH score and treadmill distance (p < 0.001) and ρ = 0.82 between the WELCH score and 6-minute walk distance (p < 0.001). These findings suggest that the English version of the WELCH questionnaire is a valid instrument for assessing walking impairment in patients with intermittent claudication.

Sheffield Hallam Staff Wellness service: Four-year follow-up of the impact on health indicators

Aims: Alongside the increasing prevalence of chronic health conditions such as cardiovascular disease and diabetes has been an increase in interventions to reverse these ill-health trends. The aim of this study was to examine the longitudinal impact of the Sheffield Hallam University Staff Wellness Service on health indicators over a five-year period. Methods: The Sheffield Hallam Staff Wellness Service was advertised to university employees. Of 2651 employees who have attended the service, 427 respondents (male = 162, female = 265) aged 49.86 ± 12.26 years attended for five years (4 years follow-up). Each year, participants were assessed on a range of health measures (i.e. cardio-respiratory fitness, body mass index, blood pressure, total cholesterol, high-density lipoproteins, lung function and percentage body fat). Participants also received lifestyle advice (based on motivational interviewing) as part of the intervention to either improve, or in some cases maintain, their current health behaviours (e.g. increased physical activity and diet change). Results: The wellness service improved staff health for those with an ‘at risk’ health profile from baseline. These improvements were maintained in subsequent follow-up assessments. Improvement from baseline to 1-year follow-up was observed for all health indicators as was the maintenance of this improvement in years 2, 3 and 4. Conclusions: The service demonstrates that a university-based wellness service using a combination of motivational interviewing and health screening to elicit behaviour change (and subsequent improvements in health-related outcomes) was successful in improving the health of employees with an ‘at risk’ profile.

Exercise in the Treatment of Multiple Sclerosis: Pragmatic Exercise Intervention in People With Mild to Moderate Multiple Sclerosis—The ExIMS Project

Exercise has been shown to be effective in improving health outcomes of people with multiple sclerosis (MS). However, systematic reviews and meta-analysis into the benefits of exercise for people with MS have highlighted a need for robustly designed research trials.This chapter discusses the development, implementation, and findings of a pragmatically designed exercise trial in people with MS, the ExIMS (Exercise Interventions in Multiple Sclerosis) trial. The pragmatic approach adopted in the ExIMS trial involved a tailored exercise program guided by the individual and cognitive behavioral techniques to promote long-term adherence. The results from the ExIMS trial increased self-reported exercise behavior, improved fatigue, and led to a sustained enhancement of health-related quality of life in people with MS.The results provide evidence that a pragmatic approach to exercise can have important long-term health benefits that improve self-management in people with MS. The ExIMS should offer encouragement to health professionals to motivate individuals with MS to exercise.

Qualitative Investigation of Exercise Perceptions and Experiences in People With Multiple Sclerosis Before, During, and After Participation in a Personally Tailored Exercise Program

OBJECTIVE To undertake a qualitative investigation of exercise perceptions and experiences in people with multiple sclerosis (PwMS) before, during, and after participation in a personally tailored program designed to promote long-term maintenance of self-directed exercise. DESIGN Focus groups and semistructured telephone interviews. SETTING University exercise science department close to the recruiting hospital. PARTICIPANTS PwMS (N=33; mean age ± SD, 47.6±7.9y). INTERVENTIONS Participants were recruited after participation in a randomized controlled exercise trial; all had been allocated to a 12-week exercise program comprising supervised and self-directed exercise sessions. MAIN OUTCOME MEASURES Exercise perceptions and experiences before, during, and after participation in the program. RESULTS Four themes emerged from the analysis: (1) the transition to inactivity; (2) lack of knowledge and confidence; (3) positive exercise experiences; and (4) perspectives on exercise adherence. CONCLUSIONS Lack of confidence and exercise knowledge, coupled with negative perceptions about physical capabilities after an MS diagnosis, are clear barriers to exercise participation in PwMS. These issues are not being adequately addressed as part of the health care pathway or in community settings. Perceptions of improved posture, ability to overcome everyday difficulties, acute mood enhancements during and after exercise, and increased opportunities for social interaction were among the reported benefits of exercise participation. Despite the provision of a personally tailored exercise plan and use of cognitive behavioral strategies, self-directed exercise continued to present challenges to PwMS, and the importance of seeking cost-effective ways to maintain motivational support was implicit in participant responses.