Lisa Robinson

Potential strategies to improve uptake of exercise interventions in non-alcoholic fatty liver disease

BACKGROUND & AIMS The management of non-alcoholic liver disease (NAFLD) concerns lifestyle modification and exercise; however, adherence is poor. Factors such as lack of confidence to exercise, poor understanding of the benefits of exercise, and a fear of falling all influence engagement in physical activity. To increase exercise in NAFLD it is important to understand the barriers to performing it. METHODS Three chronic liver disease cohorts were identified from the Newcastle Liver Database: NAFLD (n=230), alcoholic liver disease (ALD, n=110) and primary biliary cirrhosis (PBC, n=97). Assessment tools were completed by all subjects: Outcome Expectation for Exercise Scale (OEES, understanding the benefits of exercise, lower scores indicate greater understanding), Self-Efficacy for Exercise Scale (SEES, confidence to exercise), Falls Efficacy Scale-International (FES-I, higher scores indicate greater fear of falling). Activity was analysed from a functional perspective using the PROMIS-HAQ. RESULTS Understanding the benefits of exercise was similar across each group [median OEES scores: NAFLD 2.38 (range 0.0-5.0), ALD 2.25 (0.0-5.0), PBC 2.28 (1.0-5.0), p=0.6]. In NAFLD confidence to exercise was significantly lower [median SEES score 0.0 (0.0-10.0), PBC 4.5 (0.0-10.0), p<0.001]. Fear of falling was similar in NAFLD and PBC, and greatest in ALD [22 (0-64), 22 (3-64), 30 (0-64), p=0.044]. In NAFLD, fear of falling was independently associated with increasing difficulty performing activity. CONCLUSIONS NAFLD patients understand the benefits of exercise but lack confidence to perform it. Fear of falling was independently associated with more difficulty performing activity. Fear of falling and confidence are modifiable and potential targets to improve uptake and adherence for exercise intervention.

Loss of capacity to recover from acidosis in repeat exercise is strongly associated with fatigue in primary biliary cirrhosis

BACKGROUND & AIMS Upon exercise, primary biliary cirrhosis (PBC) is associated with significant acidosis in peripheral muscle with recovery rate from acidosis strongly associating with fatigue. PBC patients describe particular problems with repeat exercise describing subsequent exercise episodes being limited by perceived effects of the first. We modelled this effect by exploring kinetics of pH recovery during 3 linked exercise episodes using magnetic resonance spectroscopy (MRS). METHODS Muscle acid handling capacity was studied following 3 x 3 min exercise periods at 35% maximum voluntary capacity in matched fatigued PBC, non-fatigued PBC and healthy controls (n=8 per group). RESULTS Time to pH recovery following initial exercise was prolonged in PBC compared to controls (160 s [60-390] vs. 25 [0-180], p=0.005) with the longest recovery time seen in fatigued patients (median 210 s). All subjects shortened recovery time between exercise periods 1-2 (controls: mean -28%, non-fatigued PBC patients: -29% and fatigued PBC patients: -30%. Normals showed further recovery shortening between exercise periods 2-3 (-18%, p=ns vs. period 1-2 recovery) however this adaptive response was lost in non-fatigued PBC patients (+3%) and reversed in fatigued patients (+19%, p=0.01 vs. period 1-2). CONCLUSIONS PBC patients retain the physiological capacity to shorten pH recovery time following repeat exercise. Capacity to shorten recovery time after a 2nd exercise period is lost in low-fatigue PBC patients and replaced by recovery prolongation in fatigued patients. Improvement in post-exercise acid recovery through exercise therapy should be possible in PBC patients and could be a novel approach to peripheral fatigue treatment.

Self-management and adherence with exercise-based falls prevention programmes: a qualitative study to explore the views and experiences of older people and physiotherapists

Abstract Purpose: The aim of this study was to involve older people and physiotherapists in the development of acceptable strategies to promote uptake and adherence with an exercise-based falls prevention programme. Method: Focus groups were conducted with older people attending a regional falls and syncope service (3 groups, total 12 participants) and local physiotherapists (4 groups, total 18 participants). Framework analysis was undertaken to identify why uptake and adherence with an exercise-based falls prevention programme is currently poor and to provide suggestions for how it might be improved. Results: The older people participated in an exercise-based falls prevention programme to remain independent in activities of daily living. They valued approaches that promoted self-efficacy and self-management. In contrast, the physiotherapists perceived that many older people were reluctant to participate in an exercise-based falls prevention programme. While it was acknowledged that older people should be encouraged to take greater responsibility for the maintenance of their own health, the physiotherapists demonstrated a conflicting desire to remain in control of the treatment programme. Conclusions: A focus on self-management support may provide the key to promoting uptake and adherence with an exercise-based falls prevention programme. Physiotherapists should move from being “experts” to “enablers” who use their professional knowledge and expertise to support older people at risk of falling to maintain optimum levels of health and independence. Implications for Rehabilitation Despite the established efficacy of exercise-based falls prevention programmes, their impact remains limited by low levels of uptake and adherence. Clinical encounters between physiotherapists and older people at risk of falling offer the opportunity for the exchange of new information to promote patient empowerment and shared decision-making. Physiotherapists need to move away from being experts who care for and do to their patients to enable us to use their professional knowledge and expertise to maintain optimum levels of health and independence for older people at risk of falling.

Professionals and the public: power or partnership in health research?

RATIONALE, AIMS AND OBJECTIVES Involving members of the public in health research is said to produce higher quality research of greater clinical relevance. However, many of the anecdotal accounts of public involvement published in the academic literature to date have focused on the process of recruiting and involving members of the public and the effect of participation on these individuals rather than on how public involvement influenced the research process or outcomes. To strengthen the evidence base, there is clearly a need for more formal methods of capturing and documenting the impact of public involvement in health research. METHODS In the first half of this paper, we discuss the importance of public involvement in health research and critically review the literature to identify current barriers to its successful implementation. In the second half, we present a conceptual model for evaluating and reporting the impact of public involvement in health research. Developed from our examination of the academic literature, we provide empirical support for the model by applying it to our recent experience of conducting a clinically based falls prevention study with members of the public. RESULTS The conceptual model presented in this paper proposes key concepts and terminology that promote consistency when evaluating and reporting the impact of public involvement in health research. Reflecting on the experiential learning process, we demonstrate how the model promotes conceptual clarity whilst permitting the degree of flexibility required when working in a diverse culture such as the National Health Service. CONCLUSION If more evidence can be provided that public involvement enhances research processes and outcomes, researchers may be less inclined to treat this initiative as something they have to do in order to satisfy funding agencies and regulatory bodies and actively embrace this phenomenon, producing accounts of successful public involvement that transcend current barriers to its successful implementation.

Is late-life dependency increasing or not? A comparison of the Cognitive Function and Ageing Studies (CFAS)

Summary Background Little is known about how the proportions of dependency states have changed between generational cohorts of older people. We aimed to estimate years lived in different dependency states at age 65 years in 1991 and 2011, and new projections of future demand for care. Methods In this population-based study, we compared two Cognitive Function and Ageing Studies (CFAS I and CFAS II) of older people (aged ≥65 years) who were permanently registered with a general practice in three defined geographical areas (Cambridgeshire, Newcastle, and Nottingham; UK). These studies were done two decades apart (1991 and 2011). General practices provided lists of individuals to be contacted and were asked to exclude those who had died or might die over the next month. Baseline interviews were done in the community and care homes. Participants were stratified by age, and interviews occurred only after written informed consent was obtained. Information collected included basic sociodemographics, cognitive status, urinary incontinence, and self-reported ability to do activities of daily living. CFAS I was assigned as the 1991 cohort and CFAS II as the 2011 cohort, and both studies provided prevalence estimates of dependency in four states: high dependency (24-h care), medium dependency (daily care), low dependency (less than daily), and independent. Years in each dependency state were calculated by Sullivans method. To project future demands for social care, the proportions in each dependency state (by age group and sex) were applied to the 2014 England population projections. Findings Between 1991 and 2011, there were significant increases in years lived from age 65 years with low dependency (1·7 years [95% CI 1·0–2·4] for men and 2·4 years [1·8–3·1] for women) and increases with high dependency (0·9 years [0·2–1·7] for men and 1·3 years [0·5–2·1] for women). The majority of mens extra years of life were spent independent (36·3%) or with low dependency (36·3%) whereas for women the majority were spent with low dependency (58·0%), and only 4·8% were independent. There were substantial reductions in the proportions with medium and high dependency who lived in care homes, although, if these dependency and care home proportions remain constant in the future, further population ageing will require an extra 71 215 care home places by 2025. Interpretation On average older men now spend 2·4 years and women 3·0 years with substantial care needs, and most will live in the community. These findings have considerable implications for families of older people who provide the majority of unpaid care, but the findings also provide valuable new information for governments and care providers planning the resources and funding required for the care of their future ageing populations. Funding Medical Research Council (G9901400) and (G06010220), with support from the National Institute for Health Research Comprehensive Local research networks in West Anglia and Trent, UK, and Neurodegenerative Disease Research Network in Newcastle, UK.

Staying Steady: A community-based exercise initiative for falls prevention

Over the past decade falls in the older population have become a priority in government policy. There is good evidence to suggest that tailored exercise effectively reduces falls; however, much of this evidence takes the form of randomized controlled trials that do not reflect the diversity of clinical practice. In response to emerging evidence, a community falls prevention program, called Staying Steady, was developed targeting older people at risk of falls. The program was evaluated using a mixed methods approach to capture both the personal experiences of the five participants, and any measurable clinical outcomes. The narrative accounts, supported by the measurable clinical outcomes, indicated that it was possible to replicate the results of large trials at a local level. The qualitative aspect of the evaluation enabled detailed consideration of other issues important to falls prevention programs. A social cognitive model was used to explain the reasons why participants either did, or did not, adhere to the program. The acceptability of the program to the participants was also explored in detail. Recommendations have been made to develop the Staying Steady program for future service users.

Promoting self‐management and adherence with strength and balance training for older people with long‐term conditions: a mixed‐methods study

RATIONALE, AIMS AND OBJECTIVES In the context of an ageing population, increasing numbers of older people with long-term conditions are presenting to secondary health care facilities in the United Kingdom having experienced a fall or fall-related injury. Despite such observations, falls and long-term conditions have traditionally been regarded as entirely separate entities. The purpose of this study was to explore the process of behaviour change in a small sample of older people with the fall-associated chronic liver disease primary biliary cirrhosis (PBC) receiving either a standard or an enhanced programme of strength and balance training (SBT). METHODS A qualitatively driven mixed-methods approach was employed that juxtaposed semi-structured interviews with graphical representations of patient-reported outcome measures collected during the course of an experimental case series in nine older people with the fall-associated chronic liver disease PBC. RESULTS Participants receiving both the standard and enhanced intervention completed the programme of SBT as instructed throughout the course of the case series. However, only the enhanced intervention, which focused on self-determination and self-management support, was associated with continued active participation on completion of the programme. CONCLUSIONS Longer, but not necessarily more intensive, periods of clinical intervention are necessary to support individuals at risk of falling to move through the incremental stages of behaviour change. Effective self-management support should focus on the development of a wide range of strategies and behaviours to empower older people with long-term conditions develop an ongoing active commitment to SBT.

Medication usage change in older people (65+) in England over 20 years: findings from CFAS I and CFAS II.

Background the number of people requiring care home support is projected to rise in future years, but little information is available on the needs of new care home residents. Objective to measure the health and functioning of people moving into care homes and how they have changed between 2002 and 2015. Setting English Longitudinal Study of Ageing. Participants two hundred fifty-four of the 313 (1.99%) individuals who moved from the community into a care home, and were interviewed in the survey wave prior to entry. Main outcome measures changes over time for number of health conditions and functional deficits (deficits in activities of daily living (ADL), and instrumental ADLs (IADLs)), assessed in the survey wave prior to admission. Results over time there were significant increases in the total number of health conditions and functional deficits amongst soon to be care home entrants (P = 0.0011), the proportion with high blood pressure (OR 1.37, 95% CI: 1.17–1.62, P < 0.0001), memory problems (OR 1.33, 95% CI: 1.11–1.61, P = 0.0021) or total number of IADL deficits (P = 0.008). Non-significant increases were observed in the proportion of care home entrants with cancer (OR 1.23, 95% CI: 0.93–1.65, P = 0.15), lung disease (OR 1.21, 95% CI: 0.85–1.75), heart disease (OR 1.12, 95% CI: 0.95–1.30) and arthritis (OR 1.11, 95% CI: 0.95–1.30). Stroke and ADL deficits did not increase. No differential ageing effect was observed. Conclusions the support needs of care home entrants in England appear to be increasing over time. This has important implications for the provision and funding of care home places and community services.Background medical practice has changed over the last decades reflecting the ageing population, when multi-morbidity requiring multiple medications is more common. Objective describe and quantify self-reported medicine use including both prescription and over the counter medicines in two comparable population-based studies of older people (65+) in England and to assess the nature and scale of polypharmacy. Methods data used were from two separate population-based studies; the Cognitive Function Ageing Study I and II. Descriptive analyses were performed to summarise and quantify general medicine use. Negative binomial regression models were fitted to determine factors associated with the number of medicines used. Results medication use, including both prescribed medicines and over the counter products has increased dramatically over the last 2 decades. The number of people taking five or more items quadrupled from 12 to 49%, while the proportion of people who did not take any medication has decreased from around 1 in 5 to 1 in 13. Cardiovascular drugs were the most frequently taken medication. Polypharmacy is associated with increases in the number of diagnosed long-term conditions. Conclusions comparison between CFAS I and II reveals marked increases in medication usage and polypharmacy in the older population. The influence of healthcare organisation, introduction of new guidelines and technology changes leading to diagnosis of earlier, milder chronic diseases and treatment may be contributing to this changing pattern. Further research is needed to develop practical solutions to optimise medication management in older people, reducing the harming associated with medication.

Patients' perceptions of repair, rehabilitation and recovery after major orthopaedic trauma: a qualitative study.

INTRODUCTION The most common major trauma injuries are multiple fractures. Orthopaedic trauma research has traditionally focused on surgical techniques, and the impact of this major life event on the patient is not well understood. This study explored how patients make sense of their rehabilitation and recovery following major orthopaedic trauma. DESIGN Qualitative study using an Interpretative Phenomenological Analysis approach. METHODS Semi-structured interviews of a purposive sample of 15 patients 3 to 6 months after sustaining major orthopaedic injuries, treated at a major trauma centre in England. FINDINGS Recovery after trauma was conceptualised as a journey through repair and rehabilitation to achieve recovery. These phases were represented by three superordinate themes: getting back on your feet, getting the right help to get there, and regaining a sense of normality. Participants considered orthopaedic consultants and physiotherapists to be the primary professionals to provide the tools to enable them to help themselves. Improving physical function helped to restore emotional well-being, with recovery only attained when participants had normalised a new sense of self, and regained confidence or enjoyment in their chosen activities. CONCLUSION Rehabilitation is a complex process of coming to terms with physical and social limitations to normalise a new sense of self. Individuals considered rehabilitation to be their responsibility; however, they needed expert help to know what to do. Physiotherapists were key to getting people back on their feet, and by facilitating physical recovery, physiotherapists were able to have a positive impact on emotional well-being.

Living with incurable cancer: what are the rehabilitation needs in a palliative setting?

Abstract Background: Increasing numbers of people are living with incurable cancers. Symptoms, side effects, and treatment burdens impact on physical functioning, yet little is known about the impact on people’s lives and how best to provide rehabilitation. Materials and methods: A qualitative study employing a phenomenological approach explored the lived experience of incurable cancer. A purposive sample of six people participated in semi-structured interviews. The data were analysed thematically at a semantic level to identify the functional difficulties experienced by people living with incurable cancer, the meanings of those difficulties, and participants perceived rehabilitation needs. Results: People living with incurable cancer described cancer-related issues spanning all five domains of the International Classification of Functioning, Disability and Health (ICF). Although highly valued amongst study participants, rehabilitation services were difficult to access, poorly utilised, and referrals were sporadic and consequential; indicative of poor awareness of rehabilitation for people with incurable cancer amongst potential referrers. Discussion: Participants valued a change in terminology away from “palliative” towards more positive language in line with enhanced supportive care movements. Validated tools such as the Palliative Care Therapy Outcome Measure, which align with the ICF, would allow rehabilitation professionals to demonstrate maintenance or improvement in participation and wellbeing. Implications for Rehabilitation Incurable cancer leads to a fluctuating multifactorial disability. People living with incurable cancer can benefit from rehabilitation input throughout their illness. Offering flexible and varied rehabilitation options for people living with incurable cancer will increase physical and emotional well-being, function, and coping. Allied health professionals should take and create opportunities to promote rehabilitation for people living with incurable cancer and their services to other potentially referring healthcare professionals to increase understanding of benefits and utilisation of available services for people living with incurable cancer.