Marie Donaghy

The effects and experiences of goal setting in stroke rehabilitation - a systematic review.

Objective: To systematically integrate and appraise the evidence for effects and experiences of goal setting in stroke rehabilitation. Design: Systematic review of quantitative and qualitative studies. Methods: Relevant databases were searched from start of database to 30 April 2011. Studies of any design employing goal setting, reporting stroke-specific data and evaluating its effects and/ or experiences were included. Results: From a total of 53998 hits, 112 full texts were analysed and 17 studies were included, of which seven evaluated effects while ten explored experiences of goal setting. No eligible randomized controlled trials were identified. Most of the included studies had weak to moderate methodological strengths. The design, methods of goal setting and outcome measures differed, making pooling of results difficult. Goal setting appeared to improve recovery, performance and goal achievement, and positively influenced patients’ perceptions of self-care ability and engagement in rehabilitation. However, the actual extent of patient involvement in the goal setting process was not made clear. Patients were often unclear about their role in this process. Professionals reported higher levels of collaboration during goal setting than patients. Patients and professionals differed on how they set goals, types of goals set, and on how they perceived goal attainment. Barriers to goal setting outnumbered the facilitators. Conclusion: Due to the heterogeneity and quality of included studies, no firm conclusions could be made on the effectiveness, feasibility and acceptability of goal setting in stroke rehabilitation. Further rigorous research is required to strengthen the evidence base. Better collaboration and communication between patients and professionals and relevant education are recommended for best practice. Implications for Rehabilitation Communication is key to collaborative goal setting. Education and training of professionals regarding goal setting is recommended, especially in relation to methods of involving people with communication and cognitive impairments. Educating patients about stroke and goal setting could enhance their participation in goal setting.

Barriers to uptake of physical activity in community-based patients with schizophrenia

Background: Recent United Kingdom Government Policy documents have emphasized the need to improve the physical health of patients with mental illness. Although physical health could be improved by increasing physical activity levels, uptake of widely available community-based activity programmes is low in this patient population. Aims: To investigate the barriers to uptake of and adherence to physical activity in community-dwelling patients with a diagnosis of schizophrenia. Methods: Qualitative study on 27 community dwelling patients with a diagnosis of schizophrenia from four Community Mental Health Teams (CMHT) in Edinburgh. Patients were individually interviewed using a semi-structured questionnaire. Themes and sub themes from the interviews were identified using Interpretive Phenomenological Analysis (IPA). Results: Four barriers to physical activity uptake were identified: limited experience of physical activity engagement, impact of the illness and effects of medication, effects of anxiety and the influences of support networks. Conclusion: These patients experience complex barriers to physical activity uptake which need to be considered in the design of physical activity interventions to target obesity and related physical health problems.

Predicting health related quality of life 6 months after stroke: the role of anxiety and upper limb dysfunction

Purpose: This study examined the role of anxiety and upper limb dysfunction, amongst other variables, as predictors of health related quality of life (HRQOL) 6 months after stroke. Method: Participants: Stroke survivors (n = 85) who had previously participated in a randomised controlled trial of a physiotherapy intervention. Dependent variable: HRQOL – Nottingham Health Profile (NHP). Predictor variables: Mood – Hospital Depression and Anxiety Scale; Upper Limb Functioning - Action Research Arm Test; Rivermead Motor Assessment; Activities of Daily Living – Modified Barthel Index; Clinical and demographic factors. Results: Anxiety and depression significantly predicted 49% of variance in overall HRQOL (p < 0.05), but only anxiety significantly predicted NHP pain (13% variance, p < 0.001), emotional reactions (41% variance, p < 0.001), sleep (19% variance, p = 0.02) and social isolation (23% variance, p = 0.02). Depression and anxiety together significantly predicted 30% variance in energy level (p < 0.001). UL motor impairment and activities of daily living predicted 36% of variance in NHP physical activity score (p < 0.001). Conclusions: This study indicates that where anxiety is assessed, it appears more important in determining HRQOL than depression. UL impairment and ADL independence predicted perceived physical activity. Management strategies for anxiety and therapy for UL recovery long after stroke onset are likely to benefit perceived HRQOL. Implications for Rehabilitation Anxiety is a major predictor of quality of life six months after stroke. Post-stroke anxiety should be routinely assessed in rehabilitation. Appropriate management strategies for anxiety should occur during rehabilitation with follow-up into the chronic post-stroke period. Upper limb impairment is a stronger predictor of perceptions of physical activity than independence in activities daily living six months after stroke. Rehabilitation of the upper limb should continue into the chronic post-stroke period.

Exercise can seriously improve your mental health: Fact or fiction?

The World Health Organization predicts that depression will create the second greatest burden of disease by 2020, requiring cost-effective prevention and intervention strategies. The evidence to support the benefits of exercise in offering protection from depression and as an intervention in the treatment of mental illness is growing. The literature is reviewed with 11 prospective longitudinal studies that include measures of physical activity and depression at two or more time points showing a protective effect from physical activity. Fifteen randomized controlled trials (RCTs) and three meta-analyses provide evidence that exercise can reduce depression and that it can be as effective as cognitive therapy. Four RCTs report exercise as an intervention in alcohol addiction and two RCTs in the use of illicit drugs. While many of the studies reviewed have methodological weaknesses, including lack of concealment in randomization, limited use of intention to treat and blinding, the benefits of exercise far outweigh the risks. Neurobiological and psychological explanations as to why exercise should work are discussed. There is evidence that exercise protects against depression and is an effective intervention and adjunctive intervention for the treatment of mild to moderate depression. Exercise provides some health and psychological benefits as an adjunct to treatment in complex mental health problems such as alcohol and drug rehabilitation.

A qualitative theory guided analysis of stroke survivors’ perceived barriers and facilitators to physical activity

Abstract Purpose: After stroke, physical activity and physical fitness levels are low, impacting on health, activity and participation. It is unclear how best to support stroke survivors to increase physical activity. Little is known about the barriers and facilitators to physical activity after stroke. Thus, our aim was to explore stroke survivors’ perceived barriers and facilitators to physical activity. Methods: Semi-structured interviews with 13 ambulatory stroke survivors exploring perceived barriers and facilitators to physical activity post stroke were conducted in participants’ homes, audio-recorded and transcribed verbatim. The Theoretical Domains Framework (TDF) informed content analysis of the interview transcripts. Results: Data saturation was reached after interviews with 13 participants (median age of 76 years (inter-quartile range (IQR) = 69–83 years). The median time since stroke was 345 d (IQR = 316–366 d). The most commonly reported TDF domains were “beliefs about capabilities”, “environmental context and resources” and “social influence”. The most commonly reported perceived motivators were: social interaction, beliefs of benefits of exercise, high self-efficacy and the necessity of routine behaviours. The most commonly reported perceived barriers were: lack of professional support on discharge from hospital and follow-up, transport issues to structured classes/interventions, lack of control and negative affect. Conclusions: Stroke survivors perceive several different barriers and facilitators to physical activity. Stroke services need to address barriers to physical activity and to build on facilitators to promote physical activity after stroke. Implications for Rehabilitation Physical activity post stroke can improve physical fitness and function, yet physical activity remains low among stroke survivors. Understanding stroke survivors’ perceived barriers and facilitators to physical activity is essential to develop targeted interventions to increase physical activity. Beliefs about capabilities, environmental context and resources and social influences were the mostly commonly report influences on stroke survivors’ perceived barriers and facilitators to physical activity.

A critical review of the validity of measuring stages of change in relation to exercise and moderate physical activity

Many professionals are integrally involved in the promotion of exercise and physical activity, for specific therapeutic purposes, and with the aim of improving population health and quality of life. Design and evaluation of intervention strategies are frequently underpinned by the Transtheoretical Model, a process-oriented approach to behaviour change. One component of this model is the stage of change structure, which describes a persons behaviour in the context of a change process. It is frequently used to assess current levels of exercise or physical activity participation, and as a measure of change in behaviour following intervention. This paper discusses the importance of validity in the assessment of stages of change for exercise and physical activity. Various different scales exist and have been investigated for validity using comparisons with self-reported outcome measures and physiological markers of activity. Generally, comparative data provide evidence of stage hierarchies relating to both exercise and physical activity. However, this does not establish actual levels of activity represented by stage allocation, limiting its applicability. Further appropriately designed comparisons with objective measures are required if the stage of change structure is to be applied as a meaningful, accurate and sensitive tool for the measurement of physical activity and exercise.

A Physical Activity Intervention in a Community Alcohol Service

People recovering from alcohol-related or drug-related problems are often in poor physical condition and have an extremely sedentary lifestyle. This article describes a study in which an occupational therapist in a community alcohol service implemented a physical activity intervention. The aim of the intervention was for clients with substance misuse problems to increase independent physical activities, to engage more in community-based activities, to increase their awareness of the benefits of exercise and to perceive benefits in their health following the programme. Seven people attended a 6-week programme consisting of nine sessions. Each session included an exercise class and group-based physical activity counselling. Case studies for five of the participants are presented. It was shown that it is possible for an intervention combining physical activity counselling with supervised and independent exercise to have an impact on the lives of a few individuals with substance misuse problems. Four of the five participants made substantial gains in all the target areas relating to independence, integration, education and health. It was also shown that it is feasible for an occupational therapist to play a pivotal role in promoting fitness-oriented activities for those with substance misuse problems. Controlled studies are required with larger samples, longer follow-up periods and the comparison of different intervention elements.

Personal meanings, values and feelings relating to physical activity and exercise participation in female undergraduates: a qualitative exploration

Understanding was sought of the ways that female students understand and feel about physical activity and exercise participation, to inform effective and ethical intervention. Sixteen women participated in semi-structured interviews which were analysed thematically, using QSR NUD*IST 4. Physical activity and exercise proved emotive topics and meant different things to different people. Some women associated physical activity and exercise with enjoyment, or achieving their goals. Others saw exercise in particular as a duty, associated with feelings of guilt and inadequacy. Findings supported the value of promoting realistic goals, and careful choice of activities according to individual preferences.

A Pilot Study of a Cognitive-Behavioural Therapy Approach to Physiotherapy, for Acute Low Back Pain Patients, who Show Signs of Developing Chronic Pain

This pilot study highlighted some of the methodological issues involved in conducting a randomized controlled trial of cognitive-behavioural approach to physiotherapy with acute Low back pain (LBP) patients who showed signs of psychological distress. It also enabled calculation of sample sizes, for the main study, to detect clinically important differences in outcome measures. Acute LBP patients with signs of psychological distress ( n =12) were recruited and randomized to one of two interven tions: (i) physiotherapy+cognitive-behavioural therapy (CBT); (ii) physiotherapy. Outcome measures of pain and disability were taken at the beginning and after six treatment sessions. The results of the pilot showed no significant differences between the groups at post-intervention period. Sample size calculations showed that 62 subjects would need to be recruited to detect clinically meaningful changes in outcome measures. Some of the methodological issues identified potential bias, with the same therapist conducting both arms of the study, and included differences in time with the therapist between the two groups. A non-therapeutic intervention will be added in order to control for therapist attention time. The main study will have a longer-term follow-up period of 6 and 12 months. Outcome measures of the number of sick days off work will be included to calculate the cost effectiveness of the programme.

Should practitioners promote physical activity as a treatment for depression

For many years, experts have been debating the pros and cons of exercise for depression. Proponents of exercise for depression point to those clinical trials which have shown that exercise improves mood, while sceptics point out the methodological problems in many of the apparently positive trials, and the uncertainties around the acceptability of exercise as a treatment for depression. Here two experts critically review the evidence around exercise for depression, provide arguments for and against the promotion of physical activity as a treatment for depression, explore issues around the generalisability of exercise as a treatment for depression and look to the future by discussing ongoing trials that will provide more evidence to inform this important debate.