Paul O’Halloran

Benefits and costs of home-based pulmonary rehabilitation in chronic obstructive pulmonary disease - a multi-centre randomised controlled equivalence trial

BackgroundPulmonary rehabilitation is widely advocated for people with chronic obstructive pulmonary disease (COPD) to improve exercise capacity, symptoms and quality of life, however only a minority of individuals with COPD are able to participate. Travel and transport are frequently cited as barriers to uptake of centre-based programs. Other models of pulmonary rehabilitation, including home-based programs, have been proposed in order to improve access to this important treatment. Previous studies of home-based pulmonary rehabilitation in COPD have demonstrated improvement in exercise capacity and quality of life, but not all elements of the program were conducted in the home environment. It is uncertain whether a pulmonary rehabilitation program delivered in its entirety at home is cost effective and equally capable of producing benefits in exercise capacity, symptoms and quality of life as a hospital-based program. The aim of this study is to compare the costs and benefits of home-based and hospital-based pulmonary rehabilitation for people with COPD.Methods/DesignThis randomised, controlled, equivalence trial conducted at two centres will recruit 166 individuals with spirometrically confirmed COPD. Participants will be randomly allocated to hospital-based or home-based pulmonary rehabilitation. Hospital programs will follow the traditional outpatient model consisting of twice weekly supervised exercise training and education for eight weeks. Home-based programs will involve one home visit followed by seven weekly telephone calls, using a motivational interviewing approach to enhance exercise participation and facilitate self management. The primary outcome is change in 6-minute walk distance immediately following intervention. Measurements of exercise capacity, physical activity, symptoms and quality of life will be taken at baseline, immediately following the intervention and at 12 months, by a blinded assessor. Completion rates will be compared between programs. Direct healthcare costs and indirect (patient-related) costs will be measured to compare the cost-effectiveness of each program.DiscussionThis trial will identify whether home-based pulmonary rehabilitation can deliver equivalent benefits to centre-based pulmonary rehabilitation in a cost effective manner. The results of this study will contribute new knowledge regarding alternative models of pulmonary rehabilitation and will inform pulmonary rehabilitation guidelines for COPD.Trial registrationClinicalTrials.gov: NCT01423227.

The Lived Experiences of Transgender Persons: A Meta-Synthesis

This article synthesises findings from qualitative studies which have explored the lived experiences of transgender persons, using Noblit and Hares (1998) meta-ethnography method. Thirty-one qualitative studies related to the lived experiences of transgender individuals, published between 1998 and 2013, met the inclusion criteria. A literature search was conducted between November 2012 and September 2013 using computerized searches from nine databases as well as online manual searches of key journals. Results from these individual studies revealed five major themes: (a) crossing gender and physical problems in life, (b) experiencing psychological distress, (c) encountering discrimination and social exclusion, (d) having relationships does matter, and (e) dealing with difficulties in life. Yet, despite these negative experiences, transgender people have tried to find ways to help them deal with their difficulties. We conclude that there is a need for health care providers, social workers, and health promoters to support transgender individuals, for their health and well-being. This meta-synthesis provides a clear account of what transgender individuals experience in their lives, to support the development of sympathetic health and social care services to assist them with their difficulties, and enhance their health and well-being.

The Psychological Impact of Long-Term Injury on Australian Football League Players

This study examined the psychological responses to injury in Australian Football League players. A prospective design was utilized to explore the psychological reactions to injuries of 8 football players throughout the rehabilitation period at 3 points. Qualitative interviews with these long-term injured players generated 14 themes across the 3 injury phases. These themes related to the emotional reactions to the injury, received support, the challenge of rehabilitation, and the psychological readiness to return to play. The findings have important implications regarding the management and preparation of Australian Football League players returning to competition in a state of physical and psychological health.

Exploring Psychological Reactions to Injury in the Australian Football League (AFL)

This study explored Australian rules footballers’ psychological responses to injury. This exploratory study was the first in a series of studies planned to examine the injury-related experiences of professional Australian football players. Forty-three professional AFL players from the one team participated in semi-structured interviews. Results provided a detailed account recalled by AFL footballers of their past injury experiences. Specifically, AFL players discussed their initial emotional reactions to injury, which were dependant on the severity of the injury, the extent of isolation during injury, the repetitive nature of the rehabilitation process, and the influence of social support on their reactions.

Home-based pulmonary rehabilitation for people with COPD: A qualitative study reporting the patient perspective:

This study aimed to document the perspective of patients with chronic obstructive pulmonary disease (COPD) who underwent home-based pulmonary rehabilitation (HBPR) in a clinical trial. In this qualitative study, open-ended questions explored participants’ views regarding HBPR. Thirteen semi-structured interviews were analysed using a thematic analysis approach. Major themes from interviews included the positive impact of HBPR on physical fitness, breathing and mood. Participants valued the flexibility and convenience of the programme. Participants also highlighted the importance of social support received, both from the physiotherapist over the phone and from family and friends who encouraged their participation. Reported challenges were difficulties in initiating exercise, lack of variety in training and physical incapability. While most participants supported the home setting, one participant would have preferred receiving supervised exercise training at the hospital. Participants also reported that HBPR had helped establish an exercise routine and improved their disease management. This study suggests that people with COPD valued the convenience of HBPR, experienced positive impacts on physical fitness and symptoms and felt supported by their community and programme staff. This highly structured HBPR model may be acceptable to some people with COPD as an alternative to centre-based pulmonary rehabilitation.

Evaluation of the Dimensions of Anger Reactions-5 (DAR-5) Scale in combat veterans with posttraumatic stress disorder

After a traumatic event many people experience problems with anger which not only results in significant distress, but can also impede recovery. As such, there is value to include the assessment of anger in routine post-trauma screening procedures. The Dimensions of Anger Reactions-5 (DAR-5), as a concise measure of anger, was designed to meet such a need, its brevity minimizing the burden on client and practitioner. This study examined the psychometric properties of the DAR-5 with a sample of 163 male veterans diagnosed with Posttraumatic Stress Disorder. The DAR-5 demonstrated internal reliability (α=.86), along with convergent, concurrent and discriminant validity against a variety of established measures (e.g., HADS, PCL, STAXI). Support for the clinical cut-point score of 12 suggested by Forbes et al. (2014, Utility of the dimensions of anger reactions-5 (DAR-5) scale as a brief anger measure. Depression and Anxiety, 31, 166-173) was observed. The results support considering the DAR-5 as a preferred screening and assessment measure of problematic anger.

Identifying the sources of stress and rewards in a group of Australian apprentice jockeys

Abstract Previous stress-in-sport research has generally focused on elite athletes while overlooking the experiences of professional, paid athletes. Similarly, despite their susceptibility to chronic stress, professional athletes have rarely been examined by occupational stress researchers, and little is known about the adverse health effects of the stressors they experience. Despite the unique demands faced by jockeys, there is a paucity of research examining the incidence and impact of occupational stress on professional jockeys within the thoroughbred racing industry. This paper describes the results of a qualitative study aimed at identifying the sources of stress (demands vs. rewards) experienced by a group of Australian professional apprentice jockeys. The study also aimed to investigate whether the effort–reward imbalance (ERI) model of occupational stress can be generalised to this group of professional athletes. Thirty-five apprentice jockeys registered in an apprentice jockey training programme in an Australian capital city took part in semi-structured focus group discussions. Five major themes relating to demands emerged: time demands, role suppression, physical demands, cognitive demands and ancillary demands. Demands not only stemmed from the competitive environment, but also from the broader work environment. Five themes emerged relating to rewards: financial rewards, positive emotion, status, winning and new experiences, which generally aligned with the categories highlighted by the ERI model. Although undoubtedly a challenging career, it also emerged as an extremely rewarding vocation. For this group of apprentice jockeys, it is conceivable that the rewards outweigh the demands of the occupation.

Physiotherapists use a small number of behaviour change techniques when promoting physical activity: A systematic review comparing experimental and observational studies

OBJECTIVES Physiotherapists promote physical activity as part of their practice. This study reviewed the behaviour change techniques physiotherapists use when promoting physical activity in experimental and observational studies. DESIGN Systematic review of experimental and observational studies. METHODS Twelve databases were searched using terms related to physiotherapy and physical activity. We included experimental studies evaluating the efficacy of physiotherapist-led physical activity interventions delivered to adults in clinic-based private practice and outpatient settings to individuals with, or at risk of, non-communicable diseases. Observational studies reporting the techniques physiotherapists use when promoting physical activity were also included. The behaviour change techniques used in all studies were identified using the Behaviour Change Technique Taxonomy. The behaviour change techniques appearing in efficacious and inefficacious experimental interventions were compared using a narrative approach. RESULTS Twelve studies (nine experimental and three observational) were retained from the initial search yield of 4141. Risk of bias ranged from low to high. Physiotherapists used seven behaviour change techniques in the observational studies, compared to 30 behaviour change techniques in the experimental studies. Social support (unspecified) was the most frequently identified behaviour change technique across both settings. Efficacious experimental interventions used more behaviour change techniques (n=29) and functioned in more ways (n=6) than did inefficacious experimental interventions (behaviour change techniques=10 and functions=1). CONCLUSIONS Physiotherapists use a small number of behaviour change techniques. Less behaviour change techniques were identified in observational studies compared to experimental studies, suggesting physiotherapists use less BCTs clinically than experimentally.

The Pulmonary Rehabilitation Adapted Index of Self-Efficacy (PRAISE) tool predicts reduction in sedentary time following pulmonary rehabilitation in people with chronic obstructive pulmonary disease (COPD)

OBJECTIVES To examine the predictive validity, minimal important difference (MID) and responsiveness of the PRAISE tool. DESIGN Retrospective data analysis from HomeBase trial of home vs centre-based pulmonary rehabilitation. SETTING Tertiary health service. PARTICIPANTS One hundred and sixty-six participants with COPD (100 men) with mean age 69 (SD 9) years, FEV1% predicted 50% (19). INTERVENTIONS Eight-week pulmonary rehabilitation program, conducted at the hospital or at home. MAIN OUTCOME MEASURES The 15-item PRAISE tool comprising 10 general and five pulmonary rehabilitation-specific self-efficacy questions. Predictive validity was examined by exploring the relationship between baseline PRAISE score and objective change in physical activity following pulmonary rehabilitation using the SenseWear Armband. The MID was evaluated using anchor-based and distribution-based methods. Responsiveness was assessed with effect sizes. RESULTS A higher baseline PRAISE score (indicating better self-efficacy) was an independent predictor of reduced sedentary time following pulmonary rehabilitation (P=0.03). A one point increase in PRAISE was associated with a decrease in sedentary time of 4minutes/day (95% confidence interval -7.8 to -0.4minutes/day). Anchor-based estimates of the MID were 0.5 to 1.5 points; however sensitivity and specificity were modest (area under the curve <0.70). Change in PRAISE score following pulmonary rehabilitation had an effect size of 0.21. CONCLUSIONS The PRAISE tool has predictive validity and may be useful to identify those with high self-efficacy who are more likely to achieve important health behaviour changes with pulmonary rehabilitation. The small effect size suggests that the PRAISE tool was not responsive to changes following pulmonary rehabilitation. TRIAL REGISTRATION NUMBER NCT01423227, clinicaltrials.gov.

The behaviour change techniques used by Australian physiotherapists to promote non-treatment physical activity to patients with musculoskeletal conditions

OBJECTIVES To determine: (i) the behaviour change techniques used by a sample of Australian physiotherapists to promote non-treatment physical activity; and (ii) whether those behaviour change techniques are different to the techniques used to encourage adherence to rehabilitation exercises. DESIGN Cross-sectional survey. METHOD An online self-report survey was advertised to private practice and outpatient physiotherapists treating patients with musculoskeletal conditions. The use of 50 behaviour change techniques were measured using five-point Likert-type scale questions. RESULTS Four-hundred and eighty-six physiotherapists responded to the survey, with 216 surveys fully completed. Most respondents (85.1%) promoted non-treatment physical activity often or all of the time. Respondents frequently used 29 behaviour change techniques to promote non-treatment physical activity or encourage adherence to rehabilitation exercises. A similar number of behaviour change techniques was frequently used to encourage adherence to rehabilitation exercises (n=28) and promote non-treatment physical activity (n=26). Half of the behaviour change techniques included in the survey were frequently used for both promoting non-treatment physical activity and encouraging adherence to rehabilitation exercises (n=25). Graded tasks was the most, and punishment was the least, frequently reported technique used to promote non-treatment physical activity and encourage adherence to rehabilitation exercises. CONCLUSIONS Respondents reported using similar behaviour change techniques to promote non-treatment physical activity and encourage adherence to rehabilitation exercises. The variability in behaviour change technique use suggests the behaviour the physiotherapist is promoting influences their behaviour change technique choice. Including the frequently-used behaviour change techniques in non-treatment physical activity promotion interventions might improve their efficacy.