A qualitative study of low-load resistance training with blood flow restriction in people with advanced multiple sclerosis.

BACKGROUND: Blood flow restriction (BFR) combined with low-load resistance training could minimize exercise barriers and offer strength and mobility improvements for people with advanced Multiple Sclerosis (MS); but patient experience has not been evaluated. PURPOSE: The purpose of this study was to assess the satisfaction, acceptability, and impact of combining low-load resistance training with BFR for individuals with advanced MS (Expanded Disability Status Scale: EDSS 6.0-7.0). METHODS: We used an interpretive phenomenological research design and post-intervention interviews to explore participant experiences of a novel low-load resistance training program with BFR. RESULTS: Interview participants (n = 14) were 55.4 ± 6.2 years old and were diagnosed with MS for 19.1 ± 10.7 years. Four themes were identified (satisfaction, acceptability, impact, program refinement) with 14 subthemes. Satisfaction was mixed based on overall expectations, yet all participants recommended the intervention. Acceptability was evidenced by all participants identifying comfortable/easy aspects, and modifiable elements that could improve comfort. Impact was evidenced with translation to everyday life activities, strength/self-efficacy/psychological improvements, effectiveness, and fatigue reduction. CONCLUSIONS: Participants found BFR combined with low-load resistance training to be satisfactory (mixed initial expectations), acceptable (comfortable/easy), and impactful (translating to life improvements). Areas for program refinement were identified that should be targeted in future iterations.

Development and alpha testing of a patient shared decision aid for prosthesis design for new lower limb prosthesis users.

BACKGROUND: After lower limb amputation, several prosthesis design options exist. However, prosthesis design decisions do not always reflect a prosthesis user's needs, values, and preferences. OBJECTIVE: To develop a patient decision aid (PDA) prototype for prosthetists and new prosthesis users facing prosthesis design decisions after lower limb amputation, and to assess its usability, accuracy, and comprehensibility. STUDY DESIGN: Exploratory mixed methods. METHODS: PDA development was informed by a qualitative needs assessment and guided by the International Patient Decision Aid Standards. The PDA was evaluated by steering groups of experienced prosthesis users and prosthetic professionals (prosthetists and researchers) to test usability, accuracy, and comprehensibility through focus groups, individual interviews, and rating on a Likert scale ranging from 1 to 10. RESULTS: The resulting PDA included 6 sections: (1) Amputation and Early Recovery, (2) Communication, (3) Values, (4) Prosthesis Design, (5) Preferences, and (6) Prosthetic Journey. Usability, accuracy, and comprehensibility were rated as 9.2, 9.6, and 9.6, respectively, by prosthetic professionals, and 9.4, 9.6, and 9.6, respectively, by prosthesis users. DISCUSSION: The PDA incorporated guidance by relevant stakeholders and was rated favorably, emphasizing a need for shared decision-making support in prosthesis design. One challenge was determining the amount of information in the PDA, highlighting the diversity in end users' informational needs. Future iterations of the PDA should undergo beta testing in clinical settings. CONCLUSIONS: A standardized, iterative method was used to develop a PDA for new lower limb prosthesis users and prosthetists when considering prosthesis design decisions. The PDA was considered useable, accurate, and comprehensible.

Walking Exercise Sustainability Through Telehealth for Veterans With Lower-Limb Amputation: A Study Protocol.

OBJECTIVE: This randomized controlled superiority trial will determine if an 18-month telehealth walking exercise self-management program produces clinically meaningful changes in walking exercise sustainability compared to attention-control education for veterans living with lower-limb amputation. METHODS: Seventy-eight participants with lower-limb amputation (traumatic or nontraumatic) aged 50 to 89 years will be enrolled. Two groups will complete 6 one-on-one intervention sessions, and 6 group sessions over an 18-month intervention period. The experimental arm will receive a self-management program focusing on increasing walking exercise and the control group will receive attention-control education specific to healthy aging. Daily walking step count (primary outcome) will be continuously monitored using an accelerometer over the 18-month study period. Secondary outcomes are designed to assess potential translation of the walking exercise intervention into conventional amputation care across the Veteran Affairs Amputation System of Care. These secondary outcomes include measures of intervention reach, efficacy, likelihood of clinical adoption, potential for clinical implementation, and ability of participants to maintain long-term exercise behavior. IMPACT: The unique rehabilitation paradigm used in this study addresses the problem of chronic sedentary lifestyles following lower-limb amputation through a telehealth home-based walking exercise self-management model. The approach includes 18 months of exercise support from clinicians and peers. Trial results will provide rehabilitation knowledge necessary for implementing clinical translation of self-management interventions to sustain walking exercise for veterans living with lower-limb amputation, resulting in a healthier lifestyle.

Telehealth Walking Self-Management for Individuals With Amputation: A Qualitative Study of Therapist Perspectives on Adoption.

OBJECTIVE: The aim of this study was to understand therapist-identified factors influencing clinical adoption of a telehealth walking self-management intervention for individuals with lower limb amputation. METHODS: Semi-structured focus groups were completed with actively practicing physical and occupational therapists treating populations that are medically complex. A qualitative explorative design was employed with conventional content analysis and iterative independent parallel coding using 2 analysts. Themes and subthemes were generated with a consensus building process identifying patterns and collapsing codes to represent participant perspectives. RESULTS: Thematic saturation was met after 5 focus groups (24 therapists). Therapists were on average 34 years old and predominantly female (n = 19; 79%) physical therapists (n = 17; 71%). Three primary facilitator and barrier themes were identified for intervention adoption: system, therapist, and person. System considerations included telehealth support and interprofessional care coordination. Therapist facilitators included self-management programming that overlapped with standard of care and personalization methods. However, limited behavioral theory training was a therapist level barrier. Finally, person factors such as patient activation could influence both positively and negatively. Person facilitators included social support and barriers included the complex health condition. CONCLUSION: System, therapist, and person facilitators and barriers must be considered to maximize the adoption of similar telehealth walking self-management interventions and prior to larger scale implementation of the current intervention for individuals with lower limb amputation. IMPACT: A telehealth walking self-management intervention has potential impact for individuals with lower limb amputation and must be considered in terms of optimizing system, therapist, and person level facilitators and barriers to implementation.

Maximal daily stepping cadence partially explains functional capacity of individuals with end-stage knee osteoarthritis.

BACKGROUND: Individuals with end-stage knee osteoarthritis (OA) walk at a lower intensity (ie, slower step cadence) contributing to worse physical function. Previous literature reports daily step counts and sedentary time, with little information regarding stepping bouts or cadence. Determining relationships between daily higher stepping cadence duration and clinical outcomes can move the field toward optimal daily stepping prescription. OBJECTIVE: To quantify daily physical activity patterns of individuals with end-stage knee OA and determine the contribution of high stepping cadence to explain functional capacity variability. DESIGN: Cross-sectional analysis. SETTING: Veterans Administration medical center. PARTICIPANTS: U.S. military veterans (n = 104; age: 67.1 years [7.2]; mean [SD]; male [89.3%]) with end-stage knee OA were enrolled. INTERVENTION: Not applicable. MAIN OUTCOME MEASURE: Functional capacity (6-Minute Walk Test [6MWT]). Physical activity (activPAL wearable sensor; cadence and time sitting, standing, and stepping), pain (Western Ontario and McMaster Universities Osteoarthritis Index-pain subscale) sociodemographic variables, and comorbidities (body mass index and Functional Comorbidity Index) are the main explanatory variables. RESULTS: Participants' wake time was mainly sitting (11.0 h/day) in ≥60-minute bouts (29.7% ± 12.7 of sitting time). Standing (3.4 hours/day) and stepping (1.4 h/day) primarily occurred in 0-5 minute bouts (standing: 87.7% ± 14.4 of standing time, stepping: 98.7% ± 12.7 of stepping time) and stepping cadence was predominantly incidental (1-19 spm; 52.9% ± 9.6 of total stepping time). Backward elimination model results indicated shorter medium-to-brisk cadence bout duration, older age, and higher pain significantly explained shorter 6MWT distance (Adj R2 =0.24, p < .01). CONCLUSIONS: Individuals with knee OA spend most of their waking hours sitting, while standing and stepping occurs in short bouts at very low stepping cadence. Decreased time in high stepping cadence is associated with lower functional capacity. Future studies should explore if increasing the daily time spent in higher step cadence can improve functional capacity in this population.

Improving shared decision-making for prosthetic care: A qualitative needs assessment of prosthetists and new lower-limb prosthesis users.

BACKGROUND: Prosthesis design is complex and multiple appropriate options exist for any individual with lower-limb amputation. However, there is insufficient evidence for guiding decision-making. Shared decision-making (SDM) offers an opportunity to incorporate patient-specific values and preferences where evidence is lacking for prosthesis design decisions. To develop resources to facilitate SDM, and consistent with the International Patient Decision Aid Standards, it is necessary to identify the decisional needs of prosthetists and prosthesis users for prosthesis design decisions. OBJECTIVES: To assess the needs of prosthetists and new prosthesis users for SDM about the first prosthesis design. STUDY DESIGN: Qualitative descriptive design. METHODS: Six focus groups were conducted with 38 prosthetists. Individual semistructured interviews were conducted with 17 new prosthesis users. Transcripts were analyzed using directed content analysis, with codes defined a priori using existing frameworks for SDM: the Three Talk Model for SDM and the Ottawa Decision Support Framework. RESULTS: Four main themes were identified among prosthetists and prosthesis users: acknowledging complexity in communication, clarifying values, recognizing the role of experience to inform preferences , and understanding the prosthetic journey . CONCLUSIONS: Resources that support SDM for the first prosthesis design should consider methods for identifying individual communication needs, support with clarifying values, and resources such as experience for achieving informed preferences, within the context of the overall course of rehabilitation and recovery following lower-limb amputation. The themes identified in this work can inform SDM to promote collaborative discussion between prosthetists and new prosthesis users when making prosthesis design decisions.

Manual development for a multi-modal, dyadic intervention for persistent pain: A Qualitative Study.

Background: People who experience persistent pain often require help from a family member, partner, or friend. These caregivers frequently have pain but are often not included in interventions. Caregivers and care receivers who both experience pain are more likely to be socially isolated, and experience communication conflict and decreased quality of life. Interventions should target caregiving dyads to help them manage their pain together. However, there are few intervention manuals or research protocols developed to support the dyad. Objective: The purpose of this qualitative study was to explore the needs of caregiving dyads, including input from dyads and medical and allied health experts to inform the development of an intervention manual for dyads with persistent pain. Method: A total of 16 caregiving dyads experiencing persistent pain, one care receiver (caregiver could not participate), and 8 health experts, recruited from the community, participated in focus groups. Data were transcribed verbatim, uploaded into NVivo software, and analyzed using constant comparison qualitative methods. Results: Findings identified the importance of a new intervention to focus on modifiable approaches to managing pain as a dyad, addressing the emotional and psychological effects of experiencing pain as a dyad, and careful consideration of logistics to implement an intervention with dyads in persistent pain. Conclusion: These results highlight important considerations to meet the needs of caregiving dyads with pain. This study informed the development of the MY-Skills intervention, a novel program that merges self-management education with adaptive yoga to treat persistent pain in caregiving dyads.

Postamputation Cognitive Impairment Is Related to Worse Perceived Physical Function Among Middle-Aged and Older Prosthesis Users.

OBJECTIVE: To compare characteristics between middle-aged and older prosthesis users with and without cognitive impairment and determine whether cognitive impairment contributes to variability in perceived physical function. DESIGN: Cross-sectional, observational study SETTING: General community. PARTICIPANTS: Adults 45 years or older, at least 1-year post lower limb amputation (LLA) who were walking independently with a prosthesis (N=119). INTERVENTION: Not applicable. MAIN OUTCOME MEASURES: We identified cognitive impairment using an education-adjusted Telephone Interview for Cognitive Status-modified score. Perceived physical function was measured using the Prosthesis Mobility Questionnaire. RESULTS: Of 119 participants (mean age, 62.6±8.2 years; male: 89.1%; vascular etiology: 82.4%; years since amputation: 4.9±4.7 years), 28 (23.5%) had cognitive impairment. Compared with participants without cognitive impairment, those with cognitive impairment were more likely to use an assistive device (60.7% vs 25.3%, P=.002); were older (66.3±7.3 vs 61.5±8.1 years, P=.006) and had more chronic conditions (7.1±3.4 vs 5.4±2.5, P=.004), more depressive symptoms (6.6±5.1 vs 4.2±3.8, P=.008), and worse perceived physical function (2.0±0.6 vs 2.6±0.7, P<.001). Using backward stepwise linear regression, we found that participants with cognitive impairment had worse perceived physical function (standardized parameter estimate [ß]=-0.15, P=.02), even after adjusting for depressive symptoms (ß=-0.31, P<.001), prosthesis satisfaction (ß=0.34, P<.001), number of chronic conditions (ß=-0.19, P=.006), and assistive device use (ßcane=0.01, P=.93; ßother=-0.20, P=.003). Together, these variables explained 59% of perceived physical function variability. CONCLUSIONS: Cognitive impairment is common and associated with worse perceived physical function post LLA, even after controlling for physical and mental health differences. Tailored rehabilitation interventions may be needed to improve perceived physical function in prosthesis users with cognitive impairment.

The Impact of COVID-19 on Community-Based Exercise Classes for People With Parkinson Disease.

OBJECTIVE: he purpose of the study was to determine the impact of novel coronavirus 2019 (COVID-19) restrictions on community-based exercise classes for people with Parkinson disease (PD) and their instructors. METHODS: Data were collected via custom-designed electronic surveys for people with PD and class instructors who reported attending or teaching PD-specific exercise class ≥1 time/week for ≥3 months prior to pandemic restrictions (March 2020). The PD group also completed the Godin Leisure-Time Questionnaire, Self-Efficacy for Exercise scale, Schwab-England scale, and Parkinson's Disease Questionnaire 8. RESULTS: Eighty-seven people with PD (mean = 70 [7.3] years old) and 43 instructors (51 [12.1] years old) from the United States completed surveys (October 2020 to February 2021). Mean Schwab-England (84 [16]) and Parkinson's Disease Questionnaire 8 (21 [15]) scores indicated low-to-moderate disability in the PD group. Ninety-five percent of the PD group had COVID-19 exposure concerns, and 54% reported leaving home ≤1 time/week. Although 77% of the PD group scored "active" on the Godin Leisure-Time Questionnaire, the mean Self-Efficacy for Exercise Scale score (55 [24]) indicated only moderate exercise self-efficacy, and >50% reported decreased exercise quantity/intensity compared with pre-COVID. There was decreased in-person and increased virtual class participation for both groups. The top in-person class barrier for the PD (63%) and instructor (51%) groups was fear of participant COVID-19 exposure. The top virtual class barriers were lack of socialization (20% of PD group) and technology problems (74% of instructor group). CONCLUSION: During COVID-19, there has been less in-person and more virtual exercise class participation in people with PD and decreased exercise quantity and intensity. Virtual classes may not fully meet the needs of people with PD, and primary barriers include technology and lack of socialization. IMPACT: As COVID-19 restrictions wane, it is imperative to help people with PD increase exercise and activity. The barriers, needs, and facilitators identified in this study might help inform approaches to increase participation in exercise and activity for people with PD. LAY SUMMARY: During COVID-19, there has been less in-person and more virtual exercise class participation in people with PD and a decrease in exercise quantity and intensity. If you have PD, virtual classes might not fully meet your needs. Primary barriers may include technology problems and lack of social interaction.

Merging Yoga and Occupational Therapy for Parkinson's Disease: A Feasibility and Pilot Program.

The purpose of this study was to assess feasibility and changes in outcome measures following the Merging Yoga and Occupational Therapy for Parkinson's Disease (MY-OT for PD) program: a 14-session program which combined community-based yoga for PD, and fall-risk focused group occupational therapy sessions. Seventeen participants completed an 8-week control period consisting of their normal participation, and an 8-week intervention period (14 MY-OT for PD sessions). There were fewer self-reported falls in the intervention (6) vs. control periods (10). One fall risk factor management scale (the Fall Prevention and Management Questionnaire, p=.02), and balance (p<.01) showed significant improvement between the control and intervention. The MY-OT for PD program is an encouraging occupational therapist-led program, which may improve balance and reduce self-reported falls.

Health-related quality of life changes after the merging yoga and occupational therapy for Parkinson's disease program: A mixed-methods study.

BACKGROUND: To understand changes in health-related quality of life (HRQoL) after the Merging Yoga and Occupational Therapy for Parkinson's Disease (MY-OT for PD) program. MATERIALS AND METHODS: We used a mixed-methods convergent design and administered the Parkinson's Disease Questionnaire-8 (PDQ-8), a measure of HRQoL, with 17 participants. We considered scores 8 weeks before MY-OT for PD, just before, and upon completion. Additionally, we completed two focus groups following the program with 16 participants to assess qualitative changes in HRQoL. RESULTS: There were no significant differences in PDQ-8 scores between time points, F(2,32) = 1.60, p = 0.22, partial η2 = 0.09. Participants did discuss improvements in all 8 HRQoL domains, frequently regarding mobility and activities of daily living. CONCLUSION: Results diverged, with quantitative results showing no significant improvement in HRQoL and qualitative results indicating participant perceived improvements in all domains of the PDQ-8. The program should be explored further, and longitudinal follow-up completed.