The Development of a Multi-Modal Cancer Rehabilitation (Including Prehabilitation) Service in Sheffield, UK: Designing the Active Together Service.

Cancer patients undergoing major interventions face numerous challenges, including the adverse effects of cancer and the side effects of treatment. Cancer rehabilitation is vital in ensuring cancer patients have the support they need to maximise treatment outcomes and minimise treatment-related side effects and symptoms. The Active Together service is a multi-modal rehabilitation service designed to address critical support gaps for cancer patients. The service is located and provided in Sheffield, UK, an area with higher cancer incidence and mortality rates than the national average. The service aligns with local and regional cancer care objectives and aims to improve the clinical and quality-of-life outcomes of cancer patients by using lifestyle behaviour-change techniques to address their physical, nutritional, and psychological needs. This paper describes the design and initial implementation of the Active Together service, highlighting its potential to support and benefit cancer patients.

International consensus is needed on a core outcome set to advance the evidence of best practice in cancer prehabilitation services and research.

Prehabilitation aims to optimise patients' physical and psychological status before treatment. The types of outcomes measured to assess the impact of prehabilitation interventions vary across clinical research and service evaluation, limiting the ability to compare between studies and services and to pool data. An international workshop involving academic and clinical experts in cancer prehabilitation was convened in May 2022 at Sheffield Hallam University's Advanced Wellbeing Research Centre, England. The workshop substantiated calls for a core outcome set to advance knowledge and understanding of best practice in cancer prehabilitation and to develop national and international databases to assess outcomes at a population level.

Establishing Innovative Complex Services: Learning from the Active Together Cancer Prehabilitation and Rehabilitation Service.

Prehabilitation and rehabilitation will be essential services in an ageing population to support patients with cancer to live well through their life spans. Active Together is a novel evidence-based service embedded within existing healthcare pathways in an innovative collaboration between health, academic, and charity organisations. Designed to improve outcomes for cancer patients and reduce the demand on healthcare resources, it offers physical, nutritional, and psychological prehabilitation and rehabilitation support to patients undergoing cancer treatment. The service is underpinned by behaviour change theories and an individualised and personalised approach to care, addressing the health inequalities that might come about through age, poverty, ethnicity, or culture. Meeting the challenge of delivering high-quality services across multiple stakeholders, while addressing the complexity of patient need, has required skilled leadership, flexibility, and innovation. To support patients equally, regardless of geography or demographics, future services will need to be scaled regionally and be available in locations amenable to the populations they serve. To deliver these services across wide geographic regions, involving multiple providers and complex patient pathways, will require a systems approach. This means embracing and addressing the complexity of the contexts within which these services are delivered, to ensure efficient, high-quality provision of care, while supporting staff well-being and meeting the needs of patients.

Pulmonary Hypertension and Measurement of Exercise Capacity Remotely: Evaluation of the 1-min Sit-to-Stand Test (PERSPIRE) - a cohort study.

Background: Multiparameter risk assessment is recommended to aid treatment decisions in patients with pulmonary arterial hypertension. The 1-min sit-to-stand test (1MSTS) has been validated for use in other respiratory illnesses. The aim of this study was to evaluate its safety in the hospital setting and potential utility in remote assessment in patients with pulmonary hypertension. Methods: In a prospective cohort study design patients performed the 1MSTS and incremental shuttle walk test (ISWT) on the same day. The primary aim of the study was to assess safety signals and correlations with other metrics used in risk assessment. Results: 60 patients with pulmonary arterial hypertension and 15 with chronic thromboembolic pulmonary hypertension were enrolled. No adverse events were recorded. Post-test change in physiological parameters was lower for the 1MSTS than for the ISWT in heart rate (mean±sd change +9.4±8.0 versus +38.3±25.9 beats per min, p<0.001), oxygen saturation (-3.8±4.0% versus -8.9±7.3%, p<0.01) and systolic blood pressure (+10.1±10.5 versus +17.7±19 mmHg, p<0.001). There were significant correlations between the 1MSTS and ISWT (r=0.702, p<0.01), World Health Organization functional class (r= -0.449, p<0.01), emPHAsis-10 (-0.436, p<0.001) and N-terminal pro-b-type natriuretic peptide (r= -0.270, p=0.022). 97% of patients were willing to perform the test at home. Conclusion: This study has demonstrated the safety, sub-maximal characteristics of the 1MSTS in pulmonary arterial hypertension or chronic thromboembolic pulmonary hypertension in the hospital setting, its positive correlation with the ISWT and potential role in remote risk assessment. Further evaluation of this exercise test is now warranted.

Elective lower limb orthopedic arthroplasty surgery in patients with pulmonary hypertension.

Patients with pulmonary arterial hypertension and chronic thromboembolic pulmonary hypertension (PH) are at increased risk when undergoing anesthesia and major surgery. Data on outcomes for elective orthopedic surgery in patients with PH are limited. A patient pathway was established to provide access to elective lower limb arthroplasty. This included assessment of orthopedic needs, fitness for anesthesia, preoperative optimization, and intra- and postoperative management. Patient data were retrospectively retrieved using patient's hospital records. Between 2012 and 2020, 29 operations (21 total hip replacements [THRs], 7 total knee replacements [TKRs], 1 total hip revision) were performed in 25 patients (mean age: 67 years). Perioperatively, 72% were treated with low-dose intravenous prostanoid. All had arterial lines, and central access and perioperative lithium dilution cardiac output monitoring was used in 86% of cases. Four patients underwent GA, 21 spinal anesthesia, and 4 CSE anesthesia. Supplemental nerve blocks were performed in all patients undergoing general, and 12 of 21 undergoing spinal anesthesia. All were managed in high dependency postoperatively. Hospital length of stay and complication rates were higher than reported in non-PH patients. Perioperative complications included hypotension requiring vasopressors (n = 10), blood transfusion (n = 7), nonorthopedic infection (n = 4), and decompensated right heart failure (n = 1). There was no associated mortality. All implants were functioning well at 6 weeks and subsequent follow-up. EmPHasis-10 quality of score decreased by 5.5 (±2.1) (p = 0.04). A dedicated multiprofessional pathway can be used to safely select and manage patients with PH through elective lower limb arthroplasty.

Feasibility and benefits of a structured prehabilitation programme prior to autologous stem cell transplantation (ASCT) in patients with myeloma; a prospective feasibility study.

Evidence supports the benefits of exercise-based rehabilitation in promoting recovery in myeloma patients following autologous stem-cell transplantation (ASCT). However, 'prehabilitation' has never been evaluated prior to ASCT, despite evidence of effectiveness in other cancers. Utilising a mixed method approach the authors investigated the feasibility of a mixed strength and cardiovascular exercise intervention pre-ASCT. Quantitative data were collected to determine feasibility targets; rates of recruitment, adherence and adverse events, including 6minute walking distance (6MWD) test and patient reported outcome measures (PROMs). Qualitative interviews were undertaken with a purposive sample of patients to capture their experiences of the study and the intervention. The authors recruited 23 patients who attended a mean percentage of 75% scheduled exercise sessions. However, retention rates were limited, with only 14/23 (62%) completing the programme. In these patients, the 6MWD increased from a mean of 346 to 451m (i.e. by 105m, 95% CI 62 to 148m) with no serious adverse events. Whist participants found the exercise programme acceptable and reported improvement in their physical fitness and overall mental health and wellbeing prior to ASCT, the study identified challenges in hospital attendance for the prehabilitation schedule whilst receiving induction or re-induction chemotherapy. Evaluation of digitally-enhanced directed but remote prehabilitation models for this patient group is warranted. Trial registration number NCT03135925.

Outcome Measures Used in Studies of Rehabilitation in Pulmonary Hypertension.

Rationale: The evidence base for rehabilitation in pulmonary hypertension is expanding, but adoption in clinical practice is limited.Objectives: The World Health Organization International Classification for Functioning, Disability and Health identifies three health domains: Body Functions/Structures, Activity and Participation in society. To ensure that the wider impact of rehabilitation in pulmonary hypertension is accurately assessed, it is important that study endpoints reflect all three domains.Methods: A systematic review of the literature was conducted to identify studies of rehabilitation in patients with pulmonary hypertension from 2006 to 2019.Results: Searches across five databases yielded 2,564 articles, of which 34 met eligibility criteria; 50 different outcome measures (mean = 5, minimum = 1, maximum = 9) were identified. When mapped onto the World Health Organization International Classification for Functioning, Disability and Health, 48% of instances of outcome usage were measures of Body Functions/Structure, 33% were measures of Activity, and 18% were measures of Participation. Measures of Participation were not included in seven studies (21%).Conclusions: Studies of rehabilitation in pulmonary hypertension have focused primarily on measures of Body Functions/Structure; the impact in other health domains is not well characterized. Greater inclusion of outcome measures reflecting Activity and Participation in society is needed to allow assessment of the wider impact of rehabilitation in patients with pulmonary hypertension.

Exploring a physiotherapy well-being review to deliver community-based rehabilitation in patients with pulmonary hypertension.

BACKGROUND: Highly structured, supervised exercise training has been shown to be beneficial in patients with pulmonary hypertension. Despite evidence of the effectiveness of community-based rehabilitation in other cardiopulmonary diseases, there are limited data in patients with pulmonary hypertension. METHODS: This prospective study evaluated the intervention of a physiotherapist well-being review in patients with pulmonary hypertension who had been established on targeted drug therapy for between 3 and 12 months. The intervention included a detailed consultation assessing functional, social and motivational status to identify individual patient rehabilitation goals and facilitate tailored referrals to community-based services. RESULTS: One hundred and thirty-eight patients (79% pulmonary arterial hypertension, 17% chronic thromboembolic disease), age 67 ± 14 years, diagnosed over a one year period were evaluated between July 2017 and January 2018. Fifty-two per cent of patients were referred to community-based pulmonary rehabilitation programmes, 19% received other forms of community rehabilitation, 17% were given exercise advice, 5% had an assessment of social support and 7% declined any intervention. At the end of the study, 32% of patients were undertaking independent exercise. CONCLUSION: This study has identified that the majority of patients with pulmonary hypertension who are optimised on targeted drug therapy have rehabilitation needs. The use of a physiotherapy well-being review can identify this need and facilitate access to community-based rehabilitation. Further research is required to evaluate the efficacy of such interventions in pulmonary hypertension.

Learning from a clinical microsystems quality improvement initiative to promote integrated care across a falls care pathway.

AIM: To identify learning from a clinical microsystems (CMS) quality improvement initiative to develop a more integrated service across a falls care pathway spanning community and hospital services. BACKGROUND: Falls present a major challenge to healthcare providers internationally as populations age. A review of the falls care pathway in Sheffield, United Kingdom, identified that pathway implementation was constrained by inconsistent co-ordination and integration at the hospital-community interface. APPROACH: The initiative utilised the CMS quality improvement approach and comprised three phases. Phase 1 focussed on developing a climate for change through engaging stakeholders across the existing pathway and coaching frontline teams operating as microsystems in quality improvement. Phase 2 involved initiating change by working at the mesosystem level to identify priorities for improvement and undertake tests of change. Phase 3 engaged decision makers at the macrosystem level from across the wider pathway in achieving change identified in earlier phases of the initiative. FINDINGS: The initiative was successful in delivering change in relation to key aspects of the pathway, engaging frontline staff and decision makers from different services within the pathway, and in building quality improvement capability within the workforce. Viewing the pathway as a series of interrelated CMS enabled stakeholders to understand the complex nature of the pathway and to target key areas for change. Particular challenges encountered arose from organisational reconfiguration and cross-boundary working. CONCLUSION: CMS quality improvement methodology may be a useful approach to promoting integration across a care pathway. Using a CMS approach contributed towards clinical and professional integration of some aspects of the service. Recognition of the pathway operating at meso- and macrosystem levels fostered wider stakeholder engagement with the potential of improving integration of care across a range of health and care providers involved in the pathway.

Physiotherapy practice in pulmonary hypertension: physiotherapist and patient perspectives.

Pulmonary hypertension (PH) is a life-limiting disease affecting circulation to the lungs. The primary symptom of PH is breathlessness, yet research has shown that patients with PH can exercise safely and can benefit from exercise to improve exercise capacity and maintain quality of life. This study aimed to investigate the nature of physiotherapy delivered to patients with PH in the UK. This was a two-phase sequential, exploratory, mixed-methods study. Interviews were conducted with seven lead physiotherapists at specialist pulmonary hypertension centers and three patients. Survey data came from 63 physiotherapists caring for patients with PH in specialist and non-specialist settings. The findings from the two phases were triangulated and analyzed. Findings showed that physiotherapists and patients see the benefit and potential of physical activity for patients with PH to maintain functional wellbeing. However, current physiotherapy provision focuses on acute inpatient care and planning for discharge and is not therefore aligned with research evidence and clinical guidelines. In the absence of inpatient rehabilitation facilities, physiotherapists will occasionally access existing community services, e.g. pulmonary rehabilitation; however, specialist knowledge of this rare condition can be lacking in local services. There is aspiration among physiotherapists and patients for a new approach which supports patients from diagnosis with PH to end of life. This includes promoting and delivering rehabilitation and exercise interventions to achieve better health outcomes, in line with patient needs. Treatment would be commissioned and delivered within existing national health systems with physiotherapists developing strategies for health improvement.

Is it feasible to conduct a randomised controlled trial of pretransplant exercise (prehabilitation) for patients with multiple myeloma awaiting autologous haematopoietic stem cell transplantation? Protocol for the PREeMPT study.

INTRODUCTION: While myeloma is an incurable malignancy, developments in disease management have led to increased life expectancy in recent years. Treatment typically involves stem-cell transplantation. Increased survival rates equate to more patients living with the burden of both the disease and its treatment for increasing number of years, rendering myeloma a long-term condition.Evidence exists to demonstrate the benefits of exercise for patients recovering from stem-cell transplantation, and prehabilitation-exercise before treatment-has been shown to be effective in other disease areas. To date there has been no research into prehabilitation in patients with myeloma awaiting transplantation treatment.Our objective is to determine whether it is feasible to conduct a randomised controlled trial into pretransplant exercise for patients with multiple myeloma who are awaiting autologous stem-cell transplantation. METHODS AND ANALYSIS: This mixed methods study identifies patients with diagnosis of multiple myeloma who have been assigned to the autologous transplantation list and invites them to participate in six weekly sessions of individualised, supervised exercise while awaiting transplantation.Quantitative data to determine feasibility targets include rates of recruitment, adherence and adverse events, and outcome measures including 6 min walking distance test and quality of life.Qualitative interviews are undertaken with a purposive sample of patients to capture their experiences of the study and the intervention. ETHICS AND DISSEMINATION: Ethics committee approval has been obtained. Dissemination will be through open-access publications and presentations and will seek to reach multiprofessional bases as well as patients and carer groups, addressing the widespread interest in this area of research. TRIAL REGISTRATION NUMBER: NCT03135925; Pre-results.

Introducing on-ward volunteers to work with patients with dementia.

This article reports on an evaluation of the effect of an on-ward volunteer service in an acute orthopaedic ward with a number of dementia patients. A mixed-methods evaluation was undertaken in 2012. This included interviews with individuals who have strategic, management, operational and clinical roles in the voluntary organisation and the NHS trust, focus group discussions with volunteers, non-participant observations of practice and focused conversations with ward staff. The service had a positive effect on patient experience. Patients were engaged through a variety of activities and enjoyed the volunteers' presence. Staff valued the initiative because they could see the difference that it made to patients and their own working lives. The lessons learned from the evaluation can inform the development of similar initiatives elsewhere and are relevant, given the emphasis in healthcare policy to improve patient experience.