Physical activity for people with chronic conditions: a systematic review of toolkits to promote adherence.

PURPOSE: The World Health Organisation (WHO) recommends that health professionals develop and implement "adherence counselling toolkits" to promote adherence to long-term therapies in people with chronic conditions. This prospectively registered review aimed to systematically identify and evaluate existing toolkits developed to promote adherence to physical activity in people with chronic conditions. MATERIALS AND METHODS: Grey literature and six e-databases were searched for studies investigating the use of "toolkits" to promote adherence to physical activity or exercise recommendations in people with chronic conditions (Medline, PsycInfo, EmCare, Cochrane, CINAHL Plus, Pedro). A two-stage screening process was completed by two independent reviewers. RESULTS: Five studies describing five toolkits were included. Three toolkits displayed all WHO recommended features, including information on adherence, a clinically useful way of using this information, and behavioural tools for maintaining habits. The included toolkits featured "adherence" to the intervention; however, this was not their primary aim. There were trends towards improved physical activity with some of the included toolkits. CONCLUSIONS: There are a lack of rigorously developed toolkits that focus on adherence to physical activity in people with chronic conditions. Toolkits should be developed, tested, and implemented to improve adherence and outcomes for people with chronic conditions.

Health outcomes for people with chronic conditions may be enhanced with a focus on adherence, however there are currently no rigorously developed toolkits that meet this need.Adherence counselling toolkits should be co-designed with stakeholders for use with people with specific chronic conditions.Adherence-focused toolkits should be developed, implemented, and evaluated to ensure they are feasible to use and beneficial for health professionals working with people with chronic conditions.

'The way that we are collecting and using data has evolved' evaluating the Australian National Stroke Audit programme to inform strategic direction.

BACKGROUND: The National Stroke Audit has been used to audit and provide feedback to health professionals and stroke care services in Australia since 2007. The Australian Stroke Clinical Registry was piloted in 2009 and numbers of hospitals participating in the registry are increasing. Considering the changing data landscape in Australia, we designed this study to evaluate the stroke audit and to inform strategic direction. METHODS: We conducted a rapid review of published literature to map features of successful data programmes, followed by a mixed-methods study, comprising national surveys and interviews with clinicians and administrators about the stroke audit. We analysed quantitative data descriptively and analysed open-ended survey responses and interview data using qualitative content analysis. We integrated data from the two sources. RESULTS: We identified 47 Australian data programs, successful programs were usually funded by government sources or professional associations and typically provided twice yearly or yearly reports.106 survey participants, 14 clinician and 5 health administrator interview participants were included in the evaluation. The Stroke Audit was consistently perceived as useful for benchmarking, but there were mixed views about its value for local quality improvement. Time to enter data was the most frequently reported barrier to participation (88% of survey participants), due to the large number of datapoints and features of the audit software.Opportunities to improve the Stroke Audit included refining Audit questions, developing ways to automatically export data from electronic medical records and capturing accurate data for patients who transferred between hospitals. CONCLUSION: While the Stroke Audit was not perceived by all users to be beneficial for traditional quality improvement purposes, the ability to benchmark national stroke services and use these data in advocacy activities was a consistently reported benefit. Modifications were suggested to improve usability and usefulness for participating sites.

The first year of private practice - new graduate physiotherapists are highly engaged and satisfied but edging toward burnout.

BACKGROUND: A greater understanding of physiotherapists' work-life during their first year of work in private practice, and whether their experiences are mediated by personal traits, may provide valuable information to support their transition and retention. OBJECTIVES: Describe the first year of practice for graduate physiotherapists in terms of employee engagement, job satisfaction, performance, and burnout, and evaluate the relationship between these measures and personal traits (resilience, grit, mind-set). DESIGN: One-year longitudinal mixed-methods study. METHODS: Twenty new graduate physiotherapists completed questionnaires evaluating resilience, grit, and mind-set within 1-week of commencing employment. Engagement and job satisfaction were evaluated at 3, 6 and 12-months, and burnout evaluated at 12-months. Performance data (number of patients seen, revenue) were collected throughout the year. Individual semi-structured interviews were conducted at baseline, 3, 9 and 12-months. RESULTS: Engagement and satisfaction were high at all time points. At 12-months, burnout was at a medium level. Resilience was positively associated with job satisfaction at 6 (ρ = 0.56, p = .019) and 12-months (ρ = 0.54, p = .027). Engagement (ρ = -0.57, p = .04) and job satisfaction (ρ = -0.56, p = .03) were negatively associated with burnout at 12-months. All participants remained passionate about their work although increasing administrative burden and patient complexity contributed to feelings of burnout. CONCLUSIONS: Resilience was positively associated with job satisfaction suggesting those with capacity to 'bounce back' were more satisfied and engaged with their job. Although moderate levels of burnout were reported at 12-months, those with higher job satisfaction and employee engagement had lower levels of burnout. Participants proposed practical strategies to help mitigate burnout.

"Just that four letter word, hope": stroke survivors' perspectives of participation in an intensive upper limb exercise program; a qualitative exploration.

BACKGROUND: Less than half of stroke survivors will be able to use their arm at 6 months post-stroke. Guidelines recommend the use of intensive upper limb exercise programs to optimize recovery; however, there has been limited research exploring experiences of participation in intensive programs. AIM: To identify factors influencing adherence to an intensive upper limb exercise program in people with stroke. METHODS: Qualitative design. Semi-structured interviews were conducted with 20 stroke survivors who had participated in an intensive upper limb program. Perspectives of participation, including perceived barriers and enablers to program adherence were explored. Interviews were audio-recorded, transcribed, and imported into NVivo for analysis. Two authors mapped themes to the Capability, Opportunity, Motivation-Behavior (COM-B) behavior change model to identify barriers and enablers to adherence. RESULTS: Enablers influencing adherence included: 1) routine practice times (Motivation - automatic); 2) accountability to staff (Motivation - reflective); and 3) social support (Opportunity - social). Barriers to adherence included: 1) exercises being too difficult (Capability - physical); 2) reliance on others to help (Capability - physical); and 3) difficulty 'fitting it in' (Motivation - reflective). CONCLUSION: Findings will inform recommendations for the delivery of intensive upper limb exercise programs to improve adherence and assist services to provide rehabilitation in a manner that enables self-directed practice by stroke survivors.

Developing and implementing an exercise-based group for stroke survivors and their carers: the Carers Count group.

PURPOSE: Guidelines recommend that carers of stroke survivors should be engaged early in rehabilitation. There has been limited research implementing exercise programs that include carers. The aims of this study were to develop, facilitate, and evaluate an intervention, the Carers Count group, an exercise-based group for stroke survivors and their carers. METHODS: Over a 5-month period, a staged approach was used to design the intervention and implementation strategies which would maximise the chances of embedding the intervention within an inpatient stroke ward. Implementation strategies included planning, educating, restructuring, financing, and managing quality. Following development and facilitation of the intervention, outcomes were evaluated through collecting data about therapy time, surveys (n = 30) and interviews (n = 18) with participants, and a focus group with staff. RESULTS: Thirty stroke survivors and their carers participated in the Carers Count group. Analysis of time spent in therapy showed that participation led to increased dose of physiotherapy time (service outcome). Survey and interview data suggested that participation in the group was a rewarding and engaging experience for participants (client outcomes). CONCLUSION: Using multifaceted strategies, a group designed to include carers was implemented on a stroke rehabilitation ward. The intervention provided positive outcomes in terms of increased therapy dose and satisfaction according to participant feedback. CLINICAL TRIALS REGISTRATION NUMBER: ANZCTR12620000708954Implications for rehabilitationIt is possible to develop modes of delivery in rehabilitation that include the carers of stroke survivors and these interventions are considered enjoyable and beneficial.Health professionals should consider interventions that are engaging and fun for stroke survivors and their carers.Health professionals should carefully plan and utilise appropriate implementation strategies when aiming to introduce a new intervention into an established health service.Health professionals should ensure stroke survivors and their carers have an understanding of recovery following stroke and how to maximise outcomes through increasing amount of practice.

Viability of using a computer tablet to monitor an upper limb home exercise program in stroke.

Aims: To evaluate the feasibility of using a tablet computer to monitor the amount of upper limb practice completed by stroke patients prescribed with a home program and to explore factors that influence adherence. Method: Ten consecutive participants randomized to the intervention arm of a randomized controlled trial investigating therapy after spasticity management for stroke patients (ACTRN 12615000616572) were recruited for this sub-study. Participants were asked to perform and record a prescribed 60-min upper limb program, based on the Graded Arm Supplementary Program, on a tablet computer daily. Four randomly selected recorded sessions for each participant were analyzed by the physiotherapist to assess adherence to the amount of exercise and content. Results: Mean score for the System Usability Scale was 85.5 (range 47.5-100) indicating that participants were accepting of the technology. Participants performed exercises on average for 50.32 min (range 26.42-68.37). Self-reported practice time was 59.44 min (range 48-67.5). Conclusion: Monitoring of patient practice using a tablet computer is feasible and may prove more reliable than self-report. There is variability in the amount of upper limb exercise stroke patients do at home.

Does the addition of concurrent visual feedback increase adherence to a home exercise program in people with stroke: a single-case series?

OBJECTIVE: Evidence is accumulating for the potential benefits of technology use in stroke rehabilitation. However, few studies have examined ways in which technology can be used to increase adherence to programs after discharge from rehabilitation. The aim of this study was to determine if the addition of concurrent visual feedback, via a tablet computer, increased adherence to an exercise program following stroke. Ten participants were provided with a self-administered exercise program and were asked to perform 60 min of the exercises daily. After a baseline phase (1 week), participants were given a tablet computer (2 weeks) and were asked to video record each exercise session. The tablet computer was removed during the fourth week of the program. RESULTS: Exercise duration, measured via wrist-worn accelerometry, was investigated over the 4 weeks using the two-standard deviation (2 SD) band method. A statistically significant effect was observed in four out of ten cases, demonstrated by two successive data points occurring outside the 2 SD band during the intervention phase, suggesting that adherence was increased in response to the tablet computer use. This preliminary study indicates that the use of visual feedback, via a tablet computer, may increase adherence to an exercise program in people with stroke. Trial registration ACTRN: ACTRN12620000252910 (26 February 2020, Retrospectively registered).

A systematic review of measures of adherence to physical exercise recommendations in people with stroke.

OBJECTIVE:: To review methods for measuring adherence to exercise or physical activity practice recommendations in the stroke population and evaluate measurement properties of identified tools. DATA SOURCES:: Two systematic searches were conducted in eight databases (MEDLINE, CINAHL, PsycINFO, Cochrane Library of Systematic Reviews, Sports Discus, PEDro, PubMed and EMBASE). Phase 1 was conducted to identify measures. Phase 2 was conducted to identify studies investigating properties of these measures. REVIEW METHODS:: Phase 1 articles were selected if they were published in English, included participants with stroke, quantified adherence to exercise or physical activity recommendations, were patient or clinician reported, were defined and reproducible measures and included patients >18 years old. In phase 2, articles were included if they explored psychometric properties of the identified tools. Included articles were screened based on title/abstract and full-text review by two independent reviewers. RESULTS:: In phase 1, seven methods of adherence measurement were identified, including logbooks ( n = 16), diaries ( n = 18), 'record of practice' ( n = 3), journals ( n = 1), surveys ( n = 2) and questionnaires ( n = 4). One measurement tool was identified, the Physical Activity Scale for Individuals with Physical Disabilities ( n = 4). In phase 2, no eligible studies were identified. CONCLUSION:: There is not a consistent measure of adherence that is currently utilized. Diaries and logbooks are the most frequently utilized tools.

Intensive therapy after botulinum toxin in adults with spasticity after stroke versus botulinum toxin alone or therapy alone: a pilot, feasibility randomized trial.

BACKGROUND: Botulinum toxin-A is provided for adults with post-stroke spasticity. Following injection, there is a variation in the rehabilitation therapy type and amount provided. The purpose of this study was to determine if it is feasible to add intensive therapy to botulinum toxin-A injections for adults with spasticity and whether it is likely to be beneficial. METHODS: Randomized trial with concealed allocation, assessor blinding, and intention to treat analysis. Thirty-seven adults (n = 3 incomplete or lost follow-up) with spasticity in the upper or lower limb were allocated to one of three groups: experimental group received a single dose of botulinum toxin-A plus an intensive therapy for 8 weeks, control group 1 received a single dose of botulinum toxin-A only, and control group 2 received intensive therapy only for 8 weeks. Feasibility was measured by examining recruitment, intervention (adherence, acceptability, safety), and measurement. Benefit was measured as goal achievement (Goal Attainment Scale), upper limb activity (Box and Block Test), walking (6-min walk test) and spasticity (Tardieu scale), at baseline (week 0), immediately after (week 8), and at three months (week 12). RESULTS: Overall recruitment fraction for the trial was 37% (eligibility fraction 39%, enrolment fraction 95%). The 26 participants allocated to receive intensive rehabilitation attended 97% of clinic-based sessions (mean 11 ± 2 h) and an averaged 58% (mean 52 ± 32 h) of prescribed 90 h of independent practice. There were no study-related adverse events reported. Although participants in all groups increased their goal attainment, there were no between-group differences for this or other outcomes at week 8 or 12. CONCLUSION: Providing intensive therapy following botulinum toxin-A is feasible for adults with neurological spasticity. The study methods are appropriate for a future trial. A future trial would require 134 participants to detect a between-group difference of 7 points on Goal Attainment Scale t-scores with an alpha of 0.05 and power of 80%. TRIAL REGISTRATION: ACTRN12612000091808. Registered 18/01/2012, retrospective.