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Jason Hinterweger
Jason Hinterweger

Physiotherapy Management For Multiple Sclerosis.pdf LINK

We have co-designed a tailored blended physiotherapy intervention for people with progressive multiple sclerosis (PwPMS) who often struggle to access support for physical activity. Underpinned by self-management principles, the Lifestyle, Exercise and Activity Package for people with Multiple Sclerosis (LEAP-MS) intervention incorporates face-to-face or online physiotherapy coaching sessions with an accompanying online physical activity platform. The LEAP-MS platform is a multi-user system enabling user and physiotherapist to co-create activity plans. The LEAP-MS platform consists of an information and activity suite, interactive components enabling selection of exercises into an activity programme, goal setting and activity logging. The platform also facilitates online remote support from a physiotherapist through an embedded online messaging function. We aim to evaluate the LEAP-MS platform in a feasibility trial.

Physiotherapy Management For Multiple Sclerosis.pdf

LEAP-MS will be evaluated within a single-arm feasibility study with embedded process evaluation. After registration and initial eligible screening, 21 participants will be required to complete baseline self-completion measures. This will be followed by an initial home-based or online coaching session with a physiotherapist (who has received tailored self-management and digital resource training) and access to the online intervention for an initial 3-month period. During this period, participants are given the option to request up to five further home-based or online physiotherapy coaching sessions. Follow-up questionnaires and semi-structured interviews will be administered 3 months after baseline with participants and intervention physiotherapists. The LEAP-MS platform will be available to participants for a further 3 months. Usage of the LEAP-MS platform will be tracked during the full 6-month period and final follow-up will be conducted 6 months after baseline.

Physiotherapists play a central role as part of a multidisciplinary team of healthcare professionals who support people with progressive multiple sclerosis in the management of their symptoms [12]. Primarily focussed on maintaining, adapting or enhancing physical and sensory capabilities of individual patients, physiotherapy has been shown to be effective in, for example, improving balance [13], mobility [14] and spasticity [15] with people with MS. As part of their therapeutic toolkit, physiotherapists use exercise and have expertise in supporting and promoting physical activity [16].

Despite the potential benefits of physical activity and the value placed on supporting people with MS to remain active, there remains little evidence about the benefits of physiotherapy or physical activity for PwPMS who have more advanced disability [38]. Most research has focussed on patients who are ambulatory, despite non-ambulatory people with MS being those who are least likely to stay active [23, 39, 40]. A systematic review [41] of physiotherapy interventions, including exercise therapy, for the rehabilitation of people with progressive multiple sclerosis published in 2016 reviewed 13 studies (of eight interventions) of variable methodological quality. It concluded that physiotherapy and exercise interventions for PwPMS were potentially of benefit but that fully powered efficacy studies were required. Recently, a home-based, self-managed standing frame programme has been found to be effective in PwPMS [42]; however, there is little research into physical activity interventions in PwPMS, which may be explained by difficulties recruiting or retaining individuals with advanced disability into research studies. These challenges, which may be explained by difficulties travelling to appointments and a high prevalence of fatigue and cognitive impairment, are the same ones that must be overcome to enable PwPMS to engage in sustained physical activity. Seeking sustainable, cost-effective interventions that facilitate access to physical activity for all remains a priority.

Unlike other physiotherapy-based online activity platforms for other conditions or general education platforms, the LEAP-MS platform has a paired account function in which people with MS can be paired with their physiotherapist. Critically, rather than the physiotherapist selecting and prescribing activities, the person with MS has complete choice and control of this process. The physiotherapist can view participant activity logs, but advise only as required by the person with MS. Furthermore, the patient-facing element of the LEAP-MS intervention platform combines multimedia educational content, activity provision, activity monitoring and goal setting. It includes an online hub for physiotherapists, which draws together self-management training and provides a space for multimedia exercise in long-term neurological conditions.

A mixed-methods design, combining a cross-sectional survey and semi-structured interviews with UK-physiotherapists, was used to answer the research question. To inform the qualitative study, a cross-sectional survey collected data from physiotherapists working in neurology to understand the impact and management of anxiety in people with MS (PwMS) during rehabilitation. Analysis used descriptive statistics and the findings formed the interview guide. Semi-structured interviews with specialist physiotherapists explored barriers and facilitators to managing anxiety in PwMS in community and outpatient settings, identified perceived physiotherapy training needs and offered suggestions to develop physiotherapy research and practice. Themes were derived inductively.

The survey suggested how PwMS present with anxiety, its impact during rehabilitation, physiotherapy management practices, and physiotherapist skills and training needs. Five semi-structured interviews with specialist physiotherapists expanded on the survey findings and identified five main themes: Understanding the MS journey, modifying assessment and treatment, anxiety management toolbox, lagging behind Musculoskeletal Physiotherapy, and gaining knowledge and skills.

As there are no standardised tools available to measure the phenomenon under investigation, a questionnaire was developed using Google Forms; free to use and complying with University information governance policy. Questions were derived by LL based on direct clinical experience, gathering data relating to the impact of anxiety in PwMS during rehabilitation, physiotherapists skills and techniques to manage anxiety, perceived areas for further physiotherapy training and demographic characteristics. The questions were reviewed by a second researcher (JP) prior to piloting. The questionnaire consisted of predominantly closed questions using ranked-response, multiple choice, and Likert scales. This aimed to ease understanding for participants completing a self-administered survey and enhance the value of data obtained. Open ended questions were minimised to lessen the burden on clinicians and reduce obtaining incomplete data. The questionnaire was piloted with a sample of 3 physiotherapists, representing the target population and having shared experience with the researcher prior to this study, to enhance validity and reliability. Minor amendments were made to improve question clarity. Distribution issues delayed the questionnaire being sent; therefore, the response window was extended by a month to gain sufficient data to inform the qualitative arm of the study. The questionnaire was available from 21st May 2018 to the 2nd July 2018, aligning with the timeframe and deadline allocated to this masters project.

A significant challenge was the importance placed on physiotherapy, from patients and other professionals, to manage symptoms in the absence of any curative treatment. Misconceptions around physiotherapy necessitating hands-on treatment challenged productive self-management discussions. As the measure of success is inherently different in progressive neurological conditions, physiotherapists often felt like they were not helping their patients therefore not meeting patient expectations.

All participants reflected anxiety blocked treatment progression, particularly through greater time discussing anxiety related issues and the implications of this on physical progression. Participants felt physiotherapy itself contributed towards anxiety, referencing challenges to physical ability, indicating the importance of exploring the source and reflexively modifying treatment. Anxiety was detrimental to self-efficacy, affecting concentration and retention of information, therefore impeding self-management. An interesting insight was the impact of anxiety on physiotherapists, with clinicians feeling less competent in their clinical skills and noting feelings of inefficacy.

Participants felt neurological physiotherapy may be behind, in both research and practice, when looking at the link between physical and mental health. Reference was made to evidence supporting the psychosocial management of chronic pain within physiotherapy and how these principles could be applied to the neuro setting. Using patient narrative over gold standard research methods to understand the patient story was also deemed important in the context of neuro-research.

In addition to a lack of skills, a significant barrier to physiotherapists feeling competent was inadequate training, at both undergraduate and post-graduate level. This reflects findings from other clinical settings where physiotherapists felt their training did not equip them with skills to meet the psychological needs of their patients [18, 45]. Qualitative interviews suggested several recommendations for improvements in this area, for example the use of narrative to develop case studies and patient stories such as those used in chronic pain research. This study highlighted physiotherapists understand the impact of uncertainty and loss of identity associated with chronic disease, however, lack the skills to confidently manage the illness experience during rehabilitation. Narrative has been used to understand the lived experience of pain-related fear to better inform its physiotherapy management, reconceptualising assessment and treatment approaches as a result [46, 47]. A similar approach may be beneficial within neurological physiotherapy to better understand the multifaceted biopsychosocial aspects of MS that directly impact rehabilitation.


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