Are there differences in adherence to home-based, inspiratory ...

Are there differences in adherence to home-based, inspiratory ...

Are there differences in adherence to home-based, inspiratory muscle training programmes between athletes and non-athletes? Implications for designing community based rehabilitation programmes for respiratory patients. Dr Dimitra Nikoletou Associate Professor- Faculty of Health, Social Care and Education, Kingston and St Georges University of London. Chronic respiratory conditions and quality of care Long term conditions - care of patients absorbs 70% of hospital and primary care budgets in England alone. ---------------------------------------------------------------------- Domain 2 of NHS England- Enhancing quality of care for people with long term conditions. Self-management and community based programmesPhysiotherapist have great input

National Service Frameworks (NSF)- Evidence-based strategies for improving specific areas of care- They set measurable goals within set time-frames Adherence to community-based exercise programmes Evidence from: Stroke patients Patients with diabetes COPD patients etc. Adherence varies and has implications for effectiveness of an intervention Monitoring- phone calls/ diary cards/visits/ activity monitors/ pedometers etc. Inspiratory muscle training

Intervention to improve inspiratory muscle strength An adjunct of comprehensive pulmonary rehabilitation programmes Ideal for home-based programmes Pro-IMT Against-IMT Differences in the literature Why is there a difference in results from communitybased studies in athletes versus patients with COPD? Hypothesis: Athletes more likely to self-manage and adhere to a home-based programme than COPD patients or

Differences in physiological adaptation to chronic disease Our study Mixed methods study Aims: a) to explore adherence and other variable differences between athletes and non- athletes b) to explore perceptions about the IMT programme in the two groups. Recruitment 20 BSc Physiotherapy students Athletes

Non-Athletes (SGUL Rowing team) N=10 (no regular ex.) N=10 Baseline Assessments 4 week Home-based IMT programme Post-IMT Assessments Athletes Focus Group

Non-athletes Focus Group N=4- Randomly selected N=4- Randomly selected The IMT home programme 4 weeks duration Powerbreathe device

Training Intensity: 60%PImax and increasing by 10% per week If reached 100%PImax before week 4 then increase number of breaths by 10 Twice daily, 30 breaths per session. Our assessments: Primary Outcome: Adherence to the IMT programme Used self-report Diary cards Defined as: High (if > 71% sessions completed) Moderate (50%-70%) Low (<50%) All student-participants were instructed to complete the cards fully.

Our assessments: Meters rowed- 4 min all-out effort on a rowing ergometer Rate of Perceived Exertion (RPE) Respiratory muscle assessments Maximal Inspiratory and Expiratory pressures (PImax and PEmax) Hand-held device Participants had practice and at least 10 breaths on each occasion Nikoletou D. et al. Sniff nasal inspiratory pressure in patients with moderate to severe COPD; Learning effect and short-term between-session repeatability Respiration 2014; 88: 365-370

Qualitative assessment: Interviews- 2 Focus groups Topic guide Recorded and transcribed verbatim Thematic analysis Themes discussed among research team The Focus group topic guide What did you find easy about the IMT programme? What did you find difficult about the training? Is there anything that would make the training programme easier to follow?

Did you modify or adapt the programme in any way to make it more user friendly for yourself? Did anything change in your daily exercise routine or activities change during the 4 weeks? Any other general feedback? Results Pre Non-athletes Athletes Mean (SD) Mean (SD) N=10 Gender (M:F) Age BMI 5:5

29.9 (6.61) 24.6 (1.9) N=10 Post Between group Difference at baseline p value Change from baseline Non-Athletes Mean (SD) Athletes

Mean (SD) N=9 N=10 NonAthletes P value Athletes P value Between-group change p value (95% CI)

10:0 0.03* 22.2 (3.77) 0.05* 23.43 (1.4) 0.15 Adherence to the IMT Home-based Programme Adherence (%of sessions trained out of possible 40) Duration of training (min each session of 30 breaths took) 51.15 (30.13)

91.67 (11.65) 0.001* 10.07 (7.6) 4.09 (0.8) 0.037* Respiratory muscle function 0.12 (-6.2 to -48.7) 0.18 (-6.3 to 30.8)

PImax(cmH2O) 79.0 (27.39) 114.4 (21.68) 0.05* 89.4 (28.16) 143.7 (28.5) 0.06 0.04* PEmax(cmH2O)

124.6 (18.77) 157.9 (20.7) 0.01* 123.2 (29.5) 168.1 (28.4) 0.82 0.21 Exercise capacity and perceived exertion 888.8 1199.3 Meters Rowed (m) 867.4 (103.5) 1183.6 (47.8) 0.01*

(110.5) (53.3) RPE 8.8 (2.2) 12.0 (1.2) 0.01* 9.3 (1.77) 11.59 (1.33) 0.01* 0.01* 0.25 0.18

0.1 0.04* Thematic analysis results Themes Common themes Unique to Athletes or Non-athletes Thematic analysis results Ease of use but tedious

Motivation due to personal goals Common Themes Mid-way progress check/ information Adaptation of prescribed training

I am trying to get fit and lose weight for my wedding. I really felt this helped with my motivation to do the training every day. I first started doing it while doing other things at the same time, then realised I couldnt do that. I started using the nasal clips in week three What would have helped is more information about what the training actually does.

Id heard that IMT can improve your rowing performance, so I did it every day to see if it made a difference. I had a go at doing 30 in a row first but this was really difficult. I found three lots of 10 worked best. Maybe at the week 2 stagejust more information about the benefits of what the training was doing for

us Unique Themes- Athletes Disciplined with training we work in a 4 weekly cycle building up (rowing) and then have a rest week then building up again. I decided to do all my 5 days in a row. Then I would notice I felt a

little sore but nothing to put me off doing it Athletes Relevance to athletic goals Easy to fit into daily routine Unique Themes- Non-athletes More aware of uncomfortable sensations

I found difficult to find a suitable place and time to do it Difficulty establishing ex. routine Pain/Breathlessness/ light-headedness It wasnt pleasant and actually the first bit made me gag quite a lot Nonathletes Loss of

motivation Implications for Exercise Prescription in community programmes Participants were physiotherapy students Very short/intense programme- only 4 weeks Volunteered to help their fellow students Healthy- no evidence of Breathlessness Is knowledge about exercise benefits enough? Should we be assessing motivation before prescribing exercise?

How to use behavioural change principles in community programmes. Implications for Exercise Prescription in community programmes Need for visual feedback- numbers etc Need for programme to be varied/ more interesting More regular monitoring or progress Information written and oral CDs?/ Apps?/ Information booklets? IMT device recent improvements Visual feedback Count-down of breaths Butwould it increase/ guarantee adherence?

Acknowledgements Claire Verrier- Research student James McDermott-Research student Zac Chandler-Research student Peter Fraser- Technical support St Georges University rowing team St Georges University Gym for use of their facilities

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