Developing an intervention to promote physical activity engagement for people with multiple sclerosis living in rural settings

Abstract

Background: Increasing physical activity participation and reducing sedentary behaviour is important for the health and quality of life of people with multiple sclerosis (pwMS). It is important not only to reduce the impact of the primary impairments caused by MS but also to prevent the secondary comorbidities associated with sedentary behaviour. The challenge lies in engaging, and more importantly maintaining this engagement, of pwMS in regular physical activity. This is especially problematic for those people living in rural areas. Reasons for this may be the lack of exercise facilities and health professionals (such as physiotherapy services). Behaviour Change Interventions (BCI) and Telerehabilitation may be solutions to increase physical activity engagement long term for pwMS. Two previously described and investigated interventions aimed at improving long term engagement in physical activity for pwMS are Web-Based Physiotherapy (WBP) and Blue Prescription (BP). Combined, these two interventions may offer telerehabilitation-based BCI that may be of benefit to pwMS living rurally. Aims: This thesis aimed to understand and evaluate a combination of Web-Based Physiotherapy (WBP) and Blue Prescription (BP) to enhance long-term engagement in the physical activity of pwMS living rurally. Design: As this combined intervention can be considered a complex intervention, the United Kingdom’s Medical Research Council investigative approach to complex interventions was adopted. In this respect, a narrative literature review was undertaken to understand theoretical concepts and knowledge underpinning the topic. Then a systematic review was conducted to investigate whether the BCIs were effective in improving physical activity participation in pwMS. Described BCIs were mapped to the WBP and BP interventions as the next step to develop a better understanding of each intervention “BCI ingredients”. A proof of concept study (n=4 pwMS living rurally) using a mixing method design followed to investigate the acceptability of the combined intervention, and to trial research procedures and outcome measures. The proof of concept study related in changes being made to the delivery of the combined intervention and research design. The final study of this thesis was a feasibility study with a mixed method, RCT design (n=10 pwMS living rurally) conducted to re-evaluate the acceptability of modified intervention and research design and investigate the feasibility and potential benefits of the combined intervention. Intervention: WBP is a telerehabilitation intervention that uses website-based exercise video clips and written instructions to encourage pwMS to exercise. BP is an intervention in which the physiotherapist works alongside the person, supporting them to choose a physical activity they would like to do and when and how often they wish to do this activity. The underlying philosophy being that if the person has ownership and choice over what they do, they are more likely to maintain their participation long term. In combining the two interventions, it was anticipated that the WBP would introduce people to appropriate exercise and enhance their confidence to exercise. Having achieved this, then BP would be introduced to provide people with choice and ownership of what they would like to do (they could chose to continue with the WBP exercise or chose something else more to their liking). The combined intervention has 24 weeks in duration, comprising 12 weeks of WBP followed by 12 weeks of BP. In WBP a physiotherapist visited a participant and prescribed relevant exercises based on an in-home evaluation session. During the BP phase, the same physiotherapist interacted three times with the participant. At the first interaction, using motivational interviewing technique the physiotherapist collaboratively supported the participant’s choice of physical activity. The following interactions were aimed at barrier identification and problem-solving sessions. In between these three interactions the physiotherapist supported the participant as required via teleconference tools, email, text messages, or telephone. Data Analysis: the qualitative data were analysed with use of the Inductive Thematic Analysis. The ANOVA was used to analysis the quantitative data. Results: The systematic review showed that the BCIs might increase the physical activity level of pwMS however, the generalisation of these results were challenged by the heterogeneity of the studies. The mapping activity demonstrated that seven different BCI groups (based on the Michie taxonomy) could be found in the WBP intervention and six in the BP intervention. The proof of concept study illustrated that the combination of the interventions was acceptable to pwMS living rurally although the telerehabilitation component offered technological challenges to some participants. Some amendments were required to improve the flow between the two interventions. The feasibility study showed that the modified combined intervention was acceptable but feasibility could be improved with more training of the physiotherapists in the BP intervention training. A key finding was the importance of the human-human relationship to both participants and physiotherapists and that this cannot or should not be replaced by technology alone. Technology acts as an appropriate communication tool. However, the participants’ motivation to join and continue their interventions belonged to the physiotherapist and not the computers. No significant quantitative results were shown in the outcome measures analysis. The recruitment strategies used in the feasibility study were not optimal, resulting in a very slow and sporadic recruitment, and a less than desired sample size. Conclusion: Overall, it seems that the combination of the two interventions, WBP and BP is acceptable and potentially feasible. However, physiotherapists delivering this intervention require more training, especially in BP. More investigation is warranted to gain a better understanding of the relationships between motivation, technology and education. Future research is now required to evaluate whether the combined intervention does indeed increase physical activity engagement long term for pwMS living rurally.