Perioperative exercise programmes to promote physical activity in the medium to long term: systematic review and qualitative research

Michael W Pritchard, Amy Robinson, S. R. Lewis, Sue Gibson, Antony Chuter, R. Copeland, Euan Lawson, Andrew F. Smith
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The perioperative encounter (from initial presentation in primary care to postoperative return to function) offers potential for substantial health gains in the wider sense and over the longer term.\n \n \n \n The aim was to identify, examine and set in context a range of interventions applied perioperatively to facilitate physical activity in the medium to long term.\n \n \n \n The following databases were searched – Cochrane Central Register of Controlled Trials, MEDLINE, the Cumulative Index to Nursing and Allied Health Literature, EMBASE, PsycINFO and SPORTDiscus in October 2020. Clinical trials databases were also searched, and backward and forward citation searches were conducted.\n \n \n \n We undertook a systematic review; ran database searches in October 2020; extracted data; conducted risk-of-bias assessments of studies; and used Grading of Recommendations Assessment, Development and Evaluation assessments. We conducted focus groups and interviews with people running services designed to promote physical activity, to understand the practical and contextual factors that make such interventions ‘work’. Although the two streams of work were conducted independently, we considered overlapping themes from their findings.\n \n \n \n In the review, we found 51 randomised controlled trials and two quasi-randomised trials; nine non-randomised studies formed a supplementary data set. Studies included 8604 adults who had undergone (or were undergoing) surgery, and compared 67 interventions facilitating physical activity. Most interventions were started postoperatively and included multiple components, grouped as follows: education and advice, behavioural mechanisms and physical activity instruction. Outcomes were often measured using different tools; pooling of data was not always feasible. Compared with usual care, interventions may have slightly increased the amount of physical activity, engagement in physical activity and health-related quality of life at the study’s end (moderate-certainty evidence). We found low-certainty evidence of an increase in physical fitness and a reduction in pain, although effects generally favoured interventions. Few studies reported adherence and adverse events; certainty of these findings was very low. Although infrequently reported, participants generally provided positive feedback. For the case studies, we conducted two online focus groups and two individual interviews between November 2020 and January 2021, with nine participants from eight services of physical activity programmes. Conceptual and practical aspects included how the promotion of physical activity can be framed around the individual to recruit and retain patients; how services benefit from committed and compassionate staff; how enthusiasts, data collection and evidence play key roles; and how digital delivery could work as part of a blended approach, but inequalities in access must be considered.\n \n \n \n Outcome measures in the review varied and, despite a large data set, not all studies could be pooled. This also limited the exploration of differences between interventions; components of interventions often overlapped between studies, and we could not always determine what ‘usual care’ involved. 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Future work should also investigate the experiences of patients in different contexts, such as different communities, and with different surgical indications.\n \n \n \n This study is registered as PROSPERO CRD42019139008.\n \n \n \n This project was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme and will be published in full in Health and Social Care Delivery Research; Vol. 10, No. 21. 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引用次数: 2

Abstract

In England, more than 4 million hospital admissions lead to surgery each year. The perioperative encounter (from initial presentation in primary care to postoperative return to function) offers potential for substantial health gains in the wider sense and over the longer term. The aim was to identify, examine and set in context a range of interventions applied perioperatively to facilitate physical activity in the medium to long term. The following databases were searched – Cochrane Central Register of Controlled Trials, MEDLINE, the Cumulative Index to Nursing and Allied Health Literature, EMBASE, PsycINFO and SPORTDiscus in October 2020. Clinical trials databases were also searched, and backward and forward citation searches were conducted. We undertook a systematic review; ran database searches in October 2020; extracted data; conducted risk-of-bias assessments of studies; and used Grading of Recommendations Assessment, Development and Evaluation assessments. We conducted focus groups and interviews with people running services designed to promote physical activity, to understand the practical and contextual factors that make such interventions ‘work’. Although the two streams of work were conducted independently, we considered overlapping themes from their findings. In the review, we found 51 randomised controlled trials and two quasi-randomised trials; nine non-randomised studies formed a supplementary data set. Studies included 8604 adults who had undergone (or were undergoing) surgery, and compared 67 interventions facilitating physical activity. Most interventions were started postoperatively and included multiple components, grouped as follows: education and advice, behavioural mechanisms and physical activity instruction. Outcomes were often measured using different tools; pooling of data was not always feasible. Compared with usual care, interventions may have slightly increased the amount of physical activity, engagement in physical activity and health-related quality of life at the study’s end (moderate-certainty evidence). We found low-certainty evidence of an increase in physical fitness and a reduction in pain, although effects generally favoured interventions. Few studies reported adherence and adverse events; certainty of these findings was very low. Although infrequently reported, participants generally provided positive feedback. For the case studies, we conducted two online focus groups and two individual interviews between November 2020 and January 2021, with nine participants from eight services of physical activity programmes. Conceptual and practical aspects included how the promotion of physical activity can be framed around the individual to recruit and retain patients; how services benefit from committed and compassionate staff; how enthusiasts, data collection and evidence play key roles; and how digital delivery could work as part of a blended approach, but inequalities in access must be considered. Outcome measures in the review varied and, despite a large data set, not all studies could be pooled. This also limited the exploration of differences between interventions; components of interventions often overlapped between studies, and we could not always determine what ‘usual care’ involved. The case study exploration was limited by COVID-19 restrictions; we were unable to visit sites and observe practice, and the range of services in the focus groups was also limited. Evidence from the review indicates that interventions delivered in the perioperative setting, aimed at enhancing physical activity in the longer term, may have overall benefit. The qualitative analysis complemented these findings and indicated that interventions should be focused around the individual, delivered locally and compassionately, and promoted by a patient’s full clinical team. There is a need to develop a core outcome set for similar studies to allow quantitative synthesis. Future work should also investigate the experiences of patients in different contexts, such as different communities, and with different surgical indications. This study is registered as PROSPERO CRD42019139008. This project was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme and will be published in full in Health and Social Care Delivery Research; Vol. 10, No. 21. See the NIHR Journals Library website for further project information.
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促进中长期身体活动的围手术期运动规划:系统评价和定性研究
在英国,每年有超过400万人接受手术治疗。围手术期的遭遇(从初级保健的最初表现到术后功能的恢复)在更广泛和更长期的意义上提供了巨大的健康收益的潜力。目的是确定,检查和设置围手术期应用的一系列干预措施,以促进中期到长期的身体活动。检索了以下数据库:Cochrane中央对照试验注册库、MEDLINE、护理和相关健康文献累积索引、EMBASE、PsycINFO和SPORTDiscus,检索时间为2020年10月。检索临床试验数据库,并进行前后引文检索。我们进行了系统回顾;在2020年10月进行了数据库搜索;提取的数据;对研究进行偏倚风险评估;并使用建议分级评估,发展和评估评估。我们对开展旨在促进体育活动的服务的人员进行了焦点小组和访谈,以了解使此类干预措施“起作用”的实际和背景因素。虽然这两项工作是独立进行的,但我们从他们的发现中考虑了重叠的主题。在回顾中,我们发现51项随机对照试验和2项准随机试验;9项非随机研究形成了补充数据集。研究包括8604名接受过(或正在接受)手术的成年人,并比较了67种促进身体活动的干预措施。大多数干预措施是术后开始的,包括多个组成部分,分为以下几类:教育和建议、行为机制和身体活动指导。通常使用不同的工具来测量结果;汇集数据并不总是可行的。与常规护理相比,在研究结束时,干预措施可能略微增加了身体活动量、参与体育活动和与健康相关的生活质量(中等确定性证据)。我们发现了低确定性的证据,表明身体健康的增加和疼痛的减少,尽管效果通常有利于干预。很少有研究报告了依从性和不良事件;这些发现的确定性非常低。尽管鲜有报道,但参与者普遍提供了积极的反馈。在案例研究中,我们在2020年11月至2021年1月期间进行了两次在线焦点小组和两次个人访谈,共有来自八个体育活动项目服务机构的九名参与者。概念和实践方面包括如何围绕个人来促进体育活动以招募和留住患者;服务如何受益于忠诚和富有同情心的员工;热心人士、数据收集和证据如何发挥关键作用;以及数字交付如何作为混合方法的一部分发挥作用,但必须考虑获取方面的不平等。综述中的结果测量指标各不相同,尽管数据集很大,但并非所有研究都可以汇总。这也限制了对干预措施之间差异的探索;干预措施的组成部分经常在研究之间重叠,我们不能总是确定涉及的是什么“常规护理”。案例研究探索受到COVID-19限制的限制;我们无法实地考察和观察实践,焦点小组的服务范围也很有限。来自综述的证据表明,围手术期提供的干预措施旨在长期增强身体活动,可能具有总体效益。定性分析补充了这些发现,并表明干预措施应以个人为中心,在当地和富有同情心地提供,并由患者的整个临床团队推动。有必要为类似的研究制定一个核心结果集,以便进行定量综合。未来的工作还应调查不同背景,如不同社区和不同手术指征的患者的经验。本研究注册号为PROSPERO CRD42019139008。该项目由国家卫生和保健研究所(NIHR)卫生和社会保健提供研究方案资助,将全文发表在《卫生和社会保健提供研究》上;第10卷,第21期请参阅NIHR期刊图书馆网站了解更多项目信息。
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