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Adding web-based behavioural support to exercise referral schemes for inactive adults with chronic health conditions: the e-coachER Randomised Controlled Trial
Get PDFBackground: There is modest evidence that exercise referral schemes (ERS) increase physical activity (PA) of inactive individuals with chronic health conditions. There is a need to identify additional ways to improve the effects of ERS on long-term PA.
Objectives: To determine if adding the e-coachER intervention to ERS is more effective and cost-effective in increasing PA after one year, compared to usual ERS.
Design: Pragmatic, multicentre 2 arm randomised trial, with mixed methods process evaluation and health economic analysis. Participants were allocated 1:1 to either ERS plus e-coachER (intervention) or ERS alone (control).
Setting: Patients referred to ERS in Plymouth, Birmingham and Glasgow.
Participants: N = 450, aged 16-74 years, with BMI 30-40, hypertension, pre-diabetes, type 2 diabetes, lower limb osteoarthritis, or a current/recent history of treatment for depression; inactive; contactable via email; and an internet user.
Intervention: e-coachER was designed to augment ERS. Participants received a pedometer and fridge magnet with PA recording sheets, and a User Guide to access the web-based support in the form of 7 Steps to Health. e-coachER aimed to build the use of behavioural skills (e.g. self-monitoring) while strengthening favourable beliefs in importance for doing PA, competence, autonomy in PA choices and relatedness. All participants were referred to a standard ERS programme.
Primary outcome measure: Minutes of moderate and vigorous PA (MVPA) in ≥10 min bouts measured by accelerometer over one week at 12 months, worn ≥16 hours per day for ≥4 days including ≥1 weekend day.
Secondary outcomes: Other accelerometer-derived PA measures, self-reported PA, ERS attendance, EQ-5D-5L and HADS were collected at 4 and 12 months.
Results: Participants had a BMI mean (SD) of 32.6 (4.4), were primarily referred for weight loss, and were mostly confident self-rated IT users. Primary outcome analysis involving those with usable data showed a weak indicative effect in favour of the intervention group (N=108) compared with the control group (N=124); 11.9 weekly minutes MVPA, 95% CI -2.1 to 26.0; p = 0.10. 64% of intervention participants logged on at least once with generally positive feedback on the web-based support. The intervention had no effect on other PA outcomes, ERS attendance (78% v 75% in control and intervention, respectively), EQ-5D-5L or HADS scores, but did enhance a number of process outcomes (i.e. confidence, importance and competence) compared with the control group at 4 months but not at 12 months. At 12 months, compared to control, the intervention group incurred an additional mean cost of £439 (95% CI £-182, £1060) but generated more mean quality adjusted life years (QALYs); (0.026, 95% CI 0.013, 0.040) with an incremental cost effectiveness ratio of additional £16,885 per QALY.
Limitations: A significant proportion (46%) of participants were not included in the primary analysis, due to study withdrawal, and insufficient device wear time and the results must be interpreted with caution. The regression model fit for the primary outcome was poor, because of the considerable proportion of participants (142/243 (58%)) who recorded zero minutes of ≥10 minute bouted MVPA at 12 months.
Future work:The design and rigorous evaluation of cost-effective and scalable ways to increase ERS uptake and maintenance of MVPA are needed among patients with chronic conditions.
Conclusion: Adding e-coachER to usual ERS had only a weak indicative effect on long-term rigorously defined, objectively assessed MVPA. The provision of the e-coachER support package led to an additional cost and has a 63% probability of being cost-effective based on the UK threshold of £30,000/QALY. The intervention did improve some process outcomes as specified in our Logic Model
Why the context matters
Get PDFAim of talk
• The contextual model of psychotherapy
• The reformulated contextual model
• Why and how the context matters to all forms of health related activity – from therapy to tourism to everyday lif
A Pedagogy of Play: Reasons to be Playful in Postsecondary Education
Get PDFBackground: Teaching experientially in postsecondary education has challenges; institutional constraints, neoliberal management, and a colonized learning environment. We discuss playing as a form of experiential education. Purpose: We challenge conventional teaching and offer an alternative to enrich and broaden conventional pedagogies. We argue for the benefits of playfulness and how this leads to creativity, wellness, and improved graduate employability. Methodology/Approach: As provocation to the consequences of neoliberalism in education, we examine the literature from a biased position as advocates of play and experiential education. We argue for faculty to adopt an ontology and pedagogy of play. Findings/Conclusions: Play is well represented in the literature; contributing positively to a range of health and educational outcomes. As play manifests in numerous forms in postsecondary education, faculty would benefit from a clear educational rationale for an ontology and pedagogy of play. We share examples from our practice which highlight spontaneous and planned play and playful attitudes/behaviors and suggest how play may be integrated as planned curriculum. Implications: Ideally, these concepts resonate with faculty allowing them to challenge conventional pedagogies and confirm play in practice with the underpinning of experiential education research
Gastrointestinal Tolerance of Low, Medium and High Dose Acute Oral l-Glutamine Supplementation in Healthy Adults: A Pilot Study
Get PDFl-Glutamine (GLN) is a conditionally essential amino acid which supports gastrointestinal (GI) and immune function prior to catabolic stress (e.g., strenuous exercise). Despite potential dose-dependent benefits, GI tolerance of acute high dose oral GLN supplementation is poorly characterised. Fourteen healthy males (25 ± 5 years; 1.79 ± 0.07 cm; 77.7 ± 9.8 kg; 14.8 ± 4.6% body fat) ingested 0.3 (LOW), 0.6 (MED) or 0.9 (HIGH) g·kg·FFM−1 GLN beverages, in a randomised, double-blind, counter-balanced, cross-over trial. Individual and accumulated GI symptoms were recorded using a visual analogue scale at regular intervals up to 24-h post ingestion. GLN beverages were characterised by tonicity measurement and microscopic observations. 24-h accumulated upper- and lower- and total-GI symptoms were all greater in the HIGH, compared to LOW and MED trials (p 0.05). All beverages were isotonic and contained a dose-dependent number of GLN crystals. Acute oral GLN ingestion in dosages up to 0.9 g·kg·FFM−1 are generally well-tolerated. However, the severity of mild GI symptoms appeared dose-dependent during the first two hours post prandial and may be due to high-concentrations of GLN crystals
Influence of aerobic fitness on gastrointestinal barrier integrity and microbial translocation following a fixed-intensity military exertional heat stress test
No full textPurpose
Exertional-heat stress adversely disrupts gastrointestinal (GI) barrier integrity, whereby subsequent microbial translocation (MT) can result in potentially serious health consequences. To date, the influence of aerobic fitness on GI barrier integrity and MT following exertional-heat stress is poorly characterised.
Method
Ten untrained (UT; VO2max = 45 ± 3 ml·kg−1·min−1) and ten highly trained (HT; VO2max = 64 ± 4 ml·kg−1·min−1) males completed an ecologically valid (military) 80-min fixed-intensity exertional-heat stress test (EHST). Venous blood was drawn immediately pre- and post-EHST. GI barrier integrity was assessed using the serum dual-sugar absorption test (DSAT) and plasma Intestinal Fatty-Acid Binding Protein (I-FABP). MT was assessed using plasma Bacteroides/total 16S DNA.
Results
UT experienced greater thermoregulatory, cardiovascular and perceptual strain (p < 0.05) than HT during the EHST. Serum DSAT responses were similar between the two groups (p = 0.59), although Δ I-FABP was greater (p = 0.04) in the UT (1.14 ± 1.36 ng·ml−1) versus HT (0.20 ± 0.29 ng·ml−1) group. Bacteroides/Total 16S DNA ratio was unchanged (Δ; -0.04 ± 0.18) following the EHST in the HT group, but increased (Δ; 0.19 ± 0.25) in the UT group (p = 0.05). Weekly aerobic training hours had a weak, negative correlation with Δ I-FABP and Bacteroides/total 16S DNA responses.
Conclusion
When exercising at the same absolute workload, UT individuals are more susceptible to small intestinal epithelial injury and MT than HT individuals. These responses appear partially attributable to greater thermoregulatory, cardiovascular, and perceptual strain
The Gastrointestinal Exertional Heat Stroke Paradigm: Efficacy Of Acute Oral Glutamine Supplementation
Get PDFExertional heat stroke (EHS) is the most severe form of heat related illness. In military settings, it is considered a largely preventable cause of morbidity, however, prevalence has remained high into the 21st Century. To support disease management, various policy documents provide occupational guidance on effective risk mitigation strategies, however, these can be criticised for focussing solely on the thermoregulatory pathology of the disease. The gastrointestinal (GI) EHS paradigm is a novel pathophysiological model that links EHS to luminal microbial translocation (MT) downstream of structural GI barrier integrity disturbance. Whilst this model is still in its infancy, recent investigations have established practical nutritional interventions that can support GI barrier integrity in populations at risk of EHS. The aims of this thesis were therefore to: (1) characterise the response of GI barrier integrity biomarkers to exertional�heat stress; and (2) examine the efficacy of acute oral L-glutamine (GLN) as a nutritional countermeasure to protect GI barrier integrity.
From the experimental evidence reported in this thesis, several major conclusions were derived. First, GI barrier integrity can be reliably examined in blood samples taken at rest and following exertional-heat stress using the dual-sugar absorption test, intestinal�fatty acid binding protein and claudin-3 (chapter 4). Second, GI MT can be reliably examined in blood samples taken at rest and following exertional-heat stress using lipopolysaccharide binding protein and total 16S bacterial DNA, but not Bacteroides/total 16S DNA (chapter 4). Third, individuals with high-aerobic fitness experience blunted small intestinal epithelial injury and MT compared with untrained individuals during a fixed load exertional-heat stress test (chapter 5). Fourth, acute GLN supplementation (0.30, 0.60, 0.90 g·kg·FFM-1) causes mild dose-dependent GI symptoms at rest that generally lasted < 4 hours (chapter 6). Fifth, 0.30 g·kg·FFM-1 acute GLN supplementation does not protect GI permeability, small intestinal epithelial injury or MT when consumed 1-hour before either a low-intensity (chapter 7) or high-intensity (chapter 8) exertional-heat stress test. Taken together, GI barrier integrity loss reliably occurred in response to exertional-heat stress, a response that was blunted in individuals with high-aerobic fitness, but not following acute oral GLN supplementation
Comparison of the effects of pulmonary and extra-pulmonary symptoms on health-related quality of life in patients with severe asthma
Get PDFObjectives
To survey the frequency of extra-pulmonary symptoms reported by a sample of patients with severe asthma, their contribution to quality of life and relationship to treatment pathways.
Methods
Consenting patients (N = 100) attending a severe asthma clinic completed questionnaire measures of extra-pulmonary symptoms (the General symptom Questionnaire, GSQ), pulmonary symptoms (Asthma Control Test, ACT), quality of life (the Severe Asthma Questionnaire, SAQ) and health status (EQ-5D-5L).
Results
A median of 21 extra-pulmonary symptoms were reported per week. GSQ correlated -0.65 with the ACT and 0.69 with the SAQ. Linear regression showed that both the ACT and GSQ were significant predictors of SAQ mean score, p < 0.001. In patients not receiving biologics, those with high cumulative OCS exposure (≥1120mg per year) had significantly worse scores (p < 0.05) on all questionnaires except the ACT and GSQ compared to those with low cumulative OCS exposure.
Discussion
Extra-pulmonary symptoms were common in this sample of people with severe asthma. Extra-pulmonary and pulmonary symptoms contribute equal variance to the score of HRQoL, showing that they are equally important contributors to patients’ experience of severe asthma. Extra-pulmonary symptoms are often overlooked in clinical medicine and in measures of quality of life. Participants receiving biologic treatments had lower extra-pulmonary symptoms possibly indicating that biologics reduce systemic symptoms more effectively than other treatments
Challenging the new orthodoxy: a critique of SPLISS and variable-oriented approaches to comparing sporting nations
Get PDFResearch Question: In recent years the comparative sport policy field has become dominated by the ‘SPLISS’ approach developed by De Bosscher and colleagues. While the SPLISS approach has developed important insights into the statistical relationship between key groups of independent variables and indicators of elite sport policy success, nevertheless its attempts to identify and explain both statistical association and causal relationships have significant limitations.
The paper thus seeks to address the question of the nature of such strengths and limitations and their implications for theory, policy and practice.
Methods: As a review paper it develops a critical evaluation of claims made for the SPLISS approach to variable oriented comparative policy analysis.
Results: The paper identifies and focuses on the implications of six key problems for the SPLISS approach, namely: philosophical assumptions and causal variables; the black box problem; internal validity issues; non-equivalence and reliability; the neglect of agency; and misconceptions in the use of mixed methods.
Implications: The paper’s findings represent a challenge to the hegemony of this variable-oriented approach and they argue not for replacement or rejection of such an approach, but for recognition of its limitations, and of the opportunities for complementing it with case-driven, qualitative analysis generating causal accounts of policy outcomes
The Gastrointestinal Exertional Heat Stroke Paradigm: Pathophysiology, Assessment, Severity, Aetiology and Nutritional Countermeasures
Get PDFExertional heat stroke (EHS) is a life-threatening medical condition involving thermoregulatory failure and is the most severe condition along a continuum of heat related illnesses. Current EHS policy guidance principally advocates a thermoregulatory management approach, despite growing recognition that gastrointestinal (GI) microbial translocation contributes to the pathophysiology. Contemporary research has focussed on understanding the relevance of GI barrier integrity and strategies to maintain it during periods of exertional-heat stress. GI barrier integrity can be assessed non-invasively using a variety of in vivo techniques, including active inert mixed-weight molecular probe recovery tests and passive biomarkers indicative of GI structural integrity loss or microbial translocation. Strenuous exercise is well-characterised to disrupt GI barrier integrity, and aspects of this response correlate with the corresponding magnitude of thermal strain. The aetiology of GI barrier integrity loss following exertional-heat stress is poorly understood, though may directly relate to localised hyperthermia, splanchnic hypoperfusion mediated ischemic injury, and alternations in several neuroendocrine-immune responses. Nutritional countermeasures to maintain GI barrier integrity following exertional-heat stress provide a promising approach to mitigate EHS. The focus of this review is to evaluate: (1) the GI paradigm of exertional heat stroke; (2) techniques to assess GI barrier integrity; (3) typical GI barrier integrity responses to exertional-heat stress; (4) the aetiology of GI barrier integrity loss following exertional-heat stress; and (5) nutritional countermeasures to maintain GI barrier integrity in response to exertional-heat stress