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    Person-centred goal setting for exercise after stroke
    (Queen Margaret University, Edinburgh, 2014) Sugavanam, Thava Priya
    Clinical guidelines and policies recommend exercise after stroke. Person-centred goal setting may facilitate the uptake and maintenance of physical activity. The aim of this work was to design and evaluate a goal setting intervention in an exercise after stroke setting. Five interlinked studies were undertaken within the development and feasibility stages of the MRC framework of complex interventions. A systematic review examined 17 observational studies (11 quantitative, six qualitative) for the effects and experiences of goal setting in stroke rehabilitation (study one). Despite some positive effects, no firm conclusion could be reached regarding its effectiveness. Patients and professionals differed in their experiences. Barriers to goal setting outnumbered facilitators. The lack of a standardised goal setting method in stroke rehabilitation was highlighted. A goal setting intervention tailored to exercise after stroke was developed in study two, based on: findings from study one, Bandura’s Social Cognitive Theory and the Canadian Occupational Performance Measure. The intervention components were: dedicated time, patient education, patient involvement, regular follow-up, and a purpose-designed workbook. This intervention was piloted in study three alongside validation of the activPAL™ activity monitor with 12 stroke survivors. The intervention did not require modification. Only two variables of the activPAL™ (time spent in sitting and upright) had acceptable validity and reliability. Feasibility of the intervention and users’ experiences were investigated in study four with four stroke survivors, using mixed methods case studies. Intervention delivery and compliance were acceptable with no adverse effects. Findings regarding acceptability and content suggested a need for further work. Participants’ interest and engagement in goal setting were influenced by their familiarity with goal setting, interest in physical activity, functional ability and levels of self-efficacy, highlighting the individualisation required within goal setting. Experiences of exercise professionals involved in exercise after stroke regarding goal setting were explored in study five through three focus groups (n=6; n=6; n=3). Although goal setting was viewed positively, participants felt that its potential effectiveness was not always translated into practice due to barriers encountered: clients’ readiness to change, professionals’ lack of knowledge about stroke and a number of organisational factors. Suggestions to improve goal setting in practice were discussed. This work has enhanced our understanding of goal setting as a complex intervention. Recognition of the potential benefits of goal setting by both service users and providers, amidst the challenges, argues in favour of goal setting in the exercise after stroke setting. Areas for further research have been discussed.
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    Physical activity, physical function and arterial stiffness of people undergoing maintenance haemodialysis for stage 5 chronic kidney disease
    (Queen Margaret University, Edinburgh, 2015) Prescott, Sean
    This thesis addresses current issues regarding assessment of physical activity (PA) and physical function (PF) status of haemodialysis (HD) patients, specifically: What is the recommended wear time to provide a reliable accelerometer estimate of habitual PA and sedentary behaviour? Can similar outcomes from different accelerometers be used interchangeably? Do subjectively and objectively estimated PA outcomes agree closely enough to be pooled? Which PF assessments are potentially most ‘useful’? This thesis also explores potential risk factors of arterial stiffness, a strong predictor of mortality in this population. A PA reliability study involving 70 maintenance HD patients (55.9 ± 15.7 years) over a seven-day monitoring period indicated one dialysis day and two non-diaysis days with a minimum of eight hours wear per day would provide reliable estimates of PA and sedentary behaviour regardless of accelerometer employed, and allowed 90% sample retention. Concordance studies indicated broad agreement for similar outcomes obtained via ActivPAL and Actigraph GT3X accelerometers but they were not interchangeable. ActivPAL is recommended for monitoring steps taken and time seated, Actigraph activity count output for total/overall PA. Questionnaire and accelerometer estimated PA outcomes may not be used interchangeably or pooled. More of the shared variance of physical performance was explained by clinical, demographic and habitual PA factors than for self-reported functional status thus recommending the former. Age, blood pressure and HD vintage were determinants of arterial stiffness, however PA and cardiorespiratory fitness did not appear to be risk factors in this sample. This thesis makes clear recommendations regarding implementation of PA and PF assessment methods, and illustrates their application on sample retention, as well as characterising and potentially identifying individuals at risk of poor outcomes. Emergence of HD vintage as a risk factor for arterial stiffness underscores the need for further research into adjunctive lifestyle interventions to manage health threats in this population.