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Previous research has shown that functional performance of trunk muscles directly affects overall outcome after stroke and strategies to improve this could promote better functional recovery. Most of these previous studies have delivered trunk training exercises to people with moderate trunk weakness after stroke, but the impact on individuals with severe trunk deficits have not been investigated. The ATTEST study is seeking to investigate the possible benefits of additional trunk training to this group of stroke patients with severe trunk weakness, specifically those who cannot sit for 30 seconds without support within the first three days after stroke.

The trunk training intervention involves delivering 16 hours of targeted trunk exercises in addition to usual care during early stroke rehabilitation. Our current work is testing the feasibility of recruiting 20 people within 7 days of stroke and delivering 16 hours of additional therapy. This trial is also assessing the acceptability of the intervention from the perspective of both patients and their families, as well as the health care professionals involved in its delivery.  Drs Isaac Sorinola, Claire White and Jane Petty are working on this feasibility trial with colleagues from Primary Care & Public Health Sciences (Dr Caroline Burgess), and Guy’s and St Thomas’ NHS Foundation Trust (Prof Anthony Rudd & Gareth Jones). ATTEST has been funded by the National Institute for Health Research (NIHR) - Research for Patient Benefit (RfPB) scheme. 

Chronic low back pain is common and is a major cause of personal suffering, disability and time off work, costing the NHS over £1 billion a year. 1.26 million patients seek physiotherapy for chronic low back pain each year, yet standard physiotherapy is only moderately effective at improving patient outcomes. PACT is a new type of physiotherapy based on a form of cognitive behavioural therapy called Acceptance and Commitment Therapy (ACT).  This novel treatment is being compared to usual physiotherapy care to see which is most successful at improving people’s ability to manage their back pain in the long term. Dr Emma Godfrey and Dr Duncan Critchley are working with colleagues on the PACT trial funded by the NIHR Research for Patient Benefit Stream. The study aims to combine psychological approaches with physiotherapy to offer patients better support with their persistent back pain. The randomised controlled trial of 240 participants is being carried out by researchers at King’s College Departments of Psychology and Physiotherapy, working with physiotherapists and patients from Guy’s and St Thomas’ NHS Foundation Trust, King’s College Hospital NHS Foundation Trust and Ashford and St Peter’s Hospitals. The protocol for the randomised controlled trial was published in BMJ Open on 7 June 2016.

Stress urinary incontinence (SUI) in women poses a considerable public health problem and is associated with distress, embarrassment, lower quality of life and avoidance of physical activity. SUI is also linked with substantial personal and health care costs, estimated in one study at £818 per year in the UK alone. Pelvic floor muscle training (PFMT) exercise is effective in both preventing and treating SUI, and is the first-line treatment recommended by the National Institute for Health and Care Excellence (NICE, 2013) guidelines for the management of urinary incontinence in women. However, few women seek help for SUI and of those that do, only around a third receive the recommended treatment. The literature also indicates that many women do not adhere to PFMT exercise programmes because of uncertainty over how to perform PFMT or its effectiveness. Cath Sackley, Sarah McLachlan, and Emma Godfrey are working with colleagues in Primary Care & Public Health Sciences (Janet Peacock and Jennifer Summers) and Health Sciences & Population Research (Mark Pennington), and at the University of Leicester (Kate Williams) and Glasgow Caledonian University (Doreen McClurg), to develop a public health PFMT intervention which will be delivered to women through hairdressing and beauty salons in the UK. This setting has been selected to reach women who are unlikely to seek help for SUI from health care professionals. The development work for the project has included extensive public involvement and this will continue throughout the research.

Transient ischaemic attack (TIA) is defined as “a transient episode of neurological dysfunction caused by focal brain, spinal cord or retinal ischaemia, without acute infarction” (Easton et al., 2009). There are approximately 20,000 TIAs in England per year, and TIA has been associated with an increased risk of stroke. Although signs and symptoms are not expected to persist beyond 24 hours, the literature suggests that patients may experience functional and emotional impairments following TIA, including continued or increased depression 12 months after their event. This is particularly problematic as emotional impairments have been associated with increased risk of stroke. To address this problem, Cath Sackley and Sarah McLachlan are developing a screening tool to help identify those with maladaptive coping strategies and emotional deficits following TIA, and plan to design a psychological intervention to improve outcomes for these patients.

The MOSAIC trial evaluates a new physiotherapy treatment for people with Intermittent Claudication. The trial is now open and will include 192 people aged 50 years and over with Intermittent Claudication from four NHS trusts in London and South-East England. Find out more here.

In 2016, UK health officials instructed that hospital staff must help patients get out of bed (mobilise) within 36 hours of surgery to fix their broken hip. We spoke with several patients and their caregivers who said they would like to know why they have to get out of bed so quickly. For those who did not get out of bed within 36 hours, they said would like to know whether waiting longer was harmful.

Our study asks whether waiting more than 36 hours to get out of bed is harmful for people who had surgery for a broken hip. We also want to know if waiting is harmful for some patients but not harmful for others. If this is the case then hospitals can identify patients who should get out of bed within 36 hours of surgery, and those who can wait longer.

This project is funded by the National Institute for Health Research (NIHR).

The project's privacy notice can be found here. 

We spoke to several patients after they had broken their hip. They said they would like to do more with the physiotherapists and more exercises. They felt this would help them to get better quicker. Currently, people who have had surgery to repair a broken hip receive different types and amounts of physiotherapy. We do not know which types and amounts are most beneficial for recovery.

Our study asks whether receiving more physiotherapy and more exercises is beneficial for recovery. We also ask whether a benefit is seen for some patients but not others, and if so who benefits most (e.g. patients admitted on the weekend, patients with dementia). We also ask why patients currently get different types and amount of physiotherapy after breaking their hip.

We will look at national audit records for patients who had surgery to fix a broken hip in May and June 2017. We will see how long people stay in hospital, how many die in hospital and up to one month after their broken hip, how many go back to hospital, and how many have recovered by four months after their broken hip. We will see whether patients who get more physiotherapy recover better than those who get less physiotherapy. We will interview physiotherapists to find out why patients get different types and amounts of physiotherapy after breaking their hip. We will involve patients and their carers to help us to interpret our findings.

We will then share what we learn with health care policymakers, people who have broken a hip and their families, and physiotherapists who work with them in scientific articles, reports, news articles, blogs, presentations, and via social media. The results will help to inform decisions to improve care for patients with a broken hip.

The project’s privacy notice can be found here. 

Globally, an estimated 4.5 million people will fracture their hip in 2050. Even with surgery, 30% of patients die within a year. Among survivors, 25% never walk again and 22% change from living at home to a nursing home. Rehabilitation assists patients 'to achieve and maintain optimal functioning'. Yet, there is limited evidence to guide effective rehabilitation after hip fracture. This uncertainty may be due to between patient differences. A stratified approach could improve outcomes by tailoring rehabilitation to patient needs. Hip fracture survivors describe a tailored approach as key to recovery. Further, the NHS recommends a stratified approach as central to healthcare progress.

Aims

We aim to improve patient and carer outcomes of rehabilitation after hip fracture. Supported by patients and carers at each step, the objectives are to:

1. identify patient groups with different rehabilitation responses
2. design an intervention which matches these groups to rehabilitation tailored to their needs
3. feasibility test the intervention in two hospitals
4. create a collaborative group with patients, carers, and the public in older adult trauma rehabilitation research

Investigation plan

Identify patient groups:

We completed a systematic review and interviewed 20 patients and carers to identify four factors that influence patients rehabilitation response after hip fracture - age, sex, cognition, and prefracture mobility. We will analyse of National Hip Fracture Database (NHFD) and Physiotherapy Hip Fracture Sprint Audit (PHFSA) to estimate the prediction accuracy of poor outcome following rehabilitation according to combinations of these factors. Analyses will be supported by the National Institute for Health Research (NIHR) Statistics Group at Kings College London. We will use results to classify multifactorial groups as low-, medium-, or high- risk of poor outcome. We will discuss classification acceptability with patient, carers, and allied health professionals.

Intervention development:

Supported by patients and carers, we will design and feasibility test the intervention per the MRC framework for the development of complex interventions.

We will update the Cochrane systematic review of rehabilitation after hip fracture. We will complete an overview of reviews on acute rehabilitation for adults with frailty. We will use NHFD and PHFSA to quantify current rehabilitation provision for patients classified as low-, medium-, and high- risk. We will interview allied health professionals to obtain their views on this provision. These interviews will complement completed patient interviews. We will hold stakeholder workshops to assess patient, carer, and allied health professional views on reviews, current provision, and interviews, and to design an intervention which matches low-, medium-, and high- risk groups to rehabilitation tailored to their needs. The intervention will include behaviour change techniques and allied health care. There will be a decreasing emphasis on behaviour change from low- to high- risk groups.

We will obtain approvals prior to intervention testing in two hospitals to determine:

1. the number of eligible, recruited, and retained patients
2. the acceptability of randomization, assessments, and intervention to patients, carers, and allied health professionals
3. compliance with the intervention and fidelity of its delivery
4. adverse events
5. estimate of an effect size for a future definitive trial

Sackley (King's mentor, NIHR Senior Investigator, £50,000,000 awarded for complex intervention trials) will support intervention development.

Create a collaborative group:

We will create a group, website, and strategy for sustained collaboration with patients, carers, and the public in older adult trauma rehabilitation research. The group will be modelled on the Stroke Research Patient and Family Group at King's which has sustained public engagement since 2005.

The privacy notice for the analysis of National Hip Fracture Database and Physiotherapy Hip Fracture Sprint Audit data is available here.