Background
Research design and methods
Overview of the PREPARE-ABC RCT
Process evaluation design and methods
Participants and recruitment
Treatment arm | Gender | Ethnicity | Age | Employment Status |
---|---|---|---|---|
Hospital-Supervised Exercise | Male (n = 9) Female (n = 1) | White British (n = 9) North African (n = 1) | Range 39–79 years Mean 65 years | Employed (n = 4) Retired (n = 5) Unemployed (n = 1) |
Home-Supported Exercisea | Male (n = 8) Female (n = 6) | White British (n = 14) | Range 59–85 years Mean 71 years | Employed (n = 2) Self-employed (n = 1) Retired (n = 11) |
Treatment as Usual | Male (n = 4) Female (n = 1) | White British (n = 5) | Range 68–80 years Mean 73 years | Employed (n = 2) Retired (n = 3) |
Data collection
Data analysis
Ethical considerations
Results
Wider organisational context of colorectal units and standard care
Site | No. of new Colorectal Cancer cases in 2016 | No. of Colorectal Resections in 2016 | % Resection to total Colorectal Cancers | No. of Colorectal beds | No. of full-time equivalent (FTE) Colorectal Nurse Specialists | No. of Enhanced Recovery After Surgery (ERAS) Nurses (All Part time) | No. of FTE Colorectal Physiotherapists |
---|---|---|---|---|---|---|---|
SITE 1 | 510 | 325 | 64% | 76 | 3 | 2 | 3 |
SITE 2 | 433 | 263 | 61% | 37 | 2.5 | 0 | 1 |
SITE 3 | 406 | 287 | 71% | 28 | 3 | 0 | 0 |
SITE 4 | 400 | 320 | 80% | 28 | 4 | 0 | 2 |
SITE 5 | 326 | 177 | 54% | 48 | 1.8 | 0 | 0 |
SITE 6 | 273 | 150 | 55% | 29 | 0.8 | 0 | 0 |
SITE 7 | 237 | 166 | 70% | 32 | 2.5 | 2 | 0 |
SITE 8 | 236 | 151 | 64% | 55 | 3 | 0 | 0 |
SITE 9 | 200 | 180 | 90%a | 29 | 1 | 0 | 4 |
It’s full on if we have a patient in the [supervised exercise] hospital based, could come in 3 times a week, or there could be nothing for a period of time, but then the next patient could appear and we are off again. So, managing the time is not that easy and always being available when you are needed and we have also issues around rooms to use and that kind of thing. Although we started with having something booked regularly, but then did not have a regular patient every week then we have had to forfeit that, and book rooms as and when, so that side of things has been more of a challenge than the actual delivery itself. (Interview, Physiotherapist)
Colorectal cancer care pathways and exercise advice
Pre-operative
Nine out of 14 sites reported that patients completed a CPET in order to assess their fitness prior to surgery. Typically, CPETs appeared to function purely as a mechanism for the anaesthetist to determine the patient’s fitness for surgery. An exception to this was a patient with a chronic lung condition:CNS: “What keeps you busy?”Patient: “Golf, snooker and TV”CNS suggests “carrying on as normal.”(Observation, Pre-operative appointment, CNS)
Lead-in time to surgery was clearly an important factor for determining whether pre-operative advice about exercise was provided:Anaesthetist: “The problem is, you only have two weeks until your operation. Can we get you fitter before surgery?... I worry about how I would get you off the ventilator and at the moment I don’t think you are fit enough for an operation. We could try an exercise programme but it is no guarantee- that’s a 10 week programme.”(Observation, Pre-operative appointment, Anaesthetist)
“If there is a long run up to surgery, exercise will get mentioned, however the window of time is short and so it is often not a priority to mention it.” (Telephone interview, CNS)
Post-operative
Delivery and fidelity of exercise interventions within hospital settings
Initial counselling session
Just from experience, it’s vital because many people come in and look for excuse after excuse after excuse for not doing stuff … that’s the ones where motivational interviewing really is of prime importance as opposed to the person who says yeah, I want to get fitter...the people who are coming in are even struggling to walk up a flight of stairs and so on they’re the ones where you really have to try and engage and find ways around certain barriers that they have in their own minds (Interview, Exercise Practitioner)
Physiotherapist (Ph): “Are you doing any activity at the moment?”Patient (Pt): “Um, no, no not since I had to have my dog put down, no … I was walking with him.”Ph: “But since then not much of anything?”Pt: “No.”Ph: “O.k. that’s fine. We just want to build you up a little bit”Pt: “I must say that I’m devoted to my wheels. I hope to keep driving for a long time so you’ve got to drive every day.”Ph: “Yeah, that’s right. We just have to add some walking into that as well otherwise we’ll fail the trial” Ph says joking and patient laughs.Ph: “Start parking a bit further away.”(Observation, Exercise counselling session, Home Arm)
He was very difficult actually because there wasn’t really that much we could do to boost him up. He came in for the bike once but at home he was already rowing on his rowing machine, he had a weight machine, he was cycling every day. There wasn’t really that much more we could offer, he was going to the gym. (Interview, Physiotherapist)
Supervised exercise sessions
Variations in how the repetitions on the exercise bike were delivered were minimal between different sites and between HCPs within sites, where more than one person delivered the sessions. Where variation did occur it pertained to elements such as warm-up exercises and differences in the bikes used.We strap them up with a polar monitor, we literally put them on the bike attached to a blood pressure machine and off they go and then they do five minutes and then a rest for 2.5, I’d have to look at the manual, that’s when I would look at my manual. (Interview, Physiotherapist)
… because I had had a targeted biopsy for the prostate it made it extremely painful to ride the appropriate exercise bike that was in the study. The one that they had in the lung function area was a lot more comfortable. (Interview, Patient, Hospital Arm)
Home-based supported exercise
I’m pedalling and the rowing and strengthening exercises. You know on your thighs and your legs and pushing up and that sort of thing. So that’s what I’m doing, it’s only for half an hour twice a week and also swimming which (name of practitioner) will be really pleased about because he says I think you ought to swim! (Interview, Patient, Home Arm)
Well the first time I rang him, he was in the pub. The second time, he didn’t answer because he was in the pub and we’ve only managed three phone calls with him because the last time he was in the pub and didn’t ring us back so, mm. (Interview, Physiotherapist)
Acceptability of implementing the exercise interventions within hospital settings
Themes | Sub-themes | |
---|---|---|
Supervised exercise arm | Motivation | • Social exercise as mechanism for motivating patients • Counselling critical for inactive patientsa • Motivating patients requires sophisticated communication skills |
Social support | • Flexible, individualised support according to prior motivation and exercise levels • Understanding patient capacity | |
Interruptions | • Chemotherapy • Post-operative complications • Inability to use bike seat | |
Constraints within CRC care context | • Lead-in time to surgery limiting pre-operative exercise • Limited staff capacity • Limited space and availability of exercise bikes | |
Home-based exercise | Social support | • Regular contact on phone • Supportive, ongoing relationships as motivational • Advice on restarting exercise post-operatively • Unwanted pressure to increase activity • Difficult for HCPs to monitor progress |
Increased activity at home | • Higher intensity of current activities • Taking up new activities |
Supervised-exercise arm
I’m not certain how it would have worked if I’d say had to do it at home because exercising in a solitary manner is difficult, which is why my cardio rehab classes are so much better. They’re a social exercise. Coming here to use the bike, again it’s more social and you are actually doing something with somebody. (Interview, Patient, Hospital Arm)
Research Practitioner (RP) asks if they can “try another 0.5 kg”Pt: “No, this is how I like it.”RP: “We are doing it fairly light and we’d like to get you up to 13-15” referring to the numbers on the Borg scale.Pt: “O.k. we’ll give it a go.”
Home-based supported exercise
However, two exceptions were patients who found the telephone calls to be challenging because they felt that they were already active enough and did not want to be pressured into doing any more activity. They felt strongly that they were being asked to do too much by the study team.He sounds as if he’s like a friend. He doesn’t make it sound as if he’s asking me personal questions. He just phones me up, hello “name of patient”, lovely to talk to you, how are you feeling? And I said feeling great (name of practitioner) and he said great, he said how’s your exercising going? And I’m honest with him about that. I said I’ve got a bike in the garage now. He said oh brilliant (Interview, Patient, Home Arm)
Well I try to do it in the morning (the resistance bands) but (name of practitioner) suggested to do it in the afternoon. I says I’m 82-year-old, I’m not going in for the World Olympics or owt like that you know. (Interview, Patient, Home Arm)