Contents:
Two independent reviewers appraised the selected studies using the PEDro scale and collaborated in order to establish a rigorous perspective on the quality of the research. From papers initially, 12 studies were included in the review; 10 high quality and 2 moderate quality primary studies and involving a total of participants. There was strong evidence supporting exercise and physical activity as effective in improving the QoL for people with knee OA based on 8 high and 2 moderate quality studies.
The review did not draw any conclusions on the effects of aquatic exercise on QoL due to conflicting evidence. Also noted was conflicting levels of significance under different exercise conditions; significant difference was high when exercise was compared to a non-intervention or education control group and less so when exercise was compared with drug therapies such as NSAID. Exercise and physical activity, either combined with appropriate drug therapies, or as a single intervention is effective on improving QoL in people with knee OA.
However, the most effective exercise dose prescription, the individual aspects of a multicomponent programme, or the additional benefit of a home exercise and walking programme remain uncertain. Osteoarthritis OA , a degenerative joint disease, is one of the most common musculoskeletal disorders and represents a major, global public health problem Alkan et al.
The cause of the disease remains unknown; however, current evidence suggests that it is a result of an interplay of intrinsic and extrinsic risk factors such as old age, female gender, ethnicity, genetic factors, obesity, previous trauma, repetitive use of joints and occupation, which lead to the development of the disease particularly in weight-bearing joints like the knee Iwamoto et al. It presents with progressive structural alterations to the joint which includes loss of articular cartilage, osteophytes formation, muscle weakness, and ligamentous laxity Bennell et al.
The disease progression is usually slow and characterised by stiffness, pain, muscle weakness, joint instability and reduced physical functions such as difficulty in walking, stair climbing and squatting, moving from sitting to standing Yilmaz et al. In advanced stages pain becomes continuous, muscle atrophy and limb deformity result Micheal et al. All such complaints give rise to physical disability which could ultimately lead to restrictions in QoL with time Yilmaz et al.
The burden of knee OA does not only include physical problems, but also high economic and social burden largely attributed to the effects of the disability, comorbid diseases, treatment expenses Bitton, ; Woolf and Pfleger, It also brings with it detrimental psychological effects such as helplessness, coping difficulties and depression, all experienced at higher levels than the general population in people with the condition Litwic et al. QoL is reported to be low in people with knee OA with a correlation existing between disease progression and QoL levels dropping significantly compared with other chronic diseases Farr II et al.
It is evidenced that people with OA experience major changes in daily life influenced by the severity of symptoms and impact on functional capacity, affecting their QoL Chan and Chan, ; Egan and Mantes, Although not fatal, patients with knee OA are at risk of developing cardiovascular disease due to obesity Pietrosimone et al. Thus, with a progressive disease of multiple risk factors and symptoms, with no known cure and management of patients depending on relief of symptoms, the importance of improving QoL as an endpoint for management needs to be emphasised Kao et al.
Management of osteoarthritis has been a combination of different therapies of both pharmacological and non-pharmacological nature. In physiotherapy, a wide range of treatments including exercise and physical activity are used. The treatment of OA is focused on reducing physical disability, controlling pain while lessening the potentially harmful side effects of medicines Beckwee et al, ; Zhang et al.
Exercise is considered as an effective conventional therapy for knee OA symptoms Fransen and McConnell, Based on the evidence of a systematic review of guidelines for physical management of osteoarthritis, exercise was among the strongest recommended interventions as first choice conservative treatment particularly for knee OA Beckwee et al, ; Hootman et al. Systematic reviews have established the benefits of exercise and physical activities in patients with knee OA on outcomes of pain and function Smith et al.
However, the effects of exercise and physical activity on QoL are not well established and no review undertaken to date. Primary studies have assessed the effectiveness of exercise and physical activity on QoL in knee OA; some studies report beneficial effects regarding improving general health Sheth et al. Due to the varying primary evidence it seemed important that a systematic review was conducted with the aim of summarising the evidence of relevant literature and providing more reliable and generalizable conclusions which could be used in clinical practice.
Furthermore, identifying therapies that improve quality of life in patients with knee OA may lessen the clinical, economic and social burden of the disease Farr II et al. The review was based on the Center for Reviews and Dissemination guide CRD in order to remain focused on the research question and ensure consistency across all aspects of the review, and thereby reduce the risk of bias Boland et al.
To ensure a comprehensive search, Internet sources of Google Scholar were conducted to make sure that unpublished papers with registered databases were retrieved CRD, While the review attempted to minimise publication bias Greenhalgh et al. To ensure reliability of the decision process, a second reviewer was involved S. To minimise selection bias selection criteria was clearly established and studies were included based on their eligibility.
The criteria included; quantitative primary studies conducted in English, adult participates with clinically diagnosed knee OA, studies that investigated both knee and hip osteoarthritis, but reported the results separately for each area in order to extract data for knee OA and intervention that included exercise and or physical activity with a control group of alternative interventions.
While the review aimed to include different types of quantitative studies other than RCTs in order to ensure a comprehensive review of available evidence, however, only RCTs and one quasi-experimental study met the requirement. In total 12 studies were reviewed as outlined in the flow chart below. Quality assessment is important to ensure that included studies provided sufficient robustness for the results to be trustworthy and generalisable Boland et al. Eleven RCTs and one quasi-experimental study met the inclusion criteria. The PEDro scale available at www. Levels of scores were based on those outlined in a study by Abiebr ; study scoring below 4 was low quality, a score of was moderate quality and was high quality.
Data extraction was undertaken by the author and a reviewer independently. Depending on evidence provided, results on QoL outcomes measures were extracted at two time points; post-treatment and follow-up results and were recorded as short-term within three months and long-term follow up above three months as shown in tables 2, 3a to 3d below.
The reviewers discussed the findings and disagreement was resolved through dialogue. To comprehensively assess QoL which is a influenced by variables such as age, physical and social functioning, emotional well-being, role activities, perceived health Rejeski and Mihalko, , Shumaker et al. The literature search identified studies; duplicates, unrelated studies were removed and remained with 88 potential studies for initial screening; 9 RCTs and 1 quasi-experimental study with 2 RCTs from reference search were included in the final review.
The quality of the studies is reported in table 2 above, the PEDro score ranged from 4 to 8 and the most common weakness were blinding therapist, subjects and assessors and intention to treat analysis. To further understand the evidence, enhance transparency and prevent errors in interpretation, extracted data for study characteristics and results were tabulated as shown in table 3, 4a, 4b, 4c and 4d below. A total of participants were included.
They are reported according to short- or long-term follow-up for each outcome measure. The duration of interventions ranged from six weeks to six months respectively. Studies were grouped into physical activity, exercise, aquatic exercise and exercise and physical activity when the interventions were combined, As per protocol, when two interventions were assessed with a control group, the results of one intervention in relation to the control group were reported, thus studies by Wang et al.
This ensured that the review was inclusive for the type of exercise intervention. The efficacy of multicomponent strengthening exercises in the management of OA was directly addressed in two high quality studies; Fransen et al. Similarly, Thorstensson et al. Dias CR et al. Similar findings were observed in a high-quality study by Aglamis et al.
The MCS showed no improvement and the control group remained unchanged. While Salli et al. Three high quality studies; investigated the effectiveness of a home based strengthening exercise programme; Baker et al. However, the control group showed deterioration in QoL. While improvement was apparent in favour of the exercise, however the results were not significant as shown in table 4b. Some of this difference perhaps lies in the issue of motivation to undertake unsupervised exercise involving painful joints.
High quality studies by Wang et al. Other subscales showed less improvement and the control group remained unchanged. On the contrary, Lund et al. Established on levels of evidence by Tulder et al. There is inconsistent evidence provided by two high quality studies on the efficacy of aquatic exercise. Overall, evidence from the majority of the studies demonstrated that the interventions could improve QoL with short term effects. Provided below is the table for the level of evidence.
This systematic review summarised evidence from ten high and two moderate quality studies investigating the effectiveness of exercise and physical activity on QoL in knee OA. A number of potential studies were excluded mainly because they were a multimodal management. The review has provided strong evidence from eight high and two moderate quality studies that the interventions could be effective at improving QoL in knee OA. This evidence has established that regular, moderate levels of exercise do not aggravate symptoms in the majority of patients Messier, ; McCarthy and Oldham, Further, a qualitative study by Wilcox et al.
This could be seen consistent with other studies that found the effects of exercise and physical activity improve self-efficacy and depression, which consequently resulted in improved QoL Hartman et al. The effects of strength training on the symptoms of knee OA are supported by wider literature, both of primary and systematic review studies.
This is consistent with evidence from other studies that established the benefits of progressive strength training on symptoms in knee OA such as muscle atrophy and weakness which contribute to functional limitations and thereby restrict QoL Jenkinson et al. Regular supervision as shown in Barker et al. Activity is superior to all other treatments in the short term. This review observed that when exercise was compared with a non-intervention group, exercise results were significantly better.
Whether this is most effectively performed on land or water remains unclear as included studies provided contradictory evidence. However when activity compared with other treatment groups e. However it could not be established if the interventions had long-term effects because of the limited number of studies that assessed long-term outcomes.
Overall, studies that included a supervised progressive multicomponent strengthening exercise, supplemented with a home exercise and walking programme found significant improvement in QoL Jorge et al. This could suggest that physical activities not only provide relief of pain, but also those of psychological and general well-being as well as QoL Aglamis et al. Which activities are most effective remains uncertain however as Smith et al. This may indicate that exercise, although effective, may not be superior to other active interventions in terms of the impact on general wellbeing.
The review included primary studies of high quality and thoroughly reviewed the evidence provided. Publication bias could not be avoided as studies in other languages were removed and studies from less well-known databases may have been missed. The studies used standardised outcome measures to assess QoL but because they are not specific for measuring QoL in knee OA, they may not adequately assess the area.
Based on the PEDro scale, quality studies from moderate to high were included on which evidence was drawn, however, common limitation in the studies was the lack of blinding of participants, therapists and assessors. Some studies had small sample size while some had drop-outs, but did not use intention to treat analysis, which could have impacted on the treatment effects Joseph et al.
Clinically this suggests that exercise programmes designed to enhance QoL in knee OA patients ought to target specific impairments such as weakness, as presented in patients Focht, This review observed a correlation between pain and QoL. A reduction in pain consequently resulted in improved QoL, thus, knowledge of the interplay of knee OA symptoms on QoL might help in understanding and management of patients. However biopsychosocial factors play a role and related co-morbidities may further complicate the situation Chan and Wu In addition, included studies reported no serious adverse events indicating that moderate regular exercise and physical activity could be safe.
Future research may invest in developing a standardised outcome measure for QoL in knee OA and also developing a knee OA questionnaire assessing facilitators and barriers to exercise as increased understanding of the factors influencing exercise performance in people with OA could help physiotherapists and other health professionals support patients in initiating and maintaining an exercise routine and subsequently improve QoL post initial treatment. Based on the available evidence, exercise and physical activity appear to be effective in improving knee OA symptoms and QoL.
Land based exercise, well supervised home based exercises plus complemented with a walking programme provide significant improvement. Strength training exercises such as eccentric-concentric training provided better results. Last accessed 21 October at: The effect of a week supervised multicomponent exercise program on knee OA in Turkish women. J Back Musculoskelet Rehabil; Centre for reviews and dissemination guidance for undertaking reviews in health care.
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Definition of physical activities. Rheumatic Diseases Clinics of North America, 34 3 Data collection instrument and procedure for systematic reviews in the Guide to Community Preventive Services. Their study is interesting both in terms of the growing significance of the resilience paradigm in contemporary discourses of empowerment in tacking individual, structural and social inequalities,.
My experience over the years of co-teaching the dissertation module for final year nursing students has helped me realise that many of them embark on their literature reviews with fear and trepidation. Edward Liscott, a recent graduate of the paramedic undergraduate degree, explores the causes of inappropriate and avoidable uses of accident and emergency care.
His review discusses clearly important and currently highly topical implications for the efficient and cost-effective use of our ambulance services. Vinny Curtis, who graduated recently from the adult branch nursing degree, argues in his review that maggot therapy is an effective tool in the debridement of necrotic foot wounds. Despite this, due to the lack of rigorous random controlled trials available, there remains a lack of published evidence that supports its use. The author has an interest in the way in which students learn in the clinical setting.
The authors argue that work is understood to generally benefit health and well-being, while absence from work bestows costs to the health of the individual and to the economy. Return-To-Work plans are implemented in many workplaces to allow individuals to recommence their duties. From a critical perspective, all normative healthcare practices are shaped by broader cultural discourses, as can be seen currently in, for example, the emergence of obesity as pathology, and so it is important that healthcare professionals are reflexively attuned to this.
People whose experiences are classified by the medical model as schizophrenia, bipolar affective disorder or psychosis, die years sooner on average than people with no mental health diagnosis Department of Health DH b. It is three times more probable they will suffer premature death DH c , with increased risk of several physical illnesses, such as heart disease, diabetes, respiratory disease and infections, and obesity DH ; DH b,c; Rethink a, b, c; DH a; NICE b. The prescribing of anti-psychotic medication may lead to weight gain, sometimes up to kg in the first 2 months Foley and Morley ; Rethink a.
This may be due to several factors, including a more sedentary lifestyle and a related lack of exercise. However 27 million adults in England are not active enough to benefit their health DH , and the Secretary of State is calling for the NHS to make the promotion of active lifestyles central to all healthcare professionals work DH This literature review topic was chosen because in practice as a student nurse I have thought there is inadequate emphasis placed on exercise and believe that service users would benefit from its inclusion in mental health services.
The choice of a non-medical phrase may help in the shift from a medical to a more holistic view of the experiences of people, within which mental health difficulties are described in more compassionate, less stigmatizing ways Carless and Douglas a; Moncrieff ; Johnstone In order to first identify the research question, substantial reading was necessary in the field of interest, namely exercise and mental health.
A Boolean search was utilised in order to search most efficiently across a range of databases. From this, a few key interests emerged. As there exist a significant number of papers around depression, anxiety and exercise but little on serious mental health issues, my search was made more specific by setting the inclusion and exclusion criteria to only include papers concerning serious mental health issues. A total of 15 papers emerged as significant. These were predominantly qualitative, with four quantitative and one descriptive study. A simplified thematic analysis was performed on the papers selected Noblit and Hare ; Paterson et al ; Rice ; Aveyard Three themes emerged from the papers reviewed, which go some way towards answering the research question: The literature signified the importance of the social effects of exercise for people who experience extreme states of mind.
Participants also identified that exercise positively affects their social roles and highlight the value of shared experience Crone and Guy ; Carless and Douglas ; Hodgson et al ; Cullen and McCann Narrative inquiry seeks to find the meaning that people make of their experiences and what it means to be human. It is a creative process that can often bring about change for the participants through the process of re telling the story, narrative re-storying Carless and Douglas a.
The theme of potential benefits through the development of peer support and friendship when exercising was present in several studies. The narrative inquiry work of Carless and Douglas a, b and hasstrong peer support and friendship themes, and a clear service user voice is heard throughout. These three studies aimed to look at how men experiencing extreme states of mind utilise narrative re-storying through exercise and sport a , how they might receive social support through exercise b and the narratives of people using physical activity programmes within mental health services For some people who experience extreme states of mind, the social role that exercise provides is helpful.
This study has a strong service user voice, which makes the pertinence of the statements more compelling. The work of Hodgson et al , supported by Crone and Guy and Cullen and McCann also illustrate the role of exercise in alleviating some of the isolation felt by service users through meeting new people in the community. From a psychological perspective, the literature generally revealed how exercise may assist people who experience extreme states of mind to be more motivated, be more proud, confident, have greater self esteem, have fun and alleviate symptoms.
For some, participating in exercise or physical activity led to an increase in motivation to continue exercising Fogarty and Happell and in others, exercise increased their desire to make healthy lifestyle changes, such as reducing the intake of fast foods Klam et al Motivation can be difficult for people experiencing extreme states of mind, and whether this is because of the impact of medication on motivation or the lack of structure in their lives is unclear Crone and Guy In a Norwegian study, Tetlie et al discussed a mandatory exercise programme in a forensic setting.
The effects that exercise has on increasing motivation for this population are diverse, although some people are enabled to exercise more Fogarty and Happell ; Warren et al Nurses exercising with clients may also challenge stigma Tetlie et al , and this will be explored in more depth in the discussion chapter. In the weeks following this intervention clients were heard sharing jokes and they described how this helped them take life a little less seriously.
The fun element was something that was shared between staff and patients in the study by Tetlie et al , further breaking down the barriers between them. Having fun and experiencing pleasure in life through exercise could also be a way of distracting oneself from the negative experiences of extreme states of mind. It may, according to Cullen and McCann , be a useful tool for voice hearers, as the time spent concentrating on exercise is time spent not concentrating on voices.
Exercise may also counteract boredom, which is often an aspect of inpatient mental health services, and in the community is exacerbated through social isolation Crone and Guy ; Hodgson et al The effect of exercise on confidence, pride, self esteem and sense of purpose is reported in numerous studies Crone and Guy ; Hodgson et al ; Cullen and McCann Confidence is crucial for participating in social activities van Deurzen , and self esteem is often interconnected with this Crone and Guy In related terms, people who experience extreme states of mind have often lost their confidence Carless and Douglas a and sense of purpose Hodgson et al , and exercise might be something that can help restore this.
By extrapolation, the psychological effects of exercise might therefore influence how well an individual participates in society Tetlie et al and vice versa van Deurzen The majority of literature included in the review discusses the importance of maintaining good physical health for this population, especially given the negative impact medication and lifestyle can have on diabetes, weight, and the heart DH , b. Disappointingly there was only one paper that measured weight loss as a result of exercise Klam et al The study by Warren et al attempted to study weight loss in the USA but was flawed through a lack of accurate data recording, weight gain precipitated by meal vouchers and bias as a result of the involvement of pharmaceutical companies.
Other studies have approached the issue but also failed to gain significant results as a consequence of not including diet and nutritional advice in conjunction with exercise Schwee et al Several qualitative studies found that people exercised in order to manage and control their weight. Interestingly, only one study directly found related weight gain and associated issues to the medication prescribed for extreme states of mind — namely second generation antipsychotics Hodgson et al Again there are a majority of papers in this review who assert weight gain due to antipsychotic medication in their abstracts, yet only Hodgson et al reported empirical information on this.
Klam et al described positive physical changes to blood pressure, fasting blood sugar levels, smoking and fitness among people with extreme states of mind in Canada. However, this is a descriptive paper and not generalizable. Whilst training for a 5K race, study participants increased their mean steps by Cullen and McCann highlight that exercise can make someone feel stronger and this motivates them to eat healthier when they can see their physical health improving. It is interesting that physical rather than psychological benefits of exercise were found to be most important to the participants in study by Bassilios et al This interview-based study of 45 people who use community mental health service around Melbourne, also highlight the importance of education surrounding the benefits of exercise.
However, there remains a lack of quantitative evidence in this area. All of this highlights the urgent need to address the physical health of this population. Some studies have approached this issue but have failed to find significant results through poor planning, lack of validity and poor recording Warren et al ; Usher et al ; Scheewe et al The majority of the studies reviewed recommend that exercise is incorporated into daily mental health practice, which will require support from mental health staff.
An important aspect of personal recovery highlighted, is personalised, individualised care. The significance of peer support was a key finding, as was staff exercising with service users. The literature reflects the importance of exercise staff being highly skilled, especially in mental health. Although personal recovery frameworks advocate increased independence from mental health services, several studies recommended that mental health specific exercise support should be available for those that need it. From the literature reviewed, exercise culture can generally be viewed as a male-dominated and thus exercise provision may not be tailored to the needs and requirements of women.
Much of exercise provision is based on performance, whereas women might be more interested in the relational outcomes that exercise might bring. This hints at women perhaps gaining more from the benefits of peer support in exercise, but adquate evidence to support this is not currently available. The positive effects of exercise have been recognised in this review as similar to cohere with the four ontological realms of existentialism, notably the physical, social, spiritual and personal worlds of the individual.
The importance of personal meaning and significance is a crucial goal of recovery, and mental health nurses and researchers need to explore this realm with their service users in the context of engagement with exercise. The findings of the literature reviewed also highlight this, and also point to the benefits of peer support which may also impact on motivation and vice versa.
Someone experiencing extreme states of mind might have fun when exercising, which might them lead them to feel more motivated, which in turn may inspire them to do more exercise, thus improving their health, weight and fitness. The literature thus emphasises findings emphasise the interconnected nature of human experiences and how exercise can potentially have an impact on all areas of life.
This review has highlighted the importance of the role of exercise in the process of recovery. This is a subjective process and has a different meaning for each individual, and so, in practice, the personal meaning of recovery emerges as important. Personal recovery models have outcomes differing significantly from clinical recovery, which refers to the reduction and absence of psychiatric symptoms. Personal recovery refers more to regaining social roles, building and consolidating relationships that bring meaning and value to life, and developing hope.
The literature and policy recommend that exercise should be included in mental health services, and specifically to be included in individual care plans. Clearly, the inclusion of effective exercise in care plans it needs to be supported by mental health professionals. The DH state that promotion of active lifestyles is a key role of all healthcare professionals, therefore mental health nurses need to support the promotion of exercise and its sustainment.
Nurses also need to be equipped to educate their service users about exercise, know how to refer to other services and instigate practice development where necessary. Crone and Guy highlight the role of the mental health nurse as practice developers and one emerging suggestion is that they take a role in organising discounts with local sports facilities. For this to be implemented would require nurse education in exercise and a knowledge-base of how to drive practice developments themselves. If exercise is promoted by mental health professionals and included in care plans it needs to be tailored to individual preferences.
Mental health policy and guidelines promote the idea of individual care, especially in personal recovery frameworks. For exercise to be as effective as possible, service users need to be offered a choice of activities and programmes to suit their individual needs. The benefits of peer support in exercise, is a potentially interesting finding for future practice development and current guidance is to promote it in mental health services more generally.
Peer support in this context is the mutual and reciprocal support provided by another person who has experienced extreme states of mind Mental Health Foundation It appears to play a key role as one of the positive effects of exercise. NICE suggests the use of trained peer supporters in psychosis and schizophrenia and Rethink c also recommend the use of peers to aid personal recovery. In practice as a student nurse, I have only met two peer support workers.
As a future mental health practitioner I would like to be able to encourage service users to assume this role. It seems clear that they can help contribute directly in the recovery of others and themselves. However, Slade et al state that this needs to not be tokenistic, ensuring that suitable training and support for this role is in place.
For the role of peer support workers to be prioritised in exercise provision, clearly more research is needed. The review highlighted that in fact exercising with service users was something that increased motivation, reduced stigma and strengthened the therapeutic relationship. Nurses who have undertaken exercise alongside service users have been very positive about its impact, for the services users, themselves and in the case of inpatient services or recovery houses, on the unit as a whole Happell et al If this initiative was more widely adopted, nursing staff would be exercising also, therefore taking care of their own physical health needs.
However, exercise provision in mental health does demand skilled professionals who are also sensitive to the needs of people experiencing extreme states of mind. The value of the research into the effects of exercise for people who experience extreme states of mind does not seem sufficient to influence evidence-based practice. Future research is needed in several areas, to include gender sensitivity; how exercise increases meaning in life; peer support, motivation; and service user-led research Rose et al Importantly, there is a dearth of significant research included in this review concerning weight loss, which is a key to reducing the health risks that anti-psychotic medication poses.
Medication is a contributing health risk of this population, and pharmaceutical companies have an ethical duty to produce medication with less damaging side effects Bental ; Moncreiff This review set out to look at the effects of exercise for people who experience extreme states of mind, and how these findings might impact on mental health nursing practice. There is a lack of research in this area, particularly for women, leading to deficiencies in related evidence-based nursing practice.
However, the evidence available points to the positive social, psychological and physical effects of exercise. The literature review recognises that exercise could be used to aid personal recovery, and that this might lead to a less stigmatised view of the individual and their relationship to wider society. The importance of service users being able to re-story their lives through social acceptable activities is highly significant and mental health nursing practice needs to embrace the importance of narrative in all areas of practice.
Peer support is already recognised as a vital element of practice and this review recommends that it be explored further in relation to exercise and extreme states of mind. Nurses require education to assist their practice development in these contexts. Narrative, identity and mental health: How men with serious mental illness re-story their lives through sport and exercise. Psychology of Sport and Exercise.
Carless, D and K. Social support for and through exercise and sport in a sample of men with serious mental illness. Issues in Mental Health Nursing. The ethos of physical activity delivery in mental health: A narrative study of service user experiences. International Journal of Mental Health Nursing. Exploring the role of physical activity for people diagnosed with serious mental illness in Ireland.
Journal of Psychiatric and Mental Health Nursing. No health without Mental Health. Atypical Second Generation Antipsychotics. Priorities for Essential Change in Mental Health. Moving More, Living More. Exploring the benefits of an exercise program for people with schizophrenia: Archives of General Psychiatry. Nurses views on physical activity for people with serious mental illness. Mental Health and Physical Activity. The experiences of people with severe and enduring mental illness engaging in a physical activity programme integrated into the mental health service.
Addressing health concerns in people with schizophrenia. Journal of Psychosocial Nursing. Preventing type 2 diabetes: Psychosis and schizophrenia in adults: Psychosis and schizophrenia in adults. Promoting healthy eating, physical activity and smoking cessation. Qualitative Research Methods Series.
Metastudy of Qualitative Health Research. A report by the Schizophrenia Commission. Evidence-based practice in psychiatric and mental health nursing: Journal of the American Psychiatric Nurses Association. Lifestyle and healthy outcome in physical education. Development of a lifestyle intervention program for people with severe mental illness. A model for developing outcome measures from the perspectives of mental health service users. International Review of Psychiatry. Uses and abuses of recovery: Implementing recovery-orientated practices in mental health systems.
Exercise therapy improves mental and physical health in schizophrenia: A randomized controlled trial. Using exercise to treat patients with severe mental illness. A randomised control trial undertaken to test a nurse-led weight management and exercise intervention designed for people with serious mental illness who take second generation anti-psychotics. Journal of Advanced Nursing. Existential Counselling and Psychotherapy in Practice. However it could not be established if the interventions had long-term effects because of the limited number of studies that assessed long-term outcomes.
Overall, studies that included a supervised progressive multicomponent strengthening exercise, supplemented with a home exercise and walking programme found significant improvement in QoL Jorge et al. This could suggest that physical activities not only provide relief of pain, but also those of psychological and general well-being as well as QoL Aglamis et al.
Which activities are most effective remains uncertain however as Smith et al. This may indicate that exercise, although effective, may not be superior to other active interventions in terms of the impact on general wellbeing. The review included primary studies of high quality and thoroughly reviewed the evidence provided.
Publication bias could not be avoided as studies in other languages were removed and studies from less well-known databases may have been missed. The studies used standardised outcome measures to assess QoL but because they are not specific for measuring QoL in knee OA, they may not adequately assess the area. Based on the PEDro scale, quality studies from moderate to high were included on which evidence was drawn, however, common limitation in the studies was the lack of blinding of participants, therapists and assessors.
Some studies had small sample size while some had drop-outs, but did not use intention to treat analysis, which could have impacted on the treatment effects Joseph et al. Clinically this suggests that exercise programmes designed to enhance QoL in knee OA patients ought to target specific impairments such as weakness, as presented in patients Focht, This review observed a correlation between pain and QoL. A reduction in pain consequently resulted in improved QoL, thus, knowledge of the interplay of knee OA symptoms on QoL might help in understanding and management of patients.
However biopsychosocial factors play a role and related co-morbidities may further complicate the situation Chan and Wu In addition, included studies reported no serious adverse events indicating that moderate regular exercise and physical activity could be safe. Future research may invest in developing a standardised outcome measure for QoL in knee OA and also developing a knee OA questionnaire assessing facilitators and barriers to exercise as increased understanding of the factors influencing exercise performance in people with OA could help physiotherapists and other health professionals support patients in initiating and maintaining an exercise routine and subsequently improve QoL post initial treatment.
Based on the available evidence, exercise and physical activity appear to be effective in improving knee OA symptoms and QoL. Land based exercise, well supervised home based exercises plus complemented with a walking programme provide significant improvement. Strength training exercises such as eccentric-concentric training provided better results. Last accessed 21 October at: The effect of a week supervised multicomponent exercise program on knee OA in Turkish women.
J Back Musculoskelet Rehabil; Centre for reviews and dissemination guidance for undertaking reviews in health care. York publishing service Ltd, USA. The prevalence of Symptomatic Knee Osteoarthritis in Nigeria. Treatment allocation by minimization. British Medical Journal, , Quality of life and functional capacity of elderly women with knee osteoarthritis. Presenting and evaluating qualitative research. American Journal of Pharmaceutical Education, 74 8 , The efficacy of home based progressive strength training in older adults with knee osteoarthritis: The Journal of rheumatology, 28 7 , pp.
Overview, Strength, limitations of systematic review and meta-Analysis. Toward Optimizing Clinical Outcomes, 2, Systematic review and meta-analysis comparing land and aquatic exercise for people with hip or knee arthritis on function, mobility and other health outcomes. BMC musculoskeletal disorders, 12 1 , Osteoarthritis of the knee: Why does exercise work? A qualitative study of the literature. Ageing research reviews, 12 1 , Exercise as a treatment for osteoarthritis. Current Opinion in Rheumatology ; Management of osteoarthritis of the knee.
Quality of life in patients with knee and hip osteoarthritis. The Economic Burden Of Osteoarthritis. Reporting methods of blinding in randomized trials assessing nonpharmacological treatments. PLoS medicine, 4 2 , Efficacy of aerobic exercises for osteoarthritis Part II: Physical Therapy Reviews, 9 — Doing a systematic review.
Effect of knee osteoarthritis on the perception of quality of life in Venezuelan patients. Arthritis and rheumatism, 51 3 — No difference between home-based strength training and home-based balance training on pain in patients with knee osteoarthritis: Rheumatology Reports, 3 1 , 3. Physical activity and health. Human Kinetics Publisher, Leeds. Osteoarthritis and the impact on quality of life, health indicators. Rheumatology International, 27, 4 , Evidence based guidelines and current practice for physiotherapy management of knee osteoarthritis Research articles Research articles.
Impact of an exercise and walking protocol on quality of life for elderly people with OA of the knee. Physiotherapy Research International, 8 3 , pp. Effect of home exercise of quadriceps on knee osteoarthritis compared with nonsteroidal antiinflammatory drugs: Benefits of physical activity for knee osteoarthritis: Physical exercise and reduction of pain in adults with lower limb osteoarthritis: Journal of back and musculoskeletal rehabilitation, 23 4 — Effects of exercise and physical activity on knee osteoarthritis.
Current pain and headache reports, 15 6 , — Effectiveness of a home-based exercise therapy and walking program on osteoarthritis of the knee. Rheumatology international, 22 3 , pp. Quality of life in patients with knee osteoarthritis: Effectiveness of exercise interventions in reducing pain symptoms among older adults with knee osteoarthritis: Physical therapy is effective for patients with osteoarthritis of the knee: The Journal of rheumatology, 28 1 , pp. Therapeutic exercise for people with osteoarthritis of the hip or knee.
J Rheumatol, 29 The epidemiology of osteoarthritis in Asia. Exercise for osteoarthritis of the knee. Cochrane Database Syst Rev, 4. Accessed October 25, Effects of dietary intervention and quadriceps strengthening exercises on pain and function in overweight people with knee pain: BMJ, 3 Progressive resistance exercise in women with osteoarthritis of the knee: Clinical rehabilitation, 29 3 , pp. A systematic review finds variable use of the intention-to-treat principle in musculoskeletal randomized controlled trials with missing data.
Journal of clinical epidemiology, 68 1 , 15— Palliative Medicine, 13 1 , 75— Knee osteoarthritis prevalence, risk factors, pathogenesis and features: Muscle dysfunction and effective rehabilitation of knee osteoarthritis outcomes: What we need to find out. Rethinking the efficacy-to-effectiveness transition. American Journal of Public Health, 93 8 , How to read a paper: Perspectives in clinical research, 2 3 , Cochrane handbook for systematic reviews of interventions.
Associations between chronic disease, age and physical and mental health status. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: A randomized controlled trial of aquatic and land-based exercise in patients with knee osteoarthritis.
Journal of rehabilitation medicine, 40 2 , pp. Investigation of clinical effects of high and low-resistance training for patients with knee osteoarthritis: The epidemiology of osteoarthritis. Clinical Rheumatology, 28, 1 , To support evidence based medicine. The effectiveness of a self-management program on quality of life for knee osteoarthritis OA patients, [Online] Archives Of Gerontology And Geriatrics, 54, 2, pp. Strength training for treatment of osteoarthritis of the knee: Arthritis and rheumatism, 59 10 , — Systematic review of guidelines for the physical management of osteoarthritis, [Online] Archives of Physical Medicine and Rehabilitation, 95, 2, pp.
Principles of assessment and outcome measurement for occupational therapists and physiotherapists: Newcastle, Cambridge Scholars Publishing. Epidemiology and burden of osteoarthritis. Reliability of the PEDro scale for rating quality of randomized controlled trials.
Physical therapy, 83 8 , Health and quality of life outcomes, 3,. Physical exercise and risk of severe knee osteoarthritis requiring arthroplasty. The effectiveness of exercise in the treatment of osteoarthritic knees: Phys TherRev ; 4: Diet and exercise for obese adults with knee osteoarthritis. Clinics in geriatric medicine, 26 3 , The epidemiology, aetiology, diagnosis, and treatment of osteoarthritis of the knee. Effects of strength training on the incidence and progression of knee osteoarthritis. Updated guidelines for reporting parallel group randomized trials.
Asian Journal of Multidisciplinary Studies Available online at www. Increasing prevalence of knee pain and symptomatic knee osteoarthritis. A guide to systematic literature reviews. Surgery oxford , 27 9 , Effectiveness of home exercise on pain and disability from osteoarthritis of the knee: Annals of the Rheumatic Diseases, 58 1 , pp.
Bias due to selective inclusion and reporting of outcomes and analyses in systematic reviews of randomized trials of healthcare interventions, The Cochrane Database Of Systematic Reviews, 10, Efficacy of strengthening exercises for osteoarthritis. Physical Therapy Reviews 9: Exercise and depressive symptoms: Journals of Gerontology, 57, — Facilitators and barriers to exercising among people with osteoarthritis: Physical therapy, 90 7 , — Physical activity and quality of life in older adults: Association between quadriceps strength and self-reported physical activity in people with knee osteoarthritis, [Online] International Journal of Sports Physical Therapy, 9, 3 , Physical activity and quality of life in older adults.
The Journals of Gerontology Series A: Biological Sciences and Medical Sciences, 56 2 , Psychological health impact on 2-year changes in pain and function in persons with knee pain: Osteoarthritis Research Society, 19, — Sample size estimation in cluster randomized trials: Choosing the best research design for each question.
BMJ, , The effect of two exercise programs on various functional outcome measures in patients with osteoarthritis of the knee: A randomized controlled clinical trial. Isokinetics and Exercise Science, 18 4 , pp. Psychological tests and scales. Quality of Life Assessments in Clinical Trials.
Hydrotherapy versus conventional land-based exercise for the management of patients with osteoarthritis of the knee: Physical therapy, 88 1 , 12— A randomized controlled trial of high versus low intensity weight training versus general practitioner care for clinical depression in older adults. The Journals of Gerontology, 60 , — A systematic review to determine the optimal type and dosage of land-based exercises for treating knee osteoarthritis. A home-based pedometer-driven walking program to increase physical activity in older adults with osteoarthritis of the knee: J Am Geriatric, 51 3 — Home based exercise programme for knee pain and knee osteoarthritis: Six-week high-intensity exercise program for middle-aged patients with knee osteoarthritis: BMC Musculoskeletal Disorders, 6 1 , p.
The effect of dynamic versus isometric resistance training on pain and functioning among adults with osteoarthritis of the knee. Arch Phys Med Rehab, Factors associated with physical activity in patients with osteoarthritis of the hip or knee: Relationship between falls, knee osteoarthritis, and health-related quality of life: Effectiveness of home exercise program in patients with knee osteoarthritis. European Journal of General Medicine, 10, 2 , How to critically appraise an article. Perceived exercise barriers, enablers, and benefits among exercising and nonexercising adults with arthritis: Arthritis and rheumatism, 55 4 , — Burden of major musculoskeletal conditions.
Definition of physical activities. Rheumatic Diseases Clinics of North America, 34 3 Data collection instrument and procedure for systematic reviews in the Guide to Community Preventive Services. Their study is interesting both in terms of the growing significance of the resilience paradigm in contemporary discourses of empowerment in tacking individual, structural and social inequalities,.
My experience over the years of co-teaching the dissertation module for final year nursing students has helped me realise that many of them embark on their literature reviews with fear and trepidation. Edward Liscott, a recent graduate of the paramedic undergraduate degree, explores the causes of inappropriate and avoidable uses of accident and emergency care.
His review discusses clearly important and currently highly topical implications for the efficient and cost-effective use of our ambulance services. Vinny Curtis, who graduated recently from the adult branch nursing degree, argues in his review that maggot therapy is an effective tool in the debridement of necrotic foot wounds. Despite this, due to the lack of rigorous random controlled trials available, there remains a lack of published evidence that supports its use. The author has an interest in the way in which students learn in the clinical setting.
The authors argue that work is understood to generally benefit health and well-being, while absence from work bestows costs to the health of the individual and to the economy. Return-To-Work plans are implemented in many workplaces to allow individuals to recommence their duties. From a critical perspective, all normative healthcare practices are shaped by broader cultural discourses, as can be seen currently in, for example, the emergence of obesity as pathology, and so it is important that healthcare professionals are reflexively attuned to this.
People whose experiences are classified by the medical model as schizophrenia, bipolar affective disorder or psychosis, die years sooner on average than people with no mental health diagnosis Department of Health DH b. It is three times more probable they will suffer premature death DH c , with increased risk of several physical illnesses, such as heart disease, diabetes, respiratory disease and infections, and obesity DH ; DH b,c; Rethink a, b, c; DH a; NICE b.
The prescribing of anti-psychotic medication may lead to weight gain, sometimes up to kg in the first 2 months Foley and Morley ; Rethink a. This may be due to several factors, including a more sedentary lifestyle and a related lack of exercise. However 27 million adults in England are not active enough to benefit their health DH , and the Secretary of State is calling for the NHS to make the promotion of active lifestyles central to all healthcare professionals work DH This literature review topic was chosen because in practice as a student nurse I have thought there is inadequate emphasis placed on exercise and believe that service users would benefit from its inclusion in mental health services.
The choice of a non-medical phrase may help in the shift from a medical to a more holistic view of the experiences of people, within which mental health difficulties are described in more compassionate, less stigmatizing ways Carless and Douglas a; Moncrieff ; Johnstone In order to first identify the research question, substantial reading was necessary in the field of interest, namely exercise and mental health.
A Boolean search was utilised in order to search most efficiently across a range of databases. From this, a few key interests emerged. As there exist a significant number of papers around depression, anxiety and exercise but little on serious mental health issues, my search was made more specific by setting the inclusion and exclusion criteria to only include papers concerning serious mental health issues. A total of 15 papers emerged as significant. These were predominantly qualitative, with four quantitative and one descriptive study.
A simplified thematic analysis was performed on the papers selected Noblit and Hare ; Paterson et al ; Rice ; Aveyard Three themes emerged from the papers reviewed, which go some way towards answering the research question: The literature signified the importance of the social effects of exercise for people who experience extreme states of mind. Participants also identified that exercise positively affects their social roles and highlight the value of shared experience Crone and Guy ; Carless and Douglas ; Hodgson et al ; Cullen and McCann Narrative inquiry seeks to find the meaning that people make of their experiences and what it means to be human.
It is a creative process that can often bring about change for the participants through the process of re telling the story, narrative re-storying Carless and Douglas a. The theme of potential benefits through the development of peer support and friendship when exercising was present in several studies. The narrative inquiry work of Carless and Douglas a, b and hasstrong peer support and friendship themes, and a clear service user voice is heard throughout. These three studies aimed to look at how men experiencing extreme states of mind utilise narrative re-storying through exercise and sport a , how they might receive social support through exercise b and the narratives of people using physical activity programmes within mental health services For some people who experience extreme states of mind, the social role that exercise provides is helpful.
This study has a strong service user voice, which makes the pertinence of the statements more compelling.
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The work of Hodgson et al , supported by Crone and Guy and Cullen and McCann also illustrate the role of exercise in alleviating some of the isolation felt by service users through meeting new people in the community. From a psychological perspective, the literature generally revealed how exercise may assist people who experience extreme states of mind to be more motivated, be more proud, confident, have greater self esteem, have fun and alleviate symptoms. For some, participating in exercise or physical activity led to an increase in motivation to continue exercising Fogarty and Happell and in others, exercise increased their desire to make healthy lifestyle changes, such as reducing the intake of fast foods Klam et al Motivation can be difficult for people experiencing extreme states of mind, and whether this is because of the impact of medication on motivation or the lack of structure in their lives is unclear Crone and Guy In a Norwegian study, Tetlie et al discussed a mandatory exercise programme in a forensic setting.
The effects that exercise has on increasing motivation for this population are diverse, although some people are enabled to exercise more Fogarty and Happell ; Warren et al Nurses exercising with clients may also challenge stigma Tetlie et al , and this will be explored in more depth in the discussion chapter. In the weeks following this intervention clients were heard sharing jokes and they described how this helped them take life a little less seriously.
The fun element was something that was shared between staff and patients in the study by Tetlie et al , further breaking down the barriers between them. Having fun and experiencing pleasure in life through exercise could also be a way of distracting oneself from the negative experiences of extreme states of mind. It may, according to Cullen and McCann , be a useful tool for voice hearers, as the time spent concentrating on exercise is time spent not concentrating on voices.
Exercise may also counteract boredom, which is often an aspect of inpatient mental health services, and in the community is exacerbated through social isolation Crone and Guy ; Hodgson et al The effect of exercise on confidence, pride, self esteem and sense of purpose is reported in numerous studies Crone and Guy ; Hodgson et al ; Cullen and McCann Confidence is crucial for participating in social activities van Deurzen , and self esteem is often interconnected with this Crone and Guy In related terms, people who experience extreme states of mind have often lost their confidence Carless and Douglas a and sense of purpose Hodgson et al , and exercise might be something that can help restore this.
By extrapolation, the psychological effects of exercise might therefore influence how well an individual participates in society Tetlie et al and vice versa van Deurzen The majority of literature included in the review discusses the importance of maintaining good physical health for this population, especially given the negative impact medication and lifestyle can have on diabetes, weight, and the heart DH , b. Disappointingly there was only one paper that measured weight loss as a result of exercise Klam et al The study by Warren et al attempted to study weight loss in the USA but was flawed through a lack of accurate data recording, weight gain precipitated by meal vouchers and bias as a result of the involvement of pharmaceutical companies.
Other studies have approached the issue but also failed to gain significant results as a consequence of not including diet and nutritional advice in conjunction with exercise Schwee et al Several qualitative studies found that people exercised in order to manage and control their weight. Interestingly, only one study directly found related weight gain and associated issues to the medication prescribed for extreme states of mind — namely second generation antipsychotics Hodgson et al Again there are a majority of papers in this review who assert weight gain due to antipsychotic medication in their abstracts, yet only Hodgson et al reported empirical information on this.
Klam et al described positive physical changes to blood pressure, fasting blood sugar levels, smoking and fitness among people with extreme states of mind in Canada. However, this is a descriptive paper and not generalizable. Whilst training for a 5K race, study participants increased their mean steps by Cullen and McCann highlight that exercise can make someone feel stronger and this motivates them to eat healthier when they can see their physical health improving.
It is interesting that physical rather than psychological benefits of exercise were found to be most important to the participants in study by Bassilios et al This interview-based study of 45 people who use community mental health service around Melbourne, also highlight the importance of education surrounding the benefits of exercise. However, there remains a lack of quantitative evidence in this area. All of this highlights the urgent need to address the physical health of this population. Some studies have approached this issue but have failed to find significant results through poor planning, lack of validity and poor recording Warren et al ; Usher et al ; Scheewe et al The majority of the studies reviewed recommend that exercise is incorporated into daily mental health practice, which will require support from mental health staff.
An important aspect of personal recovery highlighted, is personalised, individualised care. The significance of peer support was a key finding, as was staff exercising with service users. The literature reflects the importance of exercise staff being highly skilled, especially in mental health.
Although personal recovery frameworks advocate increased independence from mental health services, several studies recommended that mental health specific exercise support should be available for those that need it. From the literature reviewed, exercise culture can generally be viewed as a male-dominated and thus exercise provision may not be tailored to the needs and requirements of women.
Much of exercise provision is based on performance, whereas women might be more interested in the relational outcomes that exercise might bring. This hints at women perhaps gaining more from the benefits of peer support in exercise, but adquate evidence to support this is not currently available. The positive effects of exercise have been recognised in this review as similar to cohere with the four ontological realms of existentialism, notably the physical, social, spiritual and personal worlds of the individual.
The importance of personal meaning and significance is a crucial goal of recovery, and mental health nurses and researchers need to explore this realm with their service users in the context of engagement with exercise. The findings of the literature reviewed also highlight this, and also point to the benefits of peer support which may also impact on motivation and vice versa. Someone experiencing extreme states of mind might have fun when exercising, which might them lead them to feel more motivated, which in turn may inspire them to do more exercise, thus improving their health, weight and fitness.
The literature thus emphasises findings emphasise the interconnected nature of human experiences and how exercise can potentially have an impact on all areas of life. This review has highlighted the importance of the role of exercise in the process of recovery. This is a subjective process and has a different meaning for each individual, and so, in practice, the personal meaning of recovery emerges as important.
Personal recovery models have outcomes differing significantly from clinical recovery, which refers to the reduction and absence of psychiatric symptoms. Personal recovery refers more to regaining social roles, building and consolidating relationships that bring meaning and value to life, and developing hope. The literature and policy recommend that exercise should be included in mental health services, and specifically to be included in individual care plans.
Clearly, the inclusion of effective exercise in care plans it needs to be supported by mental health professionals. The DH state that promotion of active lifestyles is a key role of all healthcare professionals, therefore mental health nurses need to support the promotion of exercise and its sustainment. Nurses also need to be equipped to educate their service users about exercise, know how to refer to other services and instigate practice development where necessary. Crone and Guy highlight the role of the mental health nurse as practice developers and one emerging suggestion is that they take a role in organising discounts with local sports facilities.
For this to be implemented would require nurse education in exercise and a knowledge-base of how to drive practice developments themselves. If exercise is promoted by mental health professionals and included in care plans it needs to be tailored to individual preferences. Mental health policy and guidelines promote the idea of individual care, especially in personal recovery frameworks.
For exercise to be as effective as possible, service users need to be offered a choice of activities and programmes to suit their individual needs. The benefits of peer support in exercise, is a potentially interesting finding for future practice development and current guidance is to promote it in mental health services more generally. Peer support in this context is the mutual and reciprocal support provided by another person who has experienced extreme states of mind Mental Health Foundation It appears to play a key role as one of the positive effects of exercise.
NICE suggests the use of trained peer supporters in psychosis and schizophrenia and Rethink c also recommend the use of peers to aid personal recovery. In practice as a student nurse, I have only met two peer support workers. As a future mental health practitioner I would like to be able to encourage service users to assume this role. It seems clear that they can help contribute directly in the recovery of others and themselves. However, Slade et al state that this needs to not be tokenistic, ensuring that suitable training and support for this role is in place.
For the role of peer support workers to be prioritised in exercise provision, clearly more research is needed. The review highlighted that in fact exercising with service users was something that increased motivation, reduced stigma and strengthened the therapeutic relationship. Nurses who have undertaken exercise alongside service users have been very positive about its impact, for the services users, themselves and in the case of inpatient services or recovery houses, on the unit as a whole Happell et al If this initiative was more widely adopted, nursing staff would be exercising also, therefore taking care of their own physical health needs.
However, exercise provision in mental health does demand skilled professionals who are also sensitive to the needs of people experiencing extreme states of mind. The value of the research into the effects of exercise for people who experience extreme states of mind does not seem sufficient to influence evidence-based practice. Future research is needed in several areas, to include gender sensitivity; how exercise increases meaning in life; peer support, motivation; and service user-led research Rose et al Importantly, there is a dearth of significant research included in this review concerning weight loss, which is a key to reducing the health risks that anti-psychotic medication poses.
Medication is a contributing health risk of this population, and pharmaceutical companies have an ethical duty to produce medication with less damaging side effects Bental ; Moncreiff This review set out to look at the effects of exercise for people who experience extreme states of mind, and how these findings might impact on mental health nursing practice.
There is a lack of research in this area, particularly for women, leading to deficiencies in related evidence-based nursing practice. However, the evidence available points to the positive social, psychological and physical effects of exercise. The literature review recognises that exercise could be used to aid personal recovery, and that this might lead to a less stigmatised view of the individual and their relationship to wider society.
The importance of service users being able to re-story their lives through social acceptable activities is highly significant and mental health nursing practice needs to embrace the importance of narrative in all areas of practice. Peer support is already recognised as a vital element of practice and this review recommends that it be explored further in relation to exercise and extreme states of mind. Nurses require education to assist their practice development in these contexts. Narrative, identity and mental health: How men with serious mental illness re-story their lives through sport and exercise.
Psychology of Sport and Exercise. Carless, D and K. Social support for and through exercise and sport in a sample of men with serious mental illness. Issues in Mental Health Nursing. The ethos of physical activity delivery in mental health: A narrative study of service user experiences. International Journal of Mental Health Nursing. Exploring the role of physical activity for people diagnosed with serious mental illness in Ireland.
Journal of Psychiatric and Mental Health Nursing. No health without Mental Health. Atypical Second Generation Antipsychotics. Priorities for Essential Change in Mental Health. Moving More, Living More. Exploring the benefits of an exercise program for people with schizophrenia: Archives of General Psychiatry. Nurses views on physical activity for people with serious mental illness. Mental Health and Physical Activity. The experiences of people with severe and enduring mental illness engaging in a physical activity programme integrated into the mental health service.
Addressing health concerns in people with schizophrenia. Journal of Psychosocial Nursing. Preventing type 2 diabetes: Psychosis and schizophrenia in adults: Psychosis and schizophrenia in adults. Promoting healthy eating, physical activity and smoking cessation. Qualitative Research Methods Series. Metastudy of Qualitative Health Research. A report by the Schizophrenia Commission. Evidence-based practice in psychiatric and mental health nursing: Journal of the American Psychiatric Nurses Association. Lifestyle and healthy outcome in physical education.
Development of a lifestyle intervention program for people with severe mental illness. A model for developing outcome measures from the perspectives of mental health service users. International Review of Psychiatry.
Uses and abuses of recovery: Implementing recovery-orientated practices in mental health systems. Exercise therapy improves mental and physical health in schizophrenia: A randomized controlled trial. Using exercise to treat patients with severe mental illness. A randomised control trial undertaken to test a nurse-led weight management and exercise intervention designed for people with serious mental illness who take second generation anti-psychotics. Journal of Advanced Nursing. Existential Counselling and Psychotherapy in Practice.
Individual Therapy in Britain, edited by W. Exercise program adherence using a 5 kilometer 5K event as an achievable goal for people with schizophrenia. Biological Research for Nursing. There are currently unprecedented levels of demand on urgent and emergency care throughout the UK University of Sheffield Medical Care Research Unit ; Agarwal et al, ; NHS England , with ED attendances and ambulance call outs increasing consistently every year Nelson ; Newton et al, In doing so, this paper also aims to demonstrate the fundamental connection between ED and ambulance services, and how their performance is mutually dependant on one another.
Twenty-seven articles were included for review and four broad themes were identified; Definition of Terms, Patient Factors, Access to Healthcare and Healthcare Frameworks. A high number of diverse and complex contributors to inappropriate emergency department ED attendance and ambulance use were identified. Whilst some patient factors contributed towards this issue, problems with wider healthcare frameworks and organisational behaviours were significantly more abundant in reviewed literature.
Fragmentation of services may be creating barriers to alternative care services to both patients and clinicians attempting to make referrals. Strategies to improve appropriate use of healthcare should focus on enhancing the way in which services work together. A systematic search was performed using an adapted methodology from Moher et al Additional keywords derived from iterative searches were added to search terms until appropriate saturation of results had been achieved. Articles were critically analysed using a tabular matrix adapted from LoBiondo-Wood and Haber Research conducted outside of the UK was excluded due to the internationally unique framework of the National Health Service.
The exception to this was material considered in systematic reviews, where articles were included as long as they were written in the UK. Articles which focused solely on self-presentation at the ED, or which did not make any explicit differentiation between routes of attendance were also excluded. Material focusing upon paediatrics or specific medical complaints was excluded, with the exception of falls, and frequent users.
Articles that did rigorously establish objectivity showed variation in their presented views. The University of Sheffield Medical Care Research Unit highlights significant inconsistency in defining appropriateness throughout healthcare research. Furthermore, Jones and Booker, Simmonds and Purdy argue that appropriateness is almost exclusively defined retrospectively by healthcare staff. However, whilst there exists significant challenges in objectively defining inappropriate use, clarification on what this looks like is crucial in aiding clinicians to identify and reduce it in real terms.
Further research in this area would be beneficial in providing clearer guidelines for prehospital clinicians when dealing with potentially inappropriate use. A significant proportion of extracted themes related to subjective factors influencing individual patient behaviour. However, this research was externally peer-reviewed, and several further articles provide consensus on this finding Agarwal et al, ; University of Sheffield Medical Care Research Unit ; Edwards et al, Conversely however, a literature review by Sheffield University University of Sheffield Medical Care Research Unit highlights that misconceptions of symptoms can potentially cause inappropriate delay or refrain from contacting emergency services.
Whilst the aforementioned makes no analysis of the ratio between inappropriate contact and non-contact, Kirkby and Roberts suggest that the majority of inappropriate classification occurs when no ambulance is required. Atenstaedt et al demonstrates the effectiveness of targeted campaigns in improving patient knowledge and reducing inappropriate attendance, however provides no cost-analysis of these strategies.
Perhaps a cost-effective opportunity exists for the ambulance service to deliver this type of patient education to inappropriate users. The ambulance service has previously demonstrated high levels of success in bringing health campaigns to public awareness Association of Ambulance Chief Executives Similarly three articles considered interpersonal factors such as relatives and carers in the decision-making process.
They found that informal carers often experienced feelings of responsibility and helplessness, prompting them to take the least risky course of action. In addition, risk-minimising behaviour was noted in patients themselves, who often felt pressured by what friends and family might think, regardless of their actual presence. The Association of Ambulance Chief Executives outlines similar risk-averse behaviour from staff in care homes, however primarily driven by misconceptions of organisational responsibility.
In many cases this is dependant on patient and carer confidence managing minor ailments and long-term conditions. Interpersonal factors can significantly influence subsequent use of ambulance services, and therefore should be considered by the prehospital clinician when attending an incident. In addition, clinicians should be aware interpersonal pressures when assessing patient wishes and when making best interest decisions. The Keogh Review NHS England identifies that the patient demographics most likely to benefit from alternative healthcare support are those least likely to be aware of it, prompting increased inappropriate dependence on urgent services.
Several articles studied the effect of patient demographics on healthcare usage. Whilst Kirby and Roberts found no statistically significant factors in their research, Dent, Hunt and Webster found that frequent ED attenders were more likely to be male, with a mean age of In a systematic review, Scott et al finds several concurring articles identifying frequent users as predominantly male.
Despite some potential bias introduced from a single initial reviewer, established methodology and quality analysis is employed. Edwards et al and Smith and McNally both agree that elderly demographics can make up a significant portion of inappropriate and frequent users.
However, Scott et al found highly mixed evidence in regards to patient age, and only one limited study suggesting that frequent use increased with age. The majority of evidence suggests that inappropriate users are heterogeneous, presenting for a variety of health and social reasons Edwards et al, ; Scott et al, However, this research was limited by a small sample size at risk of self-selected participant bias Lavrakas Whilst there exists conflicting views regarding geographical influence on appropriate healthcare use, there is an overwhelming consensus of evidence suggesting social deprivation contributes towards inappropriate and frequent use of urgent services.
Healthcare campaigns have demonstrated success when socioeconomically targeted Atenstaedt et al, , and strategies by ambulance services to manage inappropriate use appear well advised to be initially targeted at economically deprived areas. Several articles discuss patient access to community services as an influencing factor of avoidable ED attendance and inappropriate ambulance use.
The Keogh Review NHS England highlights significant variation in GP service satisfaction levels nationally, with systemic fragmentation of community services causing further access issues. This is supported by Agarwal et al , which found GP access issues to be a consistently reoccurring theme in patients attending the ED inappropriately. This might explain why in highly rigorous, mixed-method action research, Endacott et al found that inappropriate ED attendances increased dramatically during OOH periods. If barriers to community care increase rates of inappropriate ambulance and ED usage, this has significant implications for ambulance services in analysing patterns of demand and managing response levels geographically and at different time periods NHS Office of Strategic Health Authorities Indeed, Turner et al outlines the potential for supplier-induced demand, particularly in the area of alternative community services such as NHS The Keogh Review NHS England supports this notion, and furthermore highlights that GP consultations have also been increasing, despite expansion of alternative services.
Therefore the issue may be more related to general demand rather than patient access. This is supported by Edwards et al , which found that frequent use of emergency services was linked to equivalent frequent use of other community services. However, as Patton and Thakore found GP referrals via the ED were associated with lower levels of inappropriateness, it is still reasonable to suggest that better access to GP services could improve avoidable ED admission rates.
Paramedic Practitioners are now working more closely in supporting community GP services Association of Ambulance Chief Executives , and therefore perhaps this should be an important focus by ambulance trusts in managing overall demand. Inversely, ease of access to ambulance and emergency department services was also a reoccurring contributor to inappropriate use of these channels. Patton and Thakore surmise that the convenience of an ED providing hour investigations without appointment must significantly influence patient behaviour, however this was not explicitly analysed in their research.
Smith and McNally propose a similar rationale for frequent users of urgent and emergency care services, and furthermore speculate a similarity in the behaviour of ED and ambulance users; a view supported by Edwards et al Agarwal et al found confusion over alternative pathways to be a main contributor to patients accessing urgent services inappropriately. Participants in this research cited familiarity of services, and perception of efficiency over GP services as important influencers on the decision to attend the ED.
All articles appeared to demonstrate generally high levels of satisfaction amongst patients utilising ambulance and ED services, putting these services in the predicament of generating increased demand through positive performance. This represents a significant dilemma for the NHS, as these channels are by far the most expensive routes for patients to access health services NHS England In addition to improving the overall profile of the ambulance service within the NHS, the National Audit Office estimates that this would be a significantly more cost-effective response model if configured appropriately.
The Francis enquiry demonstrates how an organisational culture, and clinical behaviours within that culture, can have a significant impact on the quality of healthcare delivered to patients. A large majority of articles considered organisational and clinician factors in relation to inappropriate and frequent use of emergency care. Patton and Thakore demonstrate the potential impact of oversensitive triage from ambulance staff. Whilst a potential bias exists with the duty consultant subjectively assessing appropriateness, reviewers did rotate throughout the study, and rigorous assessment was made using both the ED notes and Patient Report Form PRF.
In addition, Newton et al demonstrates the moderate success of prehospital pathway finders adapted from the Manchester Triage System. However, whilst providing clinicians with support tools may improve confidence, it may be argued that such tools do not address the issue of clinician education, and furthermore may be inappropriate for clinically and socially complex situations.
A proposed solution to this may be the implementation of secondary triage systems Eastwood et al, in order to decrease sensitivity whilst maintaining risk management. However there exists little evidence on the most appropriate structure or benefits of this within a prehospital framework, and further research is warranted.
The National Audit Office highlights the importance of multi-service collaboration in reducing overall demand, and the knock on effect when one service becomes congested. Indeed Edwards et al and Smith and McNally both concur that collaborative multi-level interventions are most effective in tackling frequent and inappropriate use, whilst Booker, Simmonds and Purdy call for closer collaboration between primary care and ambulance services.
Whilst this was a relatively small study, this theme reoccurred consistently throughout three individual trusts, suggesting a high level of reliability May However, the National Audit Office highlights a paucity of ambulance trusts adequately collating directories of alternative services, suggesting that the underlying issue may be prehospital awareness, rather than availability. This is furthermore supported by Mason et al , which found that ECPs increased admission avoidance rates, and were most effective in a mobile setting.
However Coates rightly questions the difference between avoided admission and avoided ED attendance, highlighting a paucity of studies differentiating between the two. Since a significant cost difference is applicable, further research in this area should be considered. Reviewed material demonstrates that specialised roles have a significant benefit on admission avoidance, concurring with established literature National Audit Office ; Association of Ambulance Chief Executives However, there is still variability in the deployment of these roles NHS England , and whilst there remains such a heavy prehospital focus on targeted response times over clinical outcomes National Audit Office , it may be argued that specialised prehospital roles cannot be utilised to their fullest potential.