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Background and aim: Cancer related fatigue significantly impairs the ability to undertake sustained physical activity across the domains of daily living, work and recreation. The purpose of this study is to monitor cancer related fatigue and the factors affected or caused by it for 12 months in head and neck cancer patients following their diagnosis. Their perceptions of how fatigue might affect their activity levels in addition to identifying avenues to improve engagement with physical activity will be also explored. Methods: A single centre longitudinal mixed-methods study will be conducted. Forty head and neck cancer patients will be recruited over 6 months following the confirmation of their treatment plan, after which fatigue and physical activity will be assessed at four time points over 12 months. Additionally, other factors which influence fatigue such as body composition, blood counts, systemic inflammation levels, haemoglobin concentration, thyroid function, sleep quality, cardiorespiratory fitness and upper and lower extremity strength will be measured to understand how the multifactorial problem of fatigue may evolve over time and influence physical activity levels. Semi-structured interviews will be conducted after treatment completion and at end of twelve months which will analyse the participants fatigue experiences, understand how their perceived fatigue may have impacted physical activity and report the factors which may improve engagement with physical activity during cancer. Quantitative data will be analysed and reported using standard descriptive statistics and post-hoc pairwise comparisons. The changes in outcome measures across time will be analysed using the MIXED procedure in SPSS software. Statistical significance will be accepted at p<0.05. Qualitative data will be analysed using the Interpretative Phenomenological Approach using the NVivo software. Discussion: The results from this study may help inform the planning and delivery of appropriately timed interventions for the management of cancer related fatigue. [ABSTRACT FROM AUTHOR]

Background: UK cancer mortality is worse than in many other high-income countries, partly because of diagnostic delays in primary care. Aim: To understand beliefs and behaviours of GPs, and systems of general practice teams, to inform the Think Cancer! intervention development. Design and setting: An embedded qualitative study guided by behaviour change models (COM-B [Capability, Opportunity, Motivation – Behaviour] and theoretical domains framework [TDF]) in primary care in Wales, UK. Method: Twenty qualitative, semi-structured telephone interviews with GPs were undertaken and four face-to-face focus groups held with practice teams. Framework analysis was used and results were mapped to multiple, overlapping components of COM-B and TDF. Results: Three themes illustrate complex, multilevel referral considerations facing GPs and practice teams; external influences and constraints; and the role of practice systems and culture. Tensions emerged between individual considerations of GPs (Capability and Motivation) and context-dependent external pressures (Opportunity). Detecting cancer was guided not only by external requirements, but also by motivational factors GPs described as part of their cancer diagnostics process. External influences on the diagnosis process often resulted from the primary–secondary care interface and social pressures. GPs adapted their behaviour to deal with this disconnect. Positive practice culture and supportive practice-based systems ameliorated these tensions and complexity. Conclusion: By exploring individual GP behaviours together with practice systems and culture we contribute new understanding about how cancer diagnosis operates in primary care and how delays can be improved. We highlight commonly overlooked dynamics and tensions that are experienced by GPs as a tension between individual decision making (Capability and Motivation) and external considerations, such as pressures in secondary care (Opportunity). [ABSTRACT FROM AUTHOR]

Background and objectives: Referring clinicians' experiences of exercise referral schemes (ERS) can provide valuable insights into their uptake. However, most qualitative studies focus on patient views only. This paper explores health professionals' perceptions of their role in promoting physical activity and experiences of a National Exercise Referral Scheme (NERS) in Wales. Design: Qualitative semi-structured group interviews. Setting: General practice premises. Methods: Nine semi-structured group interviews involving 46 health professionals were conducted on general practice premises in six local health board areas. Purposive sampling taking into account area deprivation, practice size and referral rates was employed. Interviews were transcribed verbatim and analysed using the Framework method of thematic analysis. Results: Health professionals described physical activity promotion as important, although many thought it was outside of their expertise and remit, and less important than other health promotion activities such as smoking cessation. Professionals linked decisions on whether to advise physical activity to patients to their own physical activity levels and to subjective judgements of patient motivation. While some described ERS as a holistic alternative to medication, with potential social benefits, others expressed concerns regarding their limited reach and potential to exacerbate inequalities. Barriers to referral included geographic isolation and uncertainties about patient selection criteria, medico-legal responsibilities and a lack of feedback about patient progress. Conclusion: Clinicians' concerns about expertise, priority setting and time constraints should be addressed to enhance physical activity promotion in primary care. Further research is needed to fully understand decision making relating to provision of physical activity advice and use of ERS.

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.ctim.2007.01.008 Byline: Nefyn H. Williams (a), Maggie Hendry (a), Ruth Lewis (a), Ian Russell (b), Alex Westmoreland (c), Clare Wilkinson (a) Keywords: Systematic review; Back pain; Neck pain; Spinal manipulation; Psychological outcome Abstract: The most important risk factors for back and neck pain are psychosocial. Nevertheless, systematic reviews of spinal manipulation have concentrated on pain and spine related disability, and ignored psychological outcomes. Author Affiliation: (a) Department of General Practice, Cardiff University, Centre for Health Services Research/North Wales Clinical School, Gwenfro Building, Wrecsam Technology Park, Wrecsam LL13 7YP, United Kingdom (b) Institute of Medical and Social Care Research, University of Wales Bangor, United Kingdom (c) Wales Office of Research and Development for Health and Social Care, Cardiff, United Kingdom

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.ctim.2005.11.006 Byline: Jayne L. Westmoreland (a), Nefyn H. Williams (b), Clare Wilkinson (b), Fiona Wood (b), Alex Westmoreland (c) Keywords: Qualitative research; Attitude to health; Back pain; Neck pain; Osteopathy; Primary care Abstract: Spinal pain is a common reason for consulting general practitioners (GPs), and complementary therapists such as osteopaths and chiropractors. Patients express greater satisfaction with the care from chiropractors and osteopaths, because they are perceived as having more empathy, diagnostic skill and effective treatment, but their attitude to a GP providing an osteopathy service is unknown. Author Affiliation: (a) Plas Menai, Llanfairfechan, Conwy, UK (b) Department of General Practice, Cardiff University, Centre for Health Sciences/North Wales Clinical School, School of Medicine, Gwenfro Building, Wrecsam Technology Park, Wrecsam LL13 7YP, UK (c) Gwynedd Local Health Board, Caernarfon, UK

Abstract Background Hip and knee osteoarthritis is a common cause of pain and disability, which can be improved by exercise interventions. However, regular exercise is uncommon in this group because the low physical activity level in the general population is probably reduced even further by pain related fear of movement. The best method of encouraging increased activity in this patient group is not known. A booklet has been developed for patients with hip or knee osteoarthritis. It focuses on changing disadvantageous beliefs and encouraging increased physical activity. Methods/Design This paper describes the design of a Phase II randomised controlled trial (RCT) to test the effectiveness of this new booklet for patients with hip and knee osteoarthritis in influencing illness and treatment beliefs, and to assess the feasibility of conducting a larger definitive RCT in terms of health status and exercise behaviour. A computerised search of four general medical practice patients' record databases will identify patients older than 50 years of age who have consulted with hip or knee pain in the previous twelve months. A random sample of 120 will be invited to participate in the RCT comparing the new booklet with a control booklet, and we expect 100 to return final questionnaires. This trial will assess the feasibility of recruitment and randomisation, the suitability of the control intervention and outcome measurement tools, and will provide an estimate of effect size. Outcomes will include beliefs about hip and knee pain, beliefs about exercise, fear avoidance, level of physical activity, health status and health service costs. They will be measured at baseline, one month and three months. Discussion We discuss the merits of testing effectiveness in a phase II trial, in terms of intermediate outcome measures, whilst testing the processes for a larger definitive trial. We also discuss the advantages and disadvantages of testing the psychometric properties of the primary outcome measures concurrently with the trial. Trial registration Current Controlled Trials ISRCTN24554946

Abstract Background As the demographic profile of the UK changes, policy makers and practitioners have to respond to health challenges presented by a progressively ageing population. The health promotion plan for older people, aged over 50 years, in Wales included eight key areas: physical activity, healthy eating, home safety and warmth, emotional health, health protection, smoking, alcohol and sexual health. The aim of this study was to describe the extent, content and regional variation of existing health promotion initiatives for older people in Wales, provided by statutory, voluntary and private sector agencies. Method A questionnaire was sent to senior health promotion specialists employed in the 22 local authority areas in Wales to ascertain details of all projects promoting health and wellbeing in the eight key areas where the priority population was aged over 50, or the majority of users were older people. Additional information was sought from project leads and websites. Results Eighteen questionnaires were returned; not all were fully completed. Four areas did not return a questionnaire. Additional information was obtained from internet searches but this mainly concerned national initiatives rather than local projects. In all, 120 projects were included, 11 were throughout Wales. Best provision was for physical activity, with 3 national and 42 local initiatives, but local provision was patchy. Healthy eating, and home safety and warmth had far fewer initiatives, as did health protection, which comprised two national immunisation campaigns. Smoking and alcohol misuse were poorly provided for, and there was no provision for older people's sexual health. Evaluation arrangements were poorly described. Half of those who responded identified unmet training needs. Conclusion The reasons for patchy provision of services were not clear. Increased efforts to improve the coverage of interventions known to be effective should be made. Rigorous evaluation of projects is needed to ascertain the most effective and appropriate interventions, especially for alcohol misuse and sexual health. These conclusions are relevant to the other countries of the United Kingdom (UK), and more widely across Europe.

Background: Previous systematic reviews have found that nurses and pharmacists can provide equivalent, or higher, quality of care for some tasks performed by GPs in primary care. There is a lack of economic evidence for this substitution.Aim: To explore the costs and outcomes of role substitution between GPs and nurses, pharmacists, and allied health professionals in primary care.Design and Setting: A systematic review of economic evaluations exploring role substitution of allied health professionals in primary care was conducted. Role substitution was defined as 'the substitution of work that was previously completed by a GP in the past and is now completed by a nurse or allied health professional'.Method: The following databases were searched: Ovid MEDLINE, CINAHL, Cochrane Library, National Institute for Health and Care Excellence (NICE), and the Centre for Reviews and Dissemination. The review followed guidance from the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA).Results: Six economic evaluations were identified. There was some limited evidence that nurse-led care for common minor health problems was cost-effective compared with GP care, and that nurse-led interventions for chronic fatigue syndrome and pharmacy-led services for the medicines management of coronary heart disease and chronic pain were not. In South Korea, community health practitioners delivered primary care services for half the cost of physicians. The review did not identify studies for other allied health professionals such as physiotherapists and occupational therapists.Conclusion: There is limited economic evidence for role substitution in primary care; more economic evaluations are needed. [ABSTRACT FROM AUTHOR]

Objectives To describe the implementation of an enhanced rehabilitation programme for elderly hip fracture patients with mental capacity, in a randomised feasibility study compared with usual rehabilitation. To compare processes between the two and to collect the views of patients, carers and therapy staff about trial participation. Design Mixed methods process evaluation in a randomised feasibility study. Setting Patient participants were recruited on orthopaedic and rehabilitation wards; the intervention was delivered in the community following hospital discharge. Participants Sixty-one older adults (aged =65 years) recovering from surgical treatment (replacement arthroplasty or internal fixation) following hip fracture, who were living independently prior to fracture and had mental capacity and 31 of their carers. Interventions Usual care (control) or usual care plus an enhanced rehabilitation package (intervention). The enhanced rehabilitation consisted of a patient-held information workbook, goal-setting diary and up to six additional therapy sessions. Process evaluation components Recruitment of sites and rehabilitation teams, response of rehabilitation teams, recruitment and reach in patient and carer participants, intervention delivery, delivery to individuals, response of individual patients to the enhanced intervention or usual rehabilitation, response of carer participants, unintended consequences and testing intervention theory and context. Results Usual rehabilitation care was very variable. The enhanced rehabilitation group received a mean of five additional therapy sessions. All of the returned goalsetting diaries had inputs from the therapy team, and half had written comments by the patients and carers. Focus group themes: variation of usual care and its impact on delivering the intervention; the importance of goal setting; the role of the therapist in providing reassurance about safe physical activities; and acceptability of the extra therapy sessions. Conclusions Lessons learnt for a future definitive RCT include how to enhance recruitment and improve training materials, the workbook, delivery of the extra therapy sessions and recording of usual rehabilitation care. [ABSTRACT FROM AUTHOR]

Objectives To adapt the Back Beliefs Questionnaire (BBQ) to measure illness beliefs in people with osteoarthritis of the hip or knee, and to measure the psychometric properties of this new 'Hip and Knee Beliefs Questionnaire' (HKBQ) together with the 'Exercise Attitude Questionnaire-18' (EAQ-18), which measures exercise-related treatment beliefs. Method Cognitive debriefing through semi-structured interviews was used to assess the face validity of the HKBQ and the EAQ-18. Both questionnaires were tested on people with hip or knee osteoarthritis enrolled into a phase II randomized controlled trial examining the effectiveness of an evidence-based booklet in changing illness and treatment beliefs. Items in these outcome measures were accepted if they fulfilled a series of psychometric criteria including response frequency, item-total correlation, and factor analysis. The final questionnaires were tested for reliability, responsiveness, criterion, and construct validity. Results No items were discarded from either of the final questionnaires, although one item in the EAQ-18 was borderline. Both questionnaires showed evidence of internal consistency, test-retest reliability, face validity, and criterion validity; there was less evidence for construct validity. The responsiveness of the HKBQ showed a medium-sized change; the EAQ-18 a small change. Conclusion Both these outcome measures can be used in future trials and other studies which measure change in illness and exercise beliefs in people with osteoarthritis of the hip or the knee. Further testing of validity and responsiveness using interventions with larger effect sizes should be performed. Trial registration Current Controlled Trials ISRCTN24554946. [ABSTRACT FROM AUTHOR]

Background: The Hip & Knee Book: Helping you cope with osteoarthritis was developed to change disadvantageous beliefs and encourage physical activity in people with hip or knee osteoarthritis.Aim: To assess the feasibility of conducting a definitive randomised controlled trial (RCT) of this evidence-based booklet in people with hip or knee osteoarthritis.Design: Phase II feasibility randomised controlled trial (RCT).Method: Computerised searches of patients' record databases identified people with osteoarthritis of the hip or knee, who were invited to participate in the RCT comparing the new booklet with a control booklet. Outcomes were measured at baseline, 1 month, and 3 months, and included: beliefs about hip and knee pain, exercise, and fear avoidance; level of physical activity; and health service use.Results: The trial methods were feasible in terms of recruitment, randomisation, and follow-up, but most participants recruited had longstanding established symptoms. After one and 3 months, there was a small relative improvement in illness, exercise, and fear-avoidance beliefs and physical activity level in The Hip & Knee Book group (n = 59) compared with the control group (n = 60), which provides some proof of principle for using these outcomes in future trials.Conclusion: This feasibility study provided proof of principle for testing The Hip & Knee Book in a larger definitive RCT. [ABSTRACT FROM AUTHOR]

Background: The pain and disability of hip and knee osteoarthritis can be improved by exercise, but the best method of encouraging this is not known.Aim: To develop an evidence-based booklet for patients with hip or knee osteoarthritis, offering information and advice on maintaining activity.Design Of Study: Systematic review of reviews and guidelines, then focus groups.Setting: Four general practices in North East Wales.Method: Evidence-based messages were developed from a systematic review, synthesised into patient-centred messages, and then incorporated into a narrative. A draft booklet was examined by three focus groups to improve the phrasing of its messages and discuss its usefulness. The final draft was examined in a fourth focus group.Results: Six evidence-based guidelines and 54 systematic reviews were identified. The focus groups found the draft booklet to be informative and easy to read. They reported a lack of clarity about the cause of osteoarthritis and were surprised that the pain could improve. The value of exercise and weight loss beliefs was accepted and reinforced, but there was a perceived contradiction about heavy physical work being causative, while moderate exercise was beneficial. There was a fear of dependency on analgesia and misinterpretation of the message on hyaluranon injections. The information on joint replacement empowered patients to discuss referral with their GP. The text was revised to accommodate these issues.Conclusion: The booklet was readable, credible, and useful to end-users. A randomised controlled trial is planned, to test whether the booklet influences beliefs about osteoarthritis and exercise. [ABSTRACT FROM AUTHOR]

Background Cancer follow-up places a significant burden on hospital outpatient clinics. There are increasing calls to develop alternative models of provision. Aim To undertake a systematic review of qualitative studies examining patients' and healthcare professionals' views about cancer follow-up. Design of study Systematic review. Setting Primary and secondary care. Method Comprehensive literature searches included: 19 electronic databases, online trial registries, conference proceedings, and bibliographies of included studies. Eligible studies included qualitative studies examining patients' and healthcare professionals' views of cancer follow-up. Studies of patients with any type of cancer, considered free of active disease, or no longer receiving active treatment were included. Findings were synthesised using thematic analysis. Results Nineteen studies were included; seven were linked to randomised controlled trials. Eight studies examined the views of healthcare professionals (four of which included GPs) and 16 examined the views of patients. Twelve descriptive themes were identified, from which 12 perceived implications for practice were derived. Most themes related to conventional follow-up in secondary care. Some views concerning other models of care were based on participants' ideas, rather than experiences. Conclusion Patients' main concern is recurrent disease, and they find regular follow-up, expertise of specialists, and quick access to tests reassuring. Information regarding the effectiveness of follow-up is not given to patients who also have unmet information needs, which would help them to cope and be more involved. Continuity of care, unhurried consultations, and psychosocial support are important, but sometimes lacking in secondary care. GPs are thought to be unwilling and to have insufficient time and expertise to conduct follow-up. [ABSTRACT FROM AUTHOR]

Background Cancer follow-up has traditionally been undertaken in secondary care, but there are increasing calls to deliver it in primary care. Aim To compare the effectiveness and cost-effectiveness of primary versus secondary care follow-up of cancer patients, determine the effectiveness of the integration of primary care in routine hospital follow-up, and evaluate the impact of patient-initiated follow-up on primary care. Design of study Systematic review. Setting Primary and secondary care settings. Method A search was carried out of 19 electronic databases, online trial registries, conference proceedings, and bibliographies of included studies. The review included comparative studies or economic evaluations of primary versus secondary care follow-up, hospital follow-up with formal primary care involvement versus conventional hospital follow-up, and hospital follow-up versus patient-initiated or minimal follow-up if the study reported the impact on primary care. Results There was no statistically significant difference for patient wellbeing, recurrence rate, survival, recurrence-related serious clinical events, diagnostic delay, or patient satisfaction. GP-led breast cancer follow-up was cheaper than hospital follow-up. Intensified primary health care resulted in increased home-care nurse contact, and improved discharge summary led to increased GP contact. Evaluation of patient-initiated or minimal follow-up found no statistically significant impact on the number of GP consultations or cancer-related referrals. Conclusion Weak evidence suggests that breast cancer follow-up in primary care is effective. Interventions improving communication between primary and secondary care could lead to greater GP involvement. Discontinuation of formal follow-up may not increase GP workload. However, the quality of the data in general was poor, and no firm conclusions can be reached. [ABSTRACT FROM AUTHOR]

The initial clinical assessment of spinal pain consists of diagnostic triage into: (i) serious spinal pathology; (ii) other pathological entities; and (iii) non-specific symptoms. The non-specific group comprises the major burden of spinal illness. There are two broad approaches to the diagnostic challenge of non-specific spinal pain. One approach is to split the group into sub-groups explained by separate pathophysiological abnormalities. The focus of this work is to describe these proposed abnormalities in greater detail and to discover which clinical features distinguish them. The other approach is to 'lump' all of those with non-specific features into one group, and consider the common psychosocial factors that are relevant to the whole group. A variety of pathological and non-pathological models have been proposed. Pathological models include ligament laxity, facet syndrome, discogenic pain, spondylosis and instability; non-pathological models include a pain–spasm–pain cycle, muscle inhibition and deconditioning and somatic dysfunction. All of these models are problematic and do not fully account for all of non-specific spinal pain. Another approach is to consider these two different approaches together and to consider this non-specific category as orthogonal dimensions of pathology and dysfunction. [ABSTRACT FROM AUTHOR]

Background: As the demographic profile of the UK changes, policy makers and practitioners have to respond to health challenges presented by a progressively ageing population. The health promotion plan for older people, aged over 50 years, in Wales included eight key areas: physical activity, healthy eating, home safety and warmth, emotional health, health protection, smoking, alcohol and sexual health. The aim of this study was to describe the extent, content and regional variation of existing health promotion initiatives for older people in Wales, provided by statutory, voluntary and private sector agencies. Method: A questionnaire was sent to senior health promotion specialists employed in the 22 local authority areas in Wales to ascertain details of all projects promoting health and wellbeing in the eight key areas where the priority population was aged over 50, or the majority of users were older people. Additional information was sought from project leads and websites. Results: Eighteen questionnaires were returned; not all were fully completed. Four areas did not return a questionnaire. Additional information was obtained from internet searches but this mainly concerned national initiatives rather than local projects. In all, 120 projects were included, 11 were throughout Wales. Best provision was for physical activity, with 3 national and 42 local initiatives, but local provision was patchy. Healthy eating, and home safety and warmth had far fewer initiatives, as did health protection, which comprised two national immunisation campaigns. Smoking and alcohol misuse were poorly provided for, and there was no provision for older people's sexual health. Evaluation arrangements were poorly described. Half of those who responded identified unmet training needs. Conclusion: The reasons for patchy provision of services were not clear. Increased efforts to improve the coverage of interventions known to be effective should be made. Rigorous evaluation of projects is needed to ascertain the most effective and appropriate interventions, especially for alcohol misuse and sexual health. These conclusions are relevant to the other countries of the United Kingdom (UK), and more widely across Europe. [ABSTRACT FROM AUTHOR]

Background Despite the health benefits of physical activity, most adults do not take the recommended amount of exercise. Aim To assess whether exercise-referral schemes are effective in improving exercise, participation in sedentary adults. Design of study Systematic review. Method Studies were identified by searching MEDLINE, ClNAHL, EMBASE, AMED, PsyclNFO, SPORTDiscus, The Cochrane Library and SIGLE until March 2007. Randomised controlled trials (RCTs), observational studies, process evaluations and qualitative studies of exercise-referral schemes, defined as referral by a primary care clinician to a programme that encouraged physical activity or exercise were included. RCT results were combined in a meta-analysis where there was sufficient homogeneity. Results Eighteen studies were included in the review. These comprised six RCTs, one non-randomised controlled study four observational studies six process evaluations and one qualitative study. In addition, two of the RCTs and two of the process evaluations incorporated a qualitative component. Results from five RCTs were combined in a meta-analysis. There was a statistically significant increase in the numbers of participants doing moderate exercise with a combined relative risk of 1.20 (95% confidence intervals = 1.06 to 1.35). This means that 17 sedentary adults would need to be referred for one to become moderately active. This small effect may be at Ieast partly due to poor rates of uptake and adherence to the exercise schemes. Conclusion Exercise-referral schemes have a small effect on increasing physical activity in sedentary people. The key challenge, if future exercise-referral schemes are to be commissioned by the NHS, is to increase uptake and improve adherence by addressing the barriers described in these studies. [ABSTRACT FROM AUTHOR]

Abstract: Osteopaths practise a physical method of treatment within a biopsychosocial model of illness. The most important risk factors for back and neck pain are psychosocial. Psychological treatments such as cognitive behavioural therapy, multidisciplinary rehabilitation and educational booklets have been successfully used to address these risk factors. Although osteopathy is a physical treatment, any reduction in distressing symptoms may have psychological benefits. To assess whether spinal manipulation was effective in improving psychological outcomes a systematic review of randomised controlled trials (RCTs) was carried out. The review identified 129 RCTs, 12 of which adequately reported psychological outcomes. The control interventions in these RCTs were grouped into either verbal or physical treatments. Six RCTs with a verbal comparator were combined in a meta-analysis and found that spinal manipulation improved psychological outcomes, with a mean benefit equivalent to 0.34 of the population standard deviation (SD) at 1–5months; 0.27 of the SD at 6–12months. Eight RCTs with a physical treatment comparator were combined in a meta-analysis and found a much smaller mean benefit of 0.13 of the SD in favour of manipulation at 1–5months; 0.11 of the SD at 6–12months. The nature of this psychological benefit was explored in one of these RCTs, which found that spinal manipulation improved back pain beliefs but not fear avoidance beliefs. The nature of this psychological benefit had also been explored previously in a qualitative study, which found that osteopathy patients reported improved understanding, reduced fear and a positive approach that encouraged exercise rather than rest. The psychological benefit could also be due to the placebo effect due to increased clinical contact, treatment preference, or the caring effect of the therapist. However, some authors argue that such effects are better described as part of the characteristic treatment effect of a complex intervention. If so, then the psychological benefits of spinal manipulation could be optimised by integrating cognitive behavioural principles into routine osteopathic practice. The benefits of such integrated care could be tested in future RCTs. [Copyright &y& Elsevier]

The article discusses the guidelines issued by Great Britain's National Institute for Health and Care Excellence for the prevention of frailty, disability, and dementia in mid-life and incorporating these recommendations into the routine primary care management of long-term conditions. Topics discussed include the effect of maintaining physical function on quality of life, the report Start Active, Stay Active on variation in physical function, and the medical model of illness.

The author discusses on adapting exercise therapy to individual need in patients with osteoarthritis of the hip or knee. He states that effects of concurrent disease should be considered during management of patients with Osteoarthritis (OA) of the hip or knee. He discusses on the restrictions to exercise therapy according to the International Classification of Functioning (ICF). He opines that the challenge will be to match ICF classification to flexible exercise protocol as per patient needs.

The article discusses a study of the feasibility of conducting a larger definitive randomised controlled trial (RCT) of the booklet "The Hip & Knee Book: Helping You Cope With Osteoarthritis." The study involved individuals more than 50 years of age with hip or knee osteoarthritis in North East Wales. Fourteen percent of patients in the control group demonstrate improved their physical activity level. Results showed the feasibility of the trial methods in terms of recruitment and follow-up.

The author reflects on the author reflects on the measurement of clinically important changes in patients who participate in randomized controlled research trials. He suggests that clinically important differences are useful for calculating sample sizes for trials and for interpreting the size of effect of interventions in trials. He argues that specifying a minimum worthwhile change in research trials is controversial and is dependent upon the context in which it is measured.

The author discusses the reliance on clinical findings by general practitioners rather than radiographic changes in diagnosis that may be used more often by medical specialists. He mentions the phenomenon of spectrum bias where the performance on a test changes if applied to differing sub-groups, which can be relevant to both diagnostic methods.

The article reflects on the appropriate treatment dealing with individuals diagnosed with osteoarthritis. It indicates the recommendation for physical activity which has been considered effective in reducing pain and disability in hip and knee osteoarthritis. Meanwhile, the author introduces "The Hip and Knee Book: helping you cope with osteoarthritis," which encourages patients to lose weight if overweight, and use simple analgesia and anti-inflammatory gels.

Background: UK cancer deaths remain high; primary care is key for earlier cancer diagnosis as half of avoidable delays occur here. Improvement is possible through lower referral thresholds, better guideline adherence, and better safety-netting systems. Few interventions target whole practice teams. We developed a novel whole-practice team intervention to address this., Aim: To test the feasibility and acceptability of a novel, complex behavioural intervention, 'ThinkCancer!', for assessment in a subsequent Phase III trial., Design & Setting: Pragmatic, superiority pilot randomised controlled trial (RCT) with an embedded process evaluation and feasibility economic analysis in Welsh general practices., Method: Clinical outcome data were collected from practices (the unit of randomisation). Practice characteristics and cancer safety-netting systems were assessed. Individual practice staff completed evaluation and feedback forms and qualitative interviews. The intervention was adapted and refined., Results: Trial recruitment and workshop deliveries took place between March 2020 and May 2021. Trial progression criteria for recruitment, intervention fidelity, and routine data collection were met. Staff-level fidelity, retention, and individual level data collection processes were reviewed and amended. Interviews highlighted positive participant views on all aspects of the intervention. All practices set out to liberalise referral thresholds appropriately, implement guidelines, and address safety-netting plans in detail., Conclusion: 'ThinkCancer!' appears feasible and acceptable. The new iteration of the workshops was completed and the Phase III trial has been funded to assess the effectiveness and cost-effectiveness of this novel professional behaviour change intervention. Delivery at scale to multiple practices will likely improve fidelity and reach., (Copyright © 2024, The Authors.)

Introduction: Chronic stable angina is common and disabling. Cardiac rehabilitation is routinely offered to people following myocardial infarction or revascularisation procedures and has the potential to help people with chronic stable angina. However, there is insufficient evidence of effectiveness and cost-effectiveness for its routine use in this patient group. The objectives of this study are to compare the effectiveness and cost-effectiveness of the 'Activate Your Heart' cardiac rehabilitation programme for people with chronic stable angina compared with usual care., Methods and Analysis: ACTIVATE is a multicentre, parallel-group, two-arm, superiority, pragmatic randomised controlled trial, with recruitment from primary and secondary care centres in England and Wales and a target sample size of 518 (1:1 allocation; allocation sequence by minimisation programme with built-in random element). The study uses secure web-based allocation concealment. The two treatments will be optimal usual care (control) and optimal usual care plus the 'Activate Your Heart' web-based cardiac rehabilitation programme (intervention). Outcome assessment and statistical analysis will be performed blinded; participants will be unblinded. Outcomes will be measured at baseline and at 6 and 12 months' follow-up. Primary outcome will be the UK version of Seattle Angina Questionnaire (SAQ-UK), physical limitations domain at 12 months' follow-up. Secondary outcomes will be the remaining two domains of SAQ-UK, dyspnoea, anxiety and depression, health utility, self-efficacy, physical activity and the incremental shuttle walk test. All safety events will be recorded, and serious adverse events assessed to determine whether they are related to the intervention and expected. Concurrent economic evaluation will be cost-utility analysis from health service perspective. An embedded process evaluation will determine the mechanisms and processes that explain the implementation and impacts of the cardiac rehabilitation programme., Ethics and Dissemination: North of Scotland National Health Service Research Ethics Committee approval, reference 21/NS/0115. Participants will provide written informed consent. Results will be disseminated by peer-reviewed publication., Trial Registration Number: ISRCTN10054455., Competing Interests: Competing interests: NW reports additional grants from NIHR HTA outside the submitted work and deputy chair of the NIHR HTA programme funding committee (commissioned research). DL reports additional grants from the NIHR outside the submitted work and investigator-initiated educational grants from BMS and Pfizer. DL has been a speaker for Bayer, Boehringer Ingelheim, and BMS/Pfizer and has consulted for BMS, and Boehringer Ingelheim; all outside the submitted work. GHYL has been a consultant and speaker for BMS/Pfizer, Medtronic, Boehringer Ingelheim and Daiichi-Sankyo. No fees were directly received personally. BC works part-time for Welsh Government outside of the submitted work. KJ was subcommittee chair of the NIHR Programme Grants for Applied Research until 2023. BH reports additional grants from the NIHR outside the submitted work and investigator-initiated grant from Novartis. All other authors declare no competing interests., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY. Published by BMJ.)

The optimal management of hypertension in individuals aged 80 years or older with frailty remains uncertain due to multiple gaps in evidence. Complex health issues, polypharmacy, and limited physiological reserve make responding to antihypertensive treatments unpredictable. Patients in this age group may have limited life expectancy, so their quality of life should be prioritized when making treatment decisions. Further research is needed to identify which patients would benefit from more relaxed blood pressure targets and which antihypertensive medications are preferable or should be avoided. A paradigm shift is required in attitudes towards treatment, placing equal emphasis on deprescribing and prescribing when optimizing care. This review discusses the current evidence on managing hypertension in individuals aged 80 years or older with frailty, but further research is essential to address the gaps in knowledge and improve the care of this population., (Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc.)

Introduction: Individuals with Long Covid represent a new and growing patient population. In England, fewer than 90 Long Covid clinics deliver assessment and treatment informed by NICE guidelines. However, a paucity of clinical trials or longitudinal cohort studies means that the epidemiology, clinical trajectory, healthcare utilisation and effectiveness of current Long Covid care are poorly documented, and that neither evidence-based treatments nor rehabilitation strategies exist. In addition, and in part due to pre-pandemic health inequalities, access to referral and care varies, and patient experience of the Long Covid care pathways can be poor. In a mixed methods study, we therefore aim to: (1) describe the usual healthcare, outcomes and resource utilisation of individuals with Long Covid; (2) assess the extent of inequalities in access to Long Covid care, and specifically to understand Long Covid patients' experiences of stigma and discrimination., Methods and Analysis: A mixed methods study will address our aims. Qualitative data collection from patients and health professionals will be achieved through surveys, interviews and focus group discussions, to understand their experience and document the function of clinics. A patient cohort study will provide an understanding of outcomes and costs of care. Accessible data will be further analysed to understand the nature of Long Covid, and the care received., Ethics and Dissemination: Ethical approval was obtained from South Central-Berkshire Research Ethics Committee (reference 303958). The dissemination plan will be decided by the patient and public involvement and engagement (PPIE) group members and study Co-Is, but will target 1) policy makers, and those responsible for commissioning and delivering Long Covid services, 2) patients and the public, and 3) academics., Competing Interests: HM has advised Axcella Health Inc on trial design in Long Covid; has consulted for AstraZeneca on monoclonal antibody use in acute covid prevention and treatment; and Millfield Medical in the development of a new CPAP machine. CvdF-C has no competing interests to declare. GYHL: Consultant and speaker for BMS/Pfizer, Boehringer Ingelheim and Daiichi-Sankyo. No fees are received personally.

Background: GPs can play an important role in achieving earlier cancer diagnosis to improve patient outcomes, for example through prompt use of the urgent suspected cancer referral pathway. Barriers to early diagnosis include individual practitioner variation in knowledge, attitudes, beliefs, professional expectations, and norms., Aim: This programme of work (Wales Interventions and Cancer Knowledge about Early Diagnosis [WICKED]) will develop a behaviour change intervention to expedite diagnosis through primary care and contribute to improved cancer outcomes., Design & Setting: Non-experimental mixed-method study with GPs and primary care practice teams from Wales., Method: Four work packages will inform the development of the behaviour change intervention. Work package 1 will identify relevant evidence-based interventions (systematic review of reviews) and will determine why interventions do or do not work, for whom, and in what circumstances (realist review). Work package 2 will assess cancer knowledge, attitudes, and behaviour of GPs, as well as primary care teams' perspectives on cancer referral and investigation (GP survey, discrete choice experiment [DCE], interviews, and focus groups). Work package 3 will synthesise findings from earlier work packages using the behaviour change wheel as an overarching theoretical framework to guide intervention development. Work package 4 will test the feasibility and acceptability of the intervention, and determine methods for measuring costs and effects of subsequent behaviour change in a randomised feasibility trial., Results: The findings will inform the design of a future effectiveness trial, with concurrent economic evaluation, aimed at earlier diagnosis., Conclusion: This comprehensive, evidence-based programme will develop a complex GP behaviour change intervention to expedite the diagnosis of symptomatic cancer, and may be applicable to countries with similar healthcare systems.

Objectives: To develop an evidence and theory-based complex intervention for improving outcomes in elderly patients following hip fracture., Design: Complex-intervention development (Medical Research Council (MRC) framework phase I) using realist literature review, surveys and focus groups of patients and rehabilitation teams., Setting: North Wales., Participants: Surveys of therapy managers (n=13), community and hospital-based physiotherapists (n=129) and occupational therapists (n=68) throughout the UK. Focus groups with patients (n=13), their carers (n=4) and members of the multidisciplinary rehabilitation teams in North Wales (n=13)., Results: The realist review provided understanding of how rehabilitation interventions work in the real-world context and three programme theories were developed: improving patient engagement by tailoring the intervention to individual needs; reducing fear of falling and improving self-efficacy to exercise and perform activities of daily living; and coordination of rehabilitation delivery. The survey provided context about usual rehabilitation practice; focus groups provided data on the experience, acceptability and feasibility of rehabilitation interventions. An intervention to enhance usual rehabilitation was developed to target these theory areas comprising: a physical component consisting of six additional therapy sessions; and a psychological component consisting of a workbook to enhance self-efficacy and a patient-held goal-setting diary for self-monitoring., Conclusions: A realist approach may have advantages in the development of evidence-based interventions and can be used in conjunction with other established methods to contribute to the development of potentially more effective interventions. A rehabilitation intervention was developed which can be tested in a future randomised controlled trial (MRC framework phases II and III)., Trial Registration Number: ISRCTN22464643, Pre-results., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)