Researchers and clinicians from York, Sheffield and Stirling developed and piloted a practical structured education programme for people with intermittent claudication that, via a 3-hour group-based workshop, provides participants with a range of information about their condition and promotes self-managed walking exercise.
The NICE guidance for lower limb peripheral arterial disease: diagnosis and management (CG147) recommends 'Offer all people with PAD, oral and written information about their condition. Discuss it with them so they can share decision-making, and understand the course of the disease and what they can do to help prevent disease progression' Recommendation 1.1.1.
Aims and objectives
1) To develop a practical structured education programme aimed at modifying illness perceptions and increasing walking activity in people with intermittent claudication.
2) To explore the suitability of the education programme for a full-scale clinical trial.
1) To recruit 25 people with intermittent claudication to participate in focus group sessions to inform the design of the education programme
2) To develop a structured education programme, styled on the DESMOND programme in diabetes care, which addresses the key information requirements of people with intermittent claudication and promotes self-managed walking
3) To practice delivering the education programme to at least groups of patients and health professionals
4) To conduct a pilot randomised controlled trial of the structured education programme versus usual care in people with intermittent claudication
5) To assess differences between groups in illness perceptions, walking behaviour, walking capacity and quality of life at 6 weeks of follow-up
6) To evaluate the feasibility of a full-scale trial in terms of recruitment, retention, compliance and acceptability
Reasons for implementing your project
- the causes of their symptoms and the severity of their disease
- the risks of limb loss and/or cardiovascular events associated with peripheral arterial disease
- the key modifiable risk factors, such as smoking, control of diabetes, hyperlipodaemia, diet, body weight and exercise (see also recommendation 1.2.1)
- how to manage pain
- all relevant treatment options, including the risks and benefits of each
- how they can access support for dealing with depression and anxiety
We used a structured education approach to help educate patients about their condition. This decision was taken because structured education programmes are recognised by NICE and widely adopted in the UK healthcare system, at least in the management of diabetes mellitus, and because there was experience within the team of designing and evaluating structured education programmes.
How did you implement the project
We developed and piloted a practical structured education programme called Structured EDucation for Rehabilitation in Intermittent Claudication (SEDRIC) that aims to modify illness perceptions and promote self-managed walking exercise in people with intermittent claudication. The programme involves a 3-hour group-based education workshop. Led by 2 trained educators, the workshop is typically attended by 6-10 patients and uses a written theory-driven curriculum. A person-centered philosophy underpins the approach taken by SEDRIC.
The workshop includes three key sections entitled "The Patient Story", "The Professional Story", and "Walking". The Patient Story section lasts approximately 30 minutes, during which patients share their thoughts about their condition (diagnosis, symptoms, causes, consequences, treatments, key questions). The Professional Story section lasts approximately 50 minutes, and covers several of the key information requires described by NICE (what is PAD and intermittent claudication, causes of pain, potential complications, risk factors). The Walking section lasts approximately 80 minutes. The content of this section includes the types and benefits of physical activity, physical activity guidelines for the general public and people with intermittent claudication, mechanisms of improved symptoms resulting from regular walking exercise, goal setting, action planning, self-monitoring strategies). The workshop is followed by a personal call to the patient after two weeks to review progress and discuss goal setting and barriers, with the aim of supporting maintenance of behaviour change
Compared with controls, the intervention group had superior walking capacity and disease-specific quality of life at 6 weeks of follow-up. The mean difference in 6-minute walking distance was 44.9 m (95% confidence interval [CI], 6.9 to 82.9). The mean difference in treadmill maximum walking distance was 173 m (95% CI, 23 to 322). The mean differences in WIQ speed and distance scores were 21.0 (95% CI, 3.8 to 38.1) and 30.7 (95% CI, 6.4 to 55.0), respectively. The mean difference in Intermittent Claudication Questionnaire score was -10.6 (95% CI, -18.9 to -2.3). There were no significant differences between groups at follow-up for accelerometer-measured daily steps (mean difference = 440 steps, 95% CI -827 to 1708), treadmill pain-free walking distance (mean difference = 61 m, 95% CI -7 to 129), and the EQ-5D utility score (mean difference = 0.05, 95% CI -0.09 to 0.19).
The exit interviews indicated that participants valued attending the SEDRIC workshop, that it provided them with a greater understanding of their condition, and that they had been walking for exercise more since attending. Selected quotes:
- "It's sort of, err, enlightened me to the fact that, err, walking is a good, err, you know, err, therapy for what I've got".
- "I liked everything. I thought the timing was perfect - they were very, very caring to myself, the people were very nice, I could ask him stuff, I could say anything - I felt as though I was being looked after".
- "The workshop was really good; it was well run, It was well paced, It worked for all of us".
Key learning points
The group-based approach with knowledgeable and empathetic facilitators appears to address a palpable need within this patient group for recognition and support. Further research is needed to determine long-term clinical and cost effectiveness.
The Bupa Foundation funded the project.