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A novel theory-based implementation intervention to increase prescription of inspiratory muscle training… Simms, Alanna Marie 2010

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A NOVEL THEORY-BASED IMPLEMENTATION INTERVENTION TO INCREASE PRESCRIPTION OF INSPIRATORY MUSCLE TRAINING FOR PEOPLE WITH CHRONIC OBSTRUCTIVE PULMONARY DISEASE  by  Alanna Marie Simms  B.Sc.PT., University of Toronto, 1998  A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF  MASTER OF SCIENCE in  THE FACULTY OF GRADUATE STUDIES (Rehabilitation Sciences)  THE UNIVERSITY OF BRITISH COLUMBIA (Vancouver)  December 2010  © Alanna Marie Simms, 2010  ABSTRACT INTRODUCTION: A number of implementation interventions are available to address existing gaps between research and practice; little is known about the effectiveness of these interventions among rehabilitation professionals. PURPOSE: To assess the effectiveness of a behavioural-based versus an information-based intervention for increasing health professionals‘ prescription of inspiratory muscle training (IMT) in the management of chronic obstructive pulmonary disease (COPD) in out-patient pulmonary rehabilitation. STUDY DESIGN: Single Blind, Randomized Clinical Trial METHODS AND MEASURES: We recruited a convenience sample of six hospital pulmonary rehabilitation programs in Canada. After being stratified by geographical location and type of facility, paired hospitals were randomly assigned to receive either a behaviouralbased or an information-based intervention. The behavioural-based intervention consisted of an interactive workshop, delivered by an expert in two 45 minute meetings, and provision of Threshold IMT devices. The first meeting included: 1) a summary of evidence for IMT in COPD; 2) prescription details for IMT; 3) skills practice. The second meeting was a semistructured problem solving session. The information-based intervention was a 90 minute didactic lecture on: 1) evidence for IMT in COPD; 2) prescription details for IMT, which was supplemented by copies of two recent, peer-review articles. Participants in both interventions received handouts detailing how to prescribe IMT for people with COPD and a handheld respiratory pressure meter (MicroRPM). The participants were 61 health professionals, the majority being physiotherapists and respiratory therapists, and 488 patients with COPD from the six hospital out-patient pulmonary rehabilitation programs. IMT  ii  prescription was the primary outcome. A multiple choice questionnaire, used to evaluate health professionals‘ knowledge on IMT for people with COPD, was a secondary outcome. Data were analyzed using Chi-square and Mann-Whitney U test. RESULTS: No patients with COPD were prescribed IMT in the participating sites during the 6-month pre-intervention phase. Prescription rates for IMT only increased in the behaviouralbased intervention group: 12 of 118 patients with COPD who attended pulmonary rehabilitation were prescribed IMT, which reflected a 10.2% increase (95% CI: 5.7-17.1%). CONCLUSION: A behavioural-based intervention appears to be more effective than a lecture approach to increase health professionals‘ prescription of IMT for people with COPD.  iii  PREFACE This research project was initiated by discussions between Dr. Dina Brooks, Dr. Lynn Geddes, Dr. Darlene Reid (co-supervisor), and Alison Hoens (committee member). Dr. Brooks, Dr. Geddes, Dr. Linda Li (co-supervisor), Dr. Reid, Alison Hoens, and Alanna Simms contributed to the final details of the research design and protocol. Alanna Simms played the primary role in the development of the behavioural-based implementation intervention. The research was performed by Dr. Reid and Alanna Simms. Data analysis was decided on collaboratively between Drs. Li and Reid, and Alanna Simms. Alanna Simms wrote two manuscripts which were revised primarily by Drs. Li and Reid.  A version of Chapter 2 has been accepted for publication as: Simms AM, Li LC, and Reid WD. Development of a theory-based intervention to increase prescription of inspiratory muscle training by health professionals in the management of chronic obstructive pulmonary disease. Physiotherapy Canada (in press). Simms AM was the primary author and played the principal role in the literature review and the design of the behavioural-based implementation intervention described in the paper. Li LC assisted with literature review and manuscript revision. Reid WD assisted with the literature review and manuscript revision.  A version of Chapter 3 will be submitted for publication as: Simms AM, Li LC, Geddes L, Brooks D, Hoens A, and Reid WD. A behavioural intervention increases prescription of inspiratory muscle training for people with chronic obstructive pulmonary disease.  iv  Simms AM was the primary author and assisted with the design of the research program, performance of the research, data analysis, and manuscript preparation. Li LC assisted with the design of the research program and manuscript revision. Brooks D assisted with the identification and design of the research program and manuscript revision. Geddes L assisted with the identification and design of the research program and manuscript revision. Hoens A assisted with the identification and design of the research program and manuscript revision. Reid WD developed the initial design of the research program as a submission for a grant application, implemented the intervention and contributed to data analysis, and manuscript revision.  Ethics approval was required for the research. Ethics approval was obtained. The UBC BREB Number is H06-80603.  v  TABLE OF CONTENTS Abstract ............................................................................................................................ ii Preface ............................................................................................................................. iv Table of Contents ............................................................................................................. vi List of Tables ................................................................................................................... ix List of Figures ....................................................................................................................x List of Abbreviations........................................................................................................ xi Acknowledgements ......................................................................................................... xii Dedication...................................................................................................................... xiii CHAPTER 1 – BACKGROUND TO THE STUDY ...........................................................1 Introduction ..............................................................................................................1 Chronic Obstructive Pulmonary Disease ..........................................................1 The Theory of Planned Behaviour ....................................................................4 Purpose .....................................................................................................................5 Aims ........................................................................................................................5 CHAPTER 2 – DEVELOPMENT OF A THEORY-BASED INTERVENTION TO INCREASE PRESCRIPTION OF INSPIRATORY MUSCLE TRAINING BY HEALTH PROFESSIONALS IN THE MANAGEMENT OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE .................................................................................................8 Introduction ..............................................................................................................8 Background............................................................................................................. 10 Barriers in Evidence-Based Practice in Physical Therapy ............................... 10 Individual Factors ................................................................................. 10  vi  Organizational Factors .......................................................................... 11 Research Related Factors ...................................................................... 12 From Knowledge to Action ............................................................................ 13 Using Theory to Inform Implementation Intervention Development ..... 15 Theory of Planned Behaviour ................................................................ 16 Development of a Theory-Based Intervention for IMT in COPD........... 17 Conclusion .............................................................................................................. 19 CHAPTER 3 – A BEHAVIOURAL INTERVENTION INCREASES PRESCRIPTION OF INSPIRATORY MUSCLE TRAINING FOR PEOPLE WITH CHRONIC OBSTRUCTIVE PULMONARY ............................................................................................................... 25 Introduction ............................................................................................................ 25 Methods .................................................................................................................. 27 Participants .................................................................................................... 27 Randomization ............................................................................................... 28 Blinding ......................................................................................................... 28 Interventions .................................................................................................. 29 Outcomes ....................................................................................................... 30 Primary Outcome .................................................................................. 30 Secondary Outcome .............................................................................. 30 Statistical Analysis ......................................................................................... 31 Results .................................................................................................................... 31 Characteristics of Health Professionals ........................................................... 31 Prescription of IMT to Patients with COPD before and after the Intervention . 31  vii  Health Professionals‘ Knowledge – Multiple Choice Questionnaires .............. 32 Discussion............................................................................................................... 32 Study Limitations ........................................................................................... 37 Conclusions ............................................................................................................ 38 Suppliers ................................................................................................................. 38 CHAPTER 4 – SUMMARY AND FUTURE DIRECTIONS ........................................... 45 Discussion............................................................................................................... 45 Limitations and Strengths of the Thesis Research Project ........................................ 47 Future Research Directions ..................................................................................... 51 Significance of the Study ........................................................................................ 52 Personal Reflection ................................................................................................. 52 REFERENCES ................................................................................................................ 57 Appendix A: Informed consent document ........................................................................ 65 Appendix B: Survey - Use and Knowledge of Inspiratory Muscle Training in the management of patients with Chronic Obstructive Pulmonary Disease ............................. 67 Appendix C: Behavioural-Based Group – Slide presentation ........................................... 71 Appendix D: Behavioural-Based Group Handout - How to Prescribe Inspiratory Muscle Training to People with COPD ......................................................................................... 75 Appendix E: Behavioural-Based Group Handout – Inspiratory Muscle Training Information Sheet ................................................................................................................................ 81 Appendix F: Behavioural-Based Group Session 2 Guide – Problem Solving Session ....... 83 Appendix G: Information-Based Group Slides – Inspiratory Muscle Training for Adults with Chronic Obstructive Pulmonary Disease: Evidence and Clinical Recommendations ......... 84 Appendix H: Information-Based Group Handout – How to Prescribe Inspiratory Muscle Training to People with COPD ......................................................................................... 92 Appendix I: Information-Based Group - List of Publications ............................................ 98 viii  LIST OF TABLES Table 1 Classification of Dyspnea and COPD .......................................................................6 Table 2 Evolution of Systematic Reviews and Practice Guidelines on the use of Inspiratory Muscle Training in Chronic Obstructive Pulmonary Disease reprinted with permission of Physiotherapy Canada ......................................................................................................... 21 Table 3 The Theory of Planned Behaviour Applied to Health Professionals' Prescription of Inspiratory Muscle Training for People with Chronic Obstructive Pulmonary Disease reprinted with permission from Physiotherapy Canada ........................................................ 22 Table 4 Protocol and Comparison of Behavioural-based and Information-based Intervention ........................................................................................................................................... 39 Table 5 Multiple Choice Questionnaire ............................................................................... 40 Table 6 Demographic Characteristics of the Behavioural-based and Information-based Intervention groups ............................................................................................................. 41 Table 7 Analysis by Patient Count ....................................................................................... 42 Table 8 Mapping Our Research Process Using The Design Process to Improve Quality of Care Proposed by Van Bokhoven, Kok and Van Der Weijden84 .......................................... 54 Table 9 The Strengths and Limitations of Performing the Randomization at the Patient, Health Professionals, Centre, and City Levels ..................................................................... 55 Table 10 Evaluation of Feasibility Criteria .......................................................................... 56  ix  LIST OF FIGURES Figure 1 The Theory of Planned Behaviour as proposed by Ajzen (adapted from University of Massachusetts, Department of Psychology. TPB model) 21................................................7 Figure 2 The Theory of Planned Behaviour (adapted from Eccles, Hrisos, Francis, Steen, Bosch and Johnston)66 ......................................................................................................... 24 Figure 3 Behavioural-based interventions for improving IMT prescription, guided by the Theory of Planned Behaviour .............................................................................................. 43 Figure 4 Study Flow Chart ................................................................................................. 44  x  LIST OF ABBREVIATIONS CI: confidence interval COPD: chronic obstructive pulmonary disease CTS: Canadian Thoracic Society EBP: evidence based practice GOLD: Global initiative for Chronic Obstructive Lung Disease ICC: intracluster correlation coefficient IMT: inspiratory muscle training MIP: maximal inspiratory pressure MRC: Medical Research Council PT: physical therapist RCT: randomized control trial TPB: Theory of Planned Behaviour UBC: University of British Columbia US: United States  xi  ACKNOWLEDGEMENTS I would like to express my sincere thanks to my thesis supervisors, Drs. Darlene Reid and Linda Li, for helping me seek new knowledge. Your energy, encouragement, support, and mentorship allowed me to complete this thesis. Over the past four years, you were both very patient and understanding as I juggled the commitment to studies, the birth of 2 babies, work, moving, and home renovations. Your continuing confidence has allowed me to become a better clinician and budding researcher. I would also like to acknowledge Alison Hoens, thesis committee member, for ability to offer new insights through her thoughtful questions and provision of journal articles. You expanded my thinking and served as wonderful role model of a clinician researcher. I would like to acknowledge Drs. Lynn Geddes and Dina Brooks for their input into the design of the study and development of study materials as well as valuable feedback on manuscripts. I would like to acknowledge the assistance of the research assistants Jen Rurak, Jenny Ying, for your assistance with completing ethics approval forms, data input, and preparation of figures. I would like to acknowledge Dr. Jonathan Berkowitz for providing expertise in statistical analysis. I would like to acknowledge the Canadian Lung Association for partial funding of this work. I would like to thank the six hospital site coordinators and the many health care professionals who participated in this research project and donated their own valuable time. I would like to extend a very special thank-you to my husband, Kenny Simms, for your support of my academic program. As well to my friend, Greta Sproule, and the staff at the North Okanagan Child Care Centre, for the loving care they provided to my children while I was working to better myself.  xii  DEDICATION This thesis is dedicated to my children, Kora and Cadel. The family, work, school, and play balance was difficult to achieve at times. It was not easy to miss moments with you while working on this thesis. I took comfort in knowing others were enriching your lives with language, reading, arts and crafts, music, physical activity, and play. I hope one day you will appreciate my drive to improve my knowledge, myself. I love you. I would also like to dedicate this thesis to my parents. Thank you for supporting my education in many ways over all these years. I love you too.  xiii  CHAPTER 1 BACKGROUND TO THE STUDY This thesis is organized following the instructions for a Master‘s thesis at the University of British Columbia. Chapter 1 presents an overview of literature relevant to the study. Chapter 2 outlines the development of the behavioural-based implementation intervention in the form of a manuscript that has been accepted for publication; Chapter 3 presents the study in the form of a manuscript that will be submitted for publication; and Chapter 4 discusses the implications of the study and what was learned in the research process.  Introduction Chronic Obstructive Pulmonary Disease Chronic obstructive pulmonary disease (COPD) is a preventable and treatable disease1, 2 affecting as many as 3 million Canadians including about a quarter million British Columbians.3 COPD, which includes small airway disease (chronic bronchitis) and parenchymal destruction (emphysema), is a progressive debilitating lung disease that is usually caused by smoking.2 COPD is characterized by progressive, partially reversible airflow limitation, systemic manifestations, and recurrent exacerbations.1 Post bronchodilator spirometry is the ‗gold standard‘ for evaluating the presence and severity of airflow limitation (Table 1).1, 2 Acute exacerbations of COPD are associated with one of the longest lengths of hospital stays, thereby placing a huge financial burden on the Canadian health care system; the total cost of COPD in 1998 was $1.67 billion (Canadian).1 In the United States, in 2002, the direct and indirect costs of COPD totaled $18 billion (US) and 14.1 billion (US) respectively.2 The Global Burden of Disease Study has predicted that COPD will become the third leading cause of death worldwide by 2020.2  1  The major pathophysiology of COPD is airflow obstruction which causes poor gas exchange, increases the work of breathing, and leads to many systemic sequelae including poor skeletal muscle function.1 As a result, considerable physical and psychosocial impairment occurs as reflected by decreased fitness, functional capacity, and ability to work.1 Functionally, people with COPD present with breathlessness, limitation in ability to do daily activities and ultimately, decreased quality of life.1,2 One of the most common COPD symptoms that limits activities and exercise is dyspnea.1 The relationship among dyspnea, respiratory muscle dysfunction, and exercise intolerance is unclear.4 Inspiratory muscle training (IMT) has been defined as any intervention with the goal of training the inspiratory muscles; the 3 main types of IMT are threshold, targeted inspiratory resistive, and normocapneic hyperventilation.5 Due to the impact of IMT on increasing inspiratory muscle strength and decreasing dyspnea, some patients with COPD may benefit from IMT.5-7 The results of over 20 studies that investigated the effect of IMT in COPD have been reported in recent systematic reviews.5-7 Meta-analyses provide evidence that IMT, when applied in isolation, to patients with moderate-to-severe COPD, results in large reductions in dyspnea5, 6 and may also confer an increase in functional exercise capacity. 5 Furthermore, combined IMT and exercise versus exercise alone demonstrated additional gains in inspiratory muscle strength and an outcome of exercise tolerance but not in dyspnea, health related quality of life, or exercise capacity. 7 Therefore, IMT should be considered for people with COPD who are unable to participate fully in whole body exercise or those who have intractable dyspnea despite completing whole body exercise. 8 However, the disparity in training loads, modalities, and outcome measures used in the different studies has made translating and applying the findings into clinical practice challenging. Reid et al.9 and Geddes et al.10 provided guidelines for prescription of threshold or targeted inspiratory resistive training. Reid et al.9 recommended the following parameters 2  for IMT in COPD: an initial training interval of as short as three to five minutes, progressing to two 15 minute or one 30 minute session(s) per day, four to six days per week at a training intensity of 40 - 70% maximal inspiratory pressure (MIP) indefinitely. Whereas, Geddes et al.10 recommended the following parameters for IMT in COPD: a training interval of 30 minutes that can be spread over more than one session per day, at least five days per week at a training intensity of 22% - 60% MIP. Furthermore, Reid et al.9 outlined methods to obtain a reliable measure of MIP, safety precautions such as measuring vitals and monitoring for signs and symptoms of respiratory distress or inability to tolerate exercise load, and means for evaluating clinical improvement by measuring inspiratory muscle strength and endurance as these parameters change little in response to other therapies. More recently, Hill et al.8 provided recommendations for patient selection and safety, patient assessment pre and post program, training with an interval-based high intensity threshold IMT program, reassessment, and a maintenance training program. Despite the evidence supporting the use of IMT5-7 and the practical guidelines available,8-10 fewer than 5% of physical therapists working in acute care hospitals and pulmonary rehabilitation programs in Canada prescribe IMT for COPD rehabilitation.11 To our knowledge, information about IMT has been traditionally disseminated to health professionals through didactic lectures and journal articles, with the goal of improving the health professionals‘ knowledge about the treatment. However, these dissemination methods are limited in their ability to address other known barriers to using IMT, such as health professionals‘ uncertainties about the appropriateness of the treatment for their clients, a lack of equipment, and the perceived deficiency of reliable evidence about IMT. 11 Implementation interventions can be defined as interventions that put an innovation or research into practice.12 In the past 20 years, a number of implementation interventions, including educational meetings13, have been developed and evaluated in health care. An 3  important consideration in designing implementation interventions is how to obtain behavioural change among health care professionals. Some advocate the use of behavioural theory in designing implementation interventions.14 One of the more commonly used theories that underpin implementation strategies is the Theory of Planned Behaviour (TPB)15 that focuses on factors that influence behavioural change. Investigators report that theories, such as the TPB, are useful to guide the design of implementation studies because they provide a foundation to select study variables, to aid in the formation of hypotheses, to direct development of behaviour change elements, to interpret findings, and to generalize findings across contexts.16-19 The Theory of Planned Behaviour The TPB, an extension of the theory of reasoned action developed by Fishbein and Ajzen, outlines the factors that determine a person‘s decision to follow a particular behaviour.20 The TPB (Figure 1 adapted from University of Massachusetts, Department of Psychology. TPB model.21 ) postulates that the proximal determinants of behaviour are an individual‘s intention to perform the behaviour and the degree of actual control they have over that behaviour. Intentions represent an individual‘s motivation or conscious decision to exert effort to perform the behaviour. 20 According to the TPB, the strength of one‘s intention is determined by: 1) their positive or negative evaluation of the behaviour (attitude); 2) their perceptions about how significant others view the behaviour and whether these views are important to the person (subjective norm); and 3) their perception of whether they have the skills, resources, and opportunities to perform the behaviour (perceived behavioural control).20 These variables are respectively based upon three beliefs: perceived consequences of performance of the behaviour (behavioural beliefs), perceptions of important others‘ preferences about whether one should or should not engage in a behaviour  4  (normative beliefs) and perceptions of internal and external factors likely to aid or impede the performance of the behaviour (control beliefs). The TPB has been widely used to predict individual behaviour 22 and has been one of the theories most often used when exploring the determinants of professional behaviour. 15 The TPB has explained 31% of the variance in health professionals‘ clinical behaviours;15 intentions explaining 28% of the variance of behaviour should be considered ‗good‘.23 Given the TPB‘s ability to predict intention and behaviour (Chapter 2 provides more detail), we believe that it may provide a strong model to inform the development of an implementation intervention to improve health professional practice, namely, increased prescription of IMT in the management of COPD in out-patient pulmonary rehabilitation settings. Purpose The purpose of this study was to compare the effectiveness of a behavioural-based implementation intervention versus an information-based implementation intervention for increasing health professionals‘ prescription of IMT in the management of COPD in outpatient pulmonary rehabilitation settings. Aims The specific aims were to: 1. Assess the change in the prescription rate of IMT six months after the delivery of the behavioural-based implementation intervention 2. Assess the change in the prescription rate of IMT six months after delivery of the information-based implementation intervention 3. Compare the change in prescription rate of IMT between the behavioural-based and information-based group six months after the delivery of the respective implementation interventions  5  Table 1 Classification of Dyspnea and COPD Classification of Dyspnea and COPD by Symptoms and Disability and Impairment of Lung Function 1 MRC Dyspnea Scale Grade Description Stage 1 Breathless with strenuous exercise Stage 2  Short of breath when hurrying on the level or walking a slight hill  Stage 3  Walks slower than people of the same age on the level or stops for breath while walking at own pace on the level  Stage 4  Stops for breath after walking 100 yards  Stage 5  To breathless to leave the house or breathless when dressing  COPD stage Mild  CTS classification of COPD by symptoms and disability1 Symptoms Shortness of breath from COPD when walking on the level or hurrying up a slight hill (MRC2)  Moderate  Shortness of breath from COPD causing the patient to stop after walking approximately 100 metres (or after a few minutes on the level (MRC 3 to 4)  Severe  Shortness of breath from COPD resulting in the patient being too breathless to leave the house, breathless when dressing or undressing (MRC 5) or the presence of chronic respiratory failure or clinical signs of right heart failure  GOLD Classification of COPD Severity Based on Impairment of Lung Function 2 COPD Stage Spirometry (Post-Bronchodilator) Stage I: Mild FEV1/FVC < 0.70 FEV1 ≥ 80% predicted Stage II: Moderate FEV1/FVC <0.70 50% ≤ FEV1 < 80% predicted Stage III: Severe FEV1/FVC < 0.70 30% ≤ FEV1 < 50% predicted Stage IV: Very Severe FEV1/FVC < 0.70 FEV1 < 30% predicted or FEV1 < 50% predicted plus chronic respiratory failure  Abbreviations: GOLD, Global Initiative for Chronic Obstructive Lung Disease; COPD, Chronic Obstructive Pulmonary Disease; MRC, Medical Research Council; CTS, Canadian Thoracic Society  6  Figure 1 The Theory of Planned Behaviour as proposed by Ajzen (adapted from University of Massachusetts, Department of Psychology. TPB model) 21  7  CHAPTER 2 DEVELOPMENT OF A THEORY-BASED INTERVENTION TO INCREASE PRESCRIPTION OF INSPIRATORY MUSCLE TRAINING BY HEALTH PROFESSIONALS IN THE MANAGEMENT OF PEOPLE WITH CHRONIC OBSTUCTIVE PULMONARY DISEASE*  Introduction The switch from opinion-based practice to evidence-based practice (EBP) gained momentum in the early 1990s. For nearly two decades, clinicians have been encouraged to embrace EBP in which treatment decisions are made by integrating the best available evidence with clinical expertise and patient preference.24 Studies from Australia,25, 26 England,26 Sweden,27 the United States28, 29 and Canada30 have shown that physical therapists (PTs) have a positive attitude towards EBP, but this does not always translate into practice. For example, a variety of studies 5-7 have supported the use of inspiratory muscle training (IMT) for some people with chronic obstructive pulmonary disease (COPD); such as those who are unable to participate fully in whole-body exercise training because of comorbid conditions or those that have intractable dyspnea despite completing whole-body exercise.8 However, a survey of Canadian acute care hospitals and pulmonary rehabilitation programs found that fewer than 5% of PTs prescribe IMT for COPD rehabilitation.11 To our knowledge, information about IMT has been traditionally disseminated to PTs through didactic lectures and journal articles, with the goal of improving the clinician‘s knowledge about the treatment. However, these dissemination methods are limited in their ability to address other known barriers to using IMT, such as PTs‘ uncertainties about the  *  A version of this chapter has been accepted for publication as: Simms AM, Li LC, and Reid WD. Development of a theory-based intervention to increase prescription of inspiratory muscle training by health professionals in the management of people with chronic obstructive pulmonary disease. Physiotherapy Canada  8  appropriateness of the treatment for their clients, a lack of equipment, and the perceived deficiency of reliable evidence about IMT. 11 Implementation interventions in health care focus on the application or uptake of research.12 A number of interventions that aim to change practice behaviours — for example, the use of reminders, audit and feedback, and opinion leaders — have been evaluated in the management of different conditions; they produced a median improvement of 7% to 14% in patient outcomes.19, 31, 32 There is no clear pattern of findings favouring one particular method, or the context in which the intervention is effective. 19 Literature has suggested that this may be due to the lack of a theoretical basis for most interventions that are developed to improve practice behaviours.14, 16 Proponents of this view argue that social cognitive theories offer a generalizable framework to understand and predict practice behaviours, 15, 33, 34 and therefore, they can be used to guide the development of interventions for improving clinical practice, such as using IMT in the management of COPD. The purpose of this paper is two-fold. First, we provide an overview of the literature on the barriers to evidence-based practice and the effectiveness of implementation interventions in healthcare. A secondary purpose was to outline the development of a theorybased intervention to improve health professionals‘ prescription of IMT in the management of COPD based on the literature review. We have selected IMT to illustrate how a theorybased intervention can be designed to increase prescription of a specific muscle training program for two reasons: (1) IMT is inexpensive, easy to apply, and low-risk; and (2) the evidence supporting IMT is strong especially regarding outcomes of maximal inspiratory pressure, an indicator of inspiratory muscle strength, which is specific to IMT and not to exercise training of the extremities. The main target audience of this theory-based intervention is PTs, but we anticipate that the discussion will also be relevant to other health professionals in the cardiorespiratory field. 9  Background Barriers to Evidence-based Practice in Physical Therapy Evidence-based practice involves several steps: define the clinical question; acquire the best available evidence; evaluate the strength of the evidence; apply the evidence integrating clinical expertise and patient values; and assess the effectiveness of the process. 25, 35, 36  The literature 25-28, 36-41 suggests that the existing gaps between evidence and practice are  indeed the result of a combination of barriers that are related to the individual, the practice environment and the clarity of the messages about the effectiveness of a treatment. Individual factors Most PTs have a positive attitude towards EBP,25, 27, 28, 30 but the literature reveals a number of barriers. Although 97% of PTs from Canada30 and 89% of PTs from the United States28 reported being interested in research, therapists report barriers to finding, evaluating and implementing current medical findings into practice. The percentage of PTs that performed fewer than two database searches in a typical month was 65% in the US28 and 62% in Canada.42 It would appear that some Canadian PTs delegated the searching task to others.43 In the United Kingdom, although 95% of PTs were interested in research findings, almost four out of 10 indicated that locating and reading research evidence was a low priority in their daily practice.38 In the US28 and Canada,42 17% and 27% of PTs read fewer than two articles per month, respectively. The vast majority (90%) of Canadian PTs studied agreed that they needed to increase the use of evidence in their daily practice. 30 These findings bring to mind that some PTs might rely on colleagues, textbooks and/or techniques learned from their initial training to inform their clinical practice rather than reading scientific journals.26, 28, 37, 39, 40  Another barrier to EBP is the lack of skills and resources to access the current and relevant research.25, 28 In fact, skills in accessing online information, rather than the size and 10  location of the workplace, are related to research use. 37 Furthermore, PTs who are not affiliated with a university or teaching hospital might not have free and ready access to some scientific journals. Therapists‘ level of knowledge and skill in understanding research are also associated with their use of research evidence in clinical practice. For example, a study by Pain et al.37 found that although most PTs in Canada had some training in research, few were confident about understanding research design and statistics, and interpreting research findings. Similarly, in a later survey of Canadian PTs by Salbach et al.,30 the average self-efficacy ratings for the items ‗critically appraising the strengths and weaknesses of different study designs’ and ‗interpreting statistical procedures like t tests and chi-square tests‘ was 52% and 31%, respectively. The limited ability of some PTs to critically appraise research evidence may contribute to a failure to recognize an effective treatment despite evidence of its effectiveness, as in the case of IMT. Organizational factors Time constraints, often resulting from high workload, are frequently cited as a barrier to acquiring, evaluating and applying evidence in clinical practice. 25, 27, 28, 30, 38-40 Interestingly, in contrast to habitual practice, therapists tended to rely on research information when changing an overall pattern of treatment for a specific group of patients. 37 The underlying reasons, which require further study, may include whether organizations provide additional or protected time to gather information that is relevant to program alterations. Other organizational barriers identified in the previous research include inadequate facilities,38 being isolated from colleagues,38 a lack of support for the new practice from physicians,38 limited resources for the necessary equipment,40 and cumbersome administrative rules for approving new procedures.40 Finally, for those working in a 11  multidisciplinary team, reluctance to use the technique on the part of the colleagues and/or other members of the health care team‘s can also represent a barrier to changing clinical practice.40 These findings suggest that the availability of learning resources (e.g., time at work, funding and opportunities), proper equipment and a supportive practice environment are essential for facilitating the adoption of IMT in clinical practice. Research-related factors The quality of research and the presentation of information may present a barrier to evidence-based practice. Several commonly noted problems include conflicting results 38 and methodological constraints or flaws in the published research28, 30, 38, 41 Furthermore, published studies may provide insufficient details about the characteristics of the target population and the treatment, making it difficult for clinicians to replicate or adapt the treatment in their own practice. 41 In the case of IMT in COPD management, findings on the effectiveness of IMT from earlier studies are contradictory, but several of these studies had methodological issues. For example, some studies using inspiratory resistance trainers with holes of varying diameters did not control the pattern of breathing during the IMT or provide a target for flow; in these studies, the training protocol was likely sub-optimal.44-46 Nonetheless, these papers were included in the first published systematic review, which concluded that IMT was ineffective for people with COPD. 47 This conclusion, however, was refuted by several later systematic reviews. 5-7 For example, Geddes et al.5 accounted for studies with methodological differences by examining threshold and targeted trainers separately from inspiratory resistive trainers with no target and concluded that normocapneic hyperventilation, targeted inspiratory resistive, or threshold IMT significant increased inspiratory muscle strength and endurance compared to sham IMT (Table 2). The conflicting messages from the literature might have contributed to the confusion among PTs with respect 12  to this intervention (Table 2). Furthermore, gaps between the evidence for effectiveness of IMT and prioritized therapies outlined in practice guidelines for COPD management 1, 48, 49 might be an additional barrier to PTs‘ use of IMT in clinical practice (Table 2). Another factor is related to the applicability of the research findings to a PT‘s patient population. In Canada, COPD affects more women (5 %) than men (4%);50 whereas, Geddes et al.10 noted that most of the studies reviewed recruited men and that confirmation of the effectiveness of IMT in both genders is needed. Physical therapists frequently complain that the literature contains insufficient treatment details,41 but this is not the case for the use of IMT in COPD. Though the optimal IMT prescription to maximize outcomes for people with COPD is not yet known, 7 two systematic reviews10, 51 include training guidelines on mode, frequency, intensity and duration of IMT. Furthermore, several other papers4, 9, 52, 53 describe the equipment, training protocols and clinically relevant outcome measures. In summary, barriers to evidence-based physical therapy practice may exist at the research, organizational, and individual levels, some of which may be associated with the poor uptake of IMT in COPD. To develop an intervention to address barriers in the use of IMT, we reviewed the research on the effectiveness of dissemination and implementation interventions. From Knowledge to Action In the last 15 years, a number of interventions based on research evidence have been developed to change professional behaviour, but most of them were developed and tested in the medical profession.13, 19, 31, 32 Furthermore, there is no consensus on which interventions are the most effective. A recent Cochrane review on educational meetings concluded that didactic education can change practice (median adjusted risk difference 7%) but meetings that are partially or largely interactive are more effective (median adjusted risk difference 13  14% ).13 The best design for educational meetings with respect to group sizes, the length of sessions, the opportunity to practice the new skills, or involving learners in the design of the intervention remains ambiguous.13, 54 Strategies that increase attendance to meetings and educational sessions that focus on issues that are perceived as serious may increase the effectiveness of educational meetings.13 Studies on single-guideline dissemination/implementation interventions have also shown improvement in clinicians‘ practice behaviours, with an average effect size of about 10%, and revealed that multifaceted interventions that address the same attributes (e.g., knowledge and skills of the practitioner) do not necessarily improve clinical outcomes. 19 The findings of similar effects for multifaceted and single interventions are consistent with the results of others.13, 55 A systematic review reported that active multi-component knowledge translation interventions were effective for improving knowledge or changing practice behaviours of PTs, however, very few studies were available to include in this review. 56 Among implementation interventions, printed educational materials, education outreach visits and the use of opinion leaders have attracted attention in the clinical community. A Cochrane review concluded that when compared to no intervention, printed educational materials alone may have a beneficial effect on process outcomes (e.g. x-ray requests) but not patient outcomes.57 How effective printed educational materials are compared to other interventions and how to optimize educational materials is uncertain. 57 A review of educational outreach visits, also referred to as ―university-based educational detailing‖, ―academic detailing‖ or ―educational visiting‖, concluded that these visits, either alone or when combined with other interventions, produced changes in clinical practice (median adjusted risk difference in compliance desired practice was 6%).31 Doumit et al.32 concluded that interventions using opinion leaders reduced non-compliance with desired  14  practice in health professionals (10% absolute decrease), although little is known about the factors associated with the success of this intervention. A recent review reported that interventions tailored to address prospectively identified barriers to change are more likely to improve professional practice than either no intervention or dissemination of guidelines or educational materials alone. Whether this approach is more effective compared to other interventions with demonstrated effects, such as opinion leaders, is undetermined.58 Many unanswered queries with respect to interventions that target barriers and their relative effectiveness compared to other interventions or in varied clinical situations require further study. 58 In summary, research in implementation interventions has shown promise for improving clinical practice, but the mechanism of these interventions is not always clear, and so it is challenging to judge their generalizability to other health professional groups and settings. Because some of the factors that affect individual behaviours (e.g., attitude, knowledge) also affect professionals‘ behaviours, some argue in favour of using welldeveloped behavioural theories to inform the development of implementation interventions.14, 16, 18, 19 Using Theory to Inform Implementation Intervention Development A number of theories formulated to explain why people change their behaviour have been used in the development of implementation interventions to modify health care practice.15 It has been suggested that behavioural theories are relevant for developing health care interventions directed at individuals and teams.19, 59 Few studies, however, have performed head-to-head comparisons of different theoretical approaches15, 19 and so it is not clear whether any one should be given primacy when designing an implementation intervention.60 One of the more commonly used theories that underpin implementation strategies is the TPB. Investigators report that theories, such as the TPB, are useful to guide 15  the selection of variables for study, to aid in the formation of hypotheses, to direct development of behaviour change elements, to interpret findings, and to generalize findings across contexts.16-19 However, the advantage of behavioural-based implementation interventions compared to common sense derived interventions is a contentious issue18, 61 because of the lack of head-to-head comparisons. Theory of Planned Behaviour The TPB, an extension of the theory of reasoned action developed by Fishbein and Ajzen, outlines the factors that determine a person‘s decision to follow a particular behaviour.20 According to the TPB (Figure 2 adapted from University of Massachusetts, Department of Psychology. TPB model. 21) an individual‘s intention to perform a behaviour is determined by his or her: 1) positive or negative evaluation of the behaviour and the outcome of the evaluation (attitude); 2) beliefs about whether significant others value the behaviour and motivation to comply with the significant other (subjective norm); and 3) perception of whether performing the behaviour is easy or difficult based on the availability of resources, opportunities, and specialized skills (perceived behavioural control). 20 With actual control over the behaviour and strong intention, there is a greater probability that the action of the behaviour (e.g. prescribing IMT for some people with COPD) will occur. The TPB has widespread applicability and utility in understanding behaviour change.20 Meta-analyses have demonstrated that the TPB is useful to predict behaviour change related to health.20 For example, TPB-based health behaviour interventions found that attitude, subjective norm, and perceived behavioural control explain 34% of the variance in intention; whereas, intention and perceived behavioural control explain 26% of variance in behaviour.20 In reference to health professionals‘ behaviours, the predictive power of studies using the TPB was significantly better than studies using another behavioural theory, the Operant Learning Theory; the TPB explained 59% and 31% of the variance in health 16  professionals‘ clinical intention and behaviours, respectively. 15 Given the TPB‘s ability to predict intention and behaviour, we believe that it may provide a strong model to inform the development of an implementation intervention to improve health professional practice. Development of a Theory-based Intervention for IMT in COPD The TPB is not only a predictive model, but also provides a framework for developing strategies to change behaviour. 62 One should carefully define the behaviour under study.63 As recommended by Francis et al.,63 we defined the behaviour of interest in terms of target, action, and context such that the aim of our intervention is to target health care professionals in their prescribing IMT to people with COPD in the context of out-patient pulmonary rehabilitation programs. It is also important to determine which variables should be targeted.20 Beliefs identified through the current literature review of barriers to EBP, and barriers specific to IMT use, were categorized as behavioural, normative, and/or control beliefs. For example, perception of lack of equipment was classified as relating to control beliefs; whereas the perceived lack of support for the new practice from physicians fell under normative beliefs. Based on this review and the previous TPB studies of health behaviour, we determined the primary cognitive targets20 to be attitude (via behavioural beliefs) and perceived behavioural control (via control beliefs) (Table 3) whereas subjective norm (via normative beliefs) was deemed a minor construct. Cognitions can be changed by identifying new beliefs or changing existing beliefs; there is no set way to accomplish this task. 20 Ajzen, the social psychologist who developed the TPB model, suggests that the intervention should be informed by the investigator‘s experience and creativity and may include persuasive communication, face-to-face discussions, observational modeling, or other methods.64 Moreover, Michie et al.,16, 17 through expert consensus, identified techniques that may be effective in targeting 11 behaviour change domains, including beliefs about consequences and beliefs about capabilities, which respectively include the TPB constructs of attitude and 17  perceived behavioural control. We will employ a number of techniques to influence attitude, subjective norm, and perceived behavioral control. Table 3 outlines the main barriers to the uptake of IMT, the TPB constructs related to said barriers, the type of interventions we would select to modify or introduce beliefs, and the rationale for the choice of the intervention. Implementation would be informed by one‘s experience and creativity as suggested by Ajzen64 but also by the aforementioned reviews of continuing medical education65 and implementation interventions.19, 31, 32 Given that multifaceted implementation interventions are no better than a single intervention, 19 the latter will be chosen to minimize costs. Specifically, an expert on IMT in COPD (a researcher who has published in peer-reviewed journals on this topic) will deliver an interactive workshop to a small group of health professionals (< 25) in two 45-minute sessions. The first session will include an oral presentation supplemented by slides and printed materials, as well as a skill practice time with feedback. The second session, as outlined in Table 4, will be a semi-structured problemsolving session. An interactive workshop will be conducted because it was found to be effective in previous research.13 It is our belief that a small group facilitate development of skills and beliefs about capabilities. The group will be multidisciplinary and will receive a referenced, 1-page summary of evidence for use of IMT in COPD, which may be used to solicit support physicians or co-workers; these two elements may address barriers related to subjective norm. Furthermore, given that the optimal continuing education session length is still moot,13 relatively short sessions will be chosen to reflect the time constraints that are frequently cited as a barrier to EBP.25, 27, 28, 30, 38-40 An expert, as a credible source for arguments in favour of the behaviour, 17 was chosen over a local opinion leader because the identification of opinion leaders is problematic and often labour intensive.32 Furthermore, more studies are required to indentify which variables, such as personal and professional 18  attributes, training, and educational methods, are associated with the effectiveness of opinion leaders.32 In summary, a number of behaviour change techniques will be delivered to influence important predictors of health professional behaviour, attitude, subjective norm, and perceived behavioural control, in order to increase prescription of IMT to people with COPD by health professionals in pulmonary rehabilitation programs. According to the TPB, changing these predictors may increase the chance that a health professional will intend to prescribe IMT in COPD rehabilitation, and thereby increase the chance of the health care professional actually performing this behaviour. A limitation of this theory-informed design is that we used the literature about the barriers to EBP, and more specifically to IMT, to inform the selection of target variables rather than a TPB questionnaire. To avoid assumptions about the behavioural change processes responsible for any observed change, Ajzen, 64 Francis63 and others advocate the use of a structured questionnaire to identify barrier variables that need to be addressed by the intervention. In order to advance implementation science, a TPB questionnaire should be developed and administered alongside a large, definitive, cluster, randomized controlled trial to determine not only which health professional beliefs to target with respect to IMT in COPD but also whether the targeted beliefs changed as a result of the implementation intervention, to allow us to understand the mechanism of behavioural change. Conclusion In this paper we reviewed the barriers to evidence-based physical therapy practice and discussed them in the context of using IMT in the management of COPD. We have presented the current evidence on implementation interventions and contend that the TPB provides a strong foundation to inform the development of an intervention to improve the use  19  of IMT in clinical practice. Further research will be needed to evaluate the feasibility (whether it can be delivered as intended) and effectiveness of this intervention.  20  Table 2 Evolution of Systematic Reviews and Practice Guidelines on the use of Inspiratory Muscle Training in Chronic Obstructive Pulmonary Disease reprinted with permission of Physiotherapy Canada Dates  Report  Conclusions  1992  Meta-analysis47  2002  6  Meta-analysis, based on 15 studies dating from 1988 to 1998  IMT alone significantly improved inspiratory muscle strength and endurance and dyspnea at rest and during exercise. Supported the inclusion of IMT as a part of pulmonary rehabilitation for some people with COPD.  2003  Canadian Thoracic Society guidelines48  There is insufficient evidence to support the use of IMT in COPD. Recommends further study.  2005  Systematic review and meta-analysis;51 studies published between 1984 and 2002  Significant improvements in inspiratory muscle strength and endurance and in the dyspnea scale on a quality-of-life measure in participants in the IMT group versus the education group.  2005  Systematic review10  Targeted resistive or threshold IMT was associated with significant improvements in exercise capacity, dyspnea and inspiratory muscle strength and endurance relative to sham IMT.  2006  Statement on pulmonary rehabilitation from the American Thoracic Society and the European Respiratory Society49  IMT should be considered as potential therapy, especially in patients who show signs of respiratory muscle weakness.  2007  Updated Canadian Thoracic Society guidelines1  No mention of IMT.  2008  Updated systematic review5  2008  Updated systematic review7  Normocapneic hyperventilation, targeted inspiratory resistive, or threshold IMT significantly increased inspiratory muscle strength and endurance compared to sham IMT; it also improved outcomes of exercise capacity and a measure of quality of life and reduced dyspnea, in adults with stable COPD. Clinical importance of findings is unclear. Significant improvements in inspiratory muscle strength and an outcome of exercise tolerance (maximum exercise tidal volume) favoring combined IMT and exercise versus exercise alone.  IMT is not effective in COPD.  Abbreviations: IMT, Inspiratory muscle training; COPD, chronic obstructive pulmonary disease  21  Table 3 The Theory of Planned Behaviour Applied to Health Professionals' Prescription of Inspiratory Muscle Training for People with Chronic Obstructive Pulmonary Disease reprinted with permission from Physiotherapy Canada Barriers Related to Lack of IMT Use Perceived deficiency of the evidence about IMT.11  Related TPB Construct Attitude  Physical Therapists‘ uncertainties about the appropriateness of the treatment for their clients.11 Gaps in evolving literature and practice guidelines (see Table 1).  Type of Intervention Selected to Modify or Introduce Beliefs Providing a summary of recent IMT research evidence with reasons for past discrepancies in the literature highlighted.  How the Intervention Addresses the Construct Highlights the value of IMT.  Providing information on patient selection criteria, testing protocols, training parameters, safety precautions, and outcome measures specific to IMT for people with COPD.  Highlights the attributes of people with COPD who benefit from IMT.  Offering specific skill practice sessions: testing maximal inspiratory pressure, setting intensity on the Threshold trainer (Philips Respironics, Murrysville, PA), and instructing others on using the devices.  Perceived lack of support for a new practice from physicians.38  Subjective Norm  Reluctance to use a technique on the part of colleagues and/or other members of a multidisciplinary health care team.40  Lack of time 25, 27, 28, 30, 38-40 to acquire and evaluate evidence. Limited ability to critically appraise research evidence.30, 37 Limited access to equipment.11, 40  Perceived Behavioural Control  Supplying a referenced, 1-page handout summarizing the evidence for use of IMT in COPD that may be used to solicit support from physicians or coworkers. Offering an interactive workshop to the multidisciplinary group of health professionals that deliver pulmonary rehabilitation. Providing a summary of recent IMT research evidence, patient selection criteria, etc. as above, and specific skill practice sessions as above. Providing equipment: each hospital will receive an electronic inspiratory force meter as well as two cases of Threshold trainers. Offering semi-structured problemsolving session (Table 4) addressing impediments to practice, whether personal deficiencies, skills, abilities, or other barriers.  Provides information regarding behaviour or outcome and feedback which may influence ―beliefs about consequences‖17 (i.e. anticipated outcomes/attitude). Addresses normative beliefs in that significant others in the work place may all value the use of IMT for treating dyspnea in some patients with COPD, and therefore may perceive that one should prescribe IMT for some people with COPD.  Addresses internal control factors by facilitating knowledge and skills acquisition. Increase confidence in ability to safely and appropriately prescribe IMT through personal mastery experience. Addresses external control factors by providing the required equipment and evidence.  Offers social processes of encouragement, support and feedback which may influence one‘s ―beliefs about capabilities‖17 (i.e. selfefficacy). Abbreviations: TPB, Theory of Planned Behaviour; IMT, Inspiratory muscle training; COPD, chronic obstructive pulmonary disease  22  Table 4 Probing Questions for Interactive Workshop Session 2 – Problem-solving Session Topic Area Evidence Individual  Questions for discussion with the Health Care Professionals Any questions about the research evidence presented? What is working well for you in implementing inspiratory muscle training (IMT)?  Estimated Time 10 minutes 20 minutes  What challenges are you finding in implementing IMT? Do you require clarification on any the following: o Selection of appropriate individuals for IMT o Testing respiratory muscle strength or endurance o Testing maximal inspiratory pressure o Threshold endurance test o Pulmonary function lab providing measures o  o o o o o o Other  Using the inspiratory force meter or pressure manometer with multiple individuals o Obtaining spare or disposable parts o Sterilizing the device Establishing the initial IMT prescription Teaching an individual to use the Threshold trainer Keeping the Threshold training device clean Monitoring vitals and IMT tolerance Progression of frequency, intensity, or time Outcomes measures for IMT  Are there any organizational challenges in implementing IMT that you would like to discuss? o o o  10 minutes  Time pressures Availability of resources Soliciting support from physicians, management, or co-workers  23  Figure 2 The Theory of Planned Behaviour (adapted from Eccles, Hrisos, Francis, Steen, Bosch and Johnston)66  ATTITUDE (Behavioural beliefs weighted by Outcome evaluations)  SUBJECTIVE NORM (Normative Beliefs weighted by Motivation to comply)  INTENTION  BEHAVIOUR  PERCEIVED BEHAVIOURAL CONTROL (Control beliefs weighted by  the influence of control beliefs)  24  CHAPTER 3 A BEHAVIOURAL INTERVENTION INCREASES PRESCIPTION OF INSPIRATORY MUSCLE TRAINING FOR PEOPLE WITH CHRONIC OBSTRUCTIVE PULMONARY DISEASE* Introduction The gap between practice and research-based evidence is growing,67 such that some patients do not receive the most up-to-date care.68 This may occur in people with chronic obstructive pulmonary disease (COPD). COPD, which includes chronic bronchitis and emphysema, is a progressive debilitating lung disease that is usually caused by smoking.1 The World Health Organization estimates that 210 million people have COPD. 69 The major pathophysiology of COPD is airflow obstruction which causes poor gas exchange, increases the work of breathing, and leads to many systemic sequelae including poor skeletal muscle function.1 As a result, considerable physical and psychosocial impairment occurs as reflected by decreased fitness, functional capacity and ability to work. 1 Recent systematic reviews5-7 have supported the use of inspiratory muscle training (IMT) for select individuals with COPD. However, a survey of Canadian acute care hospitals and pulmonary rehabilitation programs found that fewer than 5% of physical therapists (PTs) had used IMT for COPD rehabilitation.11 To our knowledge, information about IMT has been traditionally disseminated to PTs through didactic lectures and journal articles, with the goal of improving the clinician‘s knowledge about the treatment. However, these dissemination methods are limited in their ability to address other known barriers to implementing IMT into daily clinical practice, such as PTs‘ uncertainties about the appropriateness of the treatment for their patients, a lack of equipment and the perceived deficiency of reliable evidence about IMT. 11 *  A version of this chapter will be submitted for publication as: Simms AM, Li LC, Geddes L, Brooks D, Hoens A, and Reid WD. A behavioural-based intervention increases prescription of inspiratory muscle training for people with chronic obstructive pulmonary disease.  25  Implementation research is the scientific study of methods to facilitate the use of research findings, including testing approaches to change professionals‘ behaviour, thereby increasing timely and appropriate care.70 A number of implementation interventions that aim to change practice behaviours, such as, the use of reminders, audit and feedback, educational outreach visits, educational workshops, and opinion leaders, have been evaluated in the management of different conditions and with a median of 5% to 14% improvement in patient outcomes.13, 19, 31, 32 To date, there is no clear pattern of findings favouring one particular method, or the context in which the intervention is effective.19, 56 Thus it is challenging to judge their generalizability to other health professional groups and settings,19 especially rehabilitation settings wherein a multidisciplinary team provides patient management. The lack of a theoretical basis for most interventions that are developed to improve practice behaviours may also contribute to their limited applicability to different health care settings.16, 19, 33 Because some of the factors that affect individual‘s health behaviours (i.e., attitude, beliefs) also affect professionals‘ practice behaviours, well-developed behavioural theories have been used as a foundation to inform the development of implementation interventions. 14, 16, 18, 19  For example, the Theory of Planned Behaviour (TPB) has been applied to  understand health professionals‘ intentions and behaviours.34 The TPB (Figure 3), as posited by Ajzen, proposes the proximal determinants of behaviour are intention to engage in that behaviour and control over that behaviour. 20 According to the TPB, intention is determined by three sets of factors: attitude towards the behaviour, subjective norm, and perceived behavioural control.20 These three components are respectively based upon three beliefs: behavioural beliefs, normative beliefs, and control beliefs.20 A systematic review of factors influencing health professionals‘ behaviours based on social cognitive theories found that the TPB explained 59% and 31% of the variance in 26  health professionals‘ intention to adopt a new clinical practice and the actual behaviours, respectively.15 This provides evidence that social cognitive theories, like the TPB, can specifically guide the selection of variables for study, allow development of hypotheses, direct development of behavioural-based interventions, and provide a replicable framework that facilitates interpretation and generalization of findings across contexts. 16-19 Therefore, the TPB may be used to guide the development of interventions for improving clinical practice, in this case, increasing the prescription of IMT in the management of COPD. The purpose of this study was to examine the effectiveness of a behavioural-based versus an information-based intervention for increasing health professionals‘ prescription of IMT in the management of COPD by the multidisciplinary team that delivers out-patient pulmonary rehabilitation. We hypothesized that the behavioural-based intervention, grounded in the TPB, would increase the prescription of IMT by health professionals moreso than an information-based intervention. Methods Participants We recruited a convenience sample of six hospital pulmonary rehabilitation programs in Canada that met the following inclusion criteria: enrolled at least 30 out-patients with COPD per year in an out-patient pulmonary rehabilitation program consisting of exercise and patient education, and did not incorporate IMT routinely in exercise prescription for rehabilitation patients (IMT prescribed to less than 10 patients over 3 years). Pulmonary rehabilitation programs were excluded if they have indicated strong support or disapproval toward the use of IMT. Health professionals affiliated with these pulmonary rehabilitation programs were eligible for inclusion if they were a physiotherapist, nurse, respiratory therapist, or speech language pathologist licensed to practice in Canada. An administrator or a manager of the pulmonary rehabilitation program at each hospital was asked to provide 27  consent for conducting the implementation study. The study was approved by the respective university or health authority ethics committees, and was conducted according to the Declaration of Helsinki for human experiments.71 Randomization The six hospitals were paired into three sets after being stratified by geographical location (distance to large metropolitan centre (population >500,000)) and type of facility (specialized referral hospital versus tertiary referral hospital). The hospital pairs were randomly assigned to receive either a behavioural-based or an information-based intervention (figure 4). The randomization procedure was done by coin-toss by a research assistant who was not involved in enrolment, delivery of the intervention, and outcome assessment. Although the outcome of interest (prescription of IMT) is a patient-based measure, the unit of randomization was the site rather than the individual patient or health care practitioner delivering the intervention. Randomization by site was preferable because: (1) health professionals treat more than one patient and thus contamination between groups could occur if randomization was by patient or health care practitioner; and (2) the intervention was designed to be implemented on a site-wide basis and thus randomization by site matched the manner in which the intervention was applied. Blinding This is a single-blind, randomized clinical trial. Health care professionals at all hospitals were blinded to all aspects of the study including group assignment until the conclusion of the study. Six months after the start of the behavioural-based or informationbased intervention, an investigator verbally explained the research study to the health care practitioners. Health professionals had the opportunity to withdraw their data at this point in the study. Informed consent was obtained by one of the investigators (AS or WDR). Blinding of the health care professionals during the study was approved by the clinical ethics 28  review boards and deemed essential because it was considered that health professionals may practice differently if they knew their practice behaviour was being examined. The research personnel, who delivered the interventions, were not blinded to group assignment. Interventions We applied a behavioural-based intervention and an information-based intervention. Development of the behavioural-based intervention is described elsewhere72 (see Chapter 2). Pulmonary rehabilitation programs assigned to the behavioural-based group received an interactive workshop, delivered by an expert who had published in peer-reviewed journals on this topic (WDR), in two 45-minute meetings, held four to six weeks apart. The first meeting included: 1) a PowerPoint presentation of recent IMT research evidence with reasons for past discrepancies in the literature highlighted; 2) PowerPoint presentation and printed information on patient selection criteria, testing protocols, training parameters, safety precautions, and outcome measures for evaluating IMT for people with COPD; 3) specific hands-on skill practice; 4) a one page referenced handout summarizing the evidence on the use of IMT in COPD; and 5) a supply of Thresholda trainers. The second meeting was a semi-structured problem solving session addressing impediments to prescription of IMT. The workshop targeted several constructs of the TPB (Table 4 and Figure 3). Pulmonary rehabilitation programs assigned to the information-based group received a 90-minute didactic lecture delivered by the same expert (WDR). The lecture included: 1) a PowerPoint presentation on the evidence for IMT in COPD provided in the research literature and an overview of inspiratory muscle testing and training; 2) printed copies of two recent peer-reviewed journal articles; 3) a detailed handout summarizing step by step approaches to inspiratory muscle testing, a data collection section, and information on how to order Threshold trainers; and 4) viewing of a sample Threshold device (no trainers were supplied from study resources). All the studied hospitals were provided with a MicroRPM 29  respiratory pressure meterb (Table 4). The study took place from August 2007 to August 2009. Outcomes Primary outcome. IMT prescription was determined by chart audit conducted by selfselected auditors from each centre. Due to variations in charting among pulmonary rehabilitation programs the criteria for categorizing a ‗yes/no‘ to IMT prescription was left to the discretion of the health professionals performing the audit. IMT prescription was defined by proportion of people with COPD that were prescribed IMT while participating in the pulmonary rehabilitation during the 6 months pre-intervention period and during the 6 months post- intervention period. IMT prescription was calculated for each 6 month period by the following equation: Number of people with COPD that were prescribed IMT Total number of people with COPD that participated in the pulmonary rehabilitation program  Secondary outcome. A 9-item multiple choice questionnaire (Table 5) was used to evaluate health professionals‘ knowledge on IMT for people with COPD. Questions were developed by one of the investigators (WDR) and subsequently reviewed and refined by coinvestigators (AS, LG, DB). The questions had also been previously tested on entry-level physical therapy students. In the current study, this questionnaire was completed by health professional participants in a group setting pre- and post- implementation intervention. Health professionals were asked to complete the questionnaire individually but the possibility of completion by consensus existed as completion was not under invigilation. We also obtained information on participants‘ demographic characteristics and their use and familiarity with inspiratory muscle testing and training. The questionnaire, based on a national survey11 of PTs‘ use of IMT for people with COPD, was administered to health care professionals immediately preceding the implementation intervention. 30  Statistical Analysis Chi-square analysis73 was used to assess differences in demographic variables between the two groups. Statistical analyses were performed using NCSS 2007 (Version 7).74 The proportion of patients with COPD that were prescribed IMT in the 6 month periods before and after the behavioural-based intervention and the information-based intervention was calculated. The 95% confidence intervals were calculated using the Adjusted Wald method.75 We would use Chi-square analysis73 to examine the difference in IMT prescription between the behavioural-based intervention and the information-based intervention if the change of each group was greater than zero. The Mann-Whitney U test73 was used to determine if multiple choice questionnaire scores had improved post-intervention compared to pre-intervention in both the behaviouralbased and information-based groups. Statistical analysis were performed using SPSS 16.0 (2007).76 For all analyses, p≤0.05 was considered significant. Results Characteristics of Health Professionals Sixty-one health professionals (behavioural-based group=31; information-based group=30) participated from the six sites (Table 6). The majority of them were physiotherapists (behavioural-based group = 15 (48.4%); information-based group = 20 (66.7%). There was no significant difference in the health professionals‘ demographic characteristics between groups, except for the disciplinary background (fewer physiotherapists in behavioural-based group, p=0.045) and previous IMT education (more previous IMT training in informationbased group p=0.021). Prescription of IMT to Patients with COPD before and after the Intervention The chart audit showed that rehabilitation programs assigned to the behavioural or information-based interventions treated between 102 and 145 patients during the 6 months 31  pre- and the 6 months post-intervention periods (Table 7). Of 225 COPD patients that received pulmonary rehabilitation, none were prescribed IMT at any program during the 6 months pre-intervention (Table 7). The behavioural-based intervention resulted in a 10.2% increase in the prescription of IMT to people with COPD, whereas, the information-based intervention resulted in no change in IMT prescription (Table 7). Analysis by program revealed that two of three programs receiving the behavioural-based intervention implemented IMT whereas none of the three programs receiving the information-based intervention implemented IMT. Health Professionals’ Knowledge - Multiple Choice Questionnaires On the multiple choice questionnaire administered pre-intervention, 31 practitioners in the behavioural-based group and 30 in the information-based group had a mean score of 6.1 ± 2.6 and 6.0 ± 1.5, respectively out of a maximum of 9.0. After the intervention, 21 questionnaires were completed, 7 in the behavioural-based group and 14 in the informationbased group. Both groups showed improvement in the multiple choice questionnaire, with a mean scores of 7.8 ± 1.2 and 7.1 ± 1.0 for the behavioural–based and information-based groups, respectively (p=0.045). Discussion To our knowledge, this is the first study to assess the effectiveness of a behaviouralbased intervention, grounded in the TPB, to change practice patterns of members of a multi-disciplinary team (PTs, respiratory therapists, nurses, speech-language pathologists). We found that the behavioural-based intervention increased the prescription of IMT by health professionals to people with COPD in out-patient pulmonary rehabilitation settings by approximately 10%, whereas an information-based implementation intervention did not. Our study was conducted in publicly-funded hospitals in Canada and, in our view; the findings are generalizable to similar type of hospitals across the country. 32  The magnitude of change in the IMT prescription rate due to the behavioural–based intervention is consistent to that reported for similar implementation interventions that aim to change clinical practice.13, 19, 31, 32 Some of our findings are also consistent with a recent systematic review reporting that mixed interactive and didactic education was more effective than either alone for changing professional practice. 13 Few of the reviewed studies tested different ways of modifying educational meetings and none mirrored our approach of comparing primarily interactive education (behavioural-based intervention) versus didactic education (information-based intervention).13 The common features of our work to the studies described in the systematic review are that some of the interventions were: set in hospital; targeted a prescribing behaviour; used a non-intensive intervention; were built on a known theory; and/or measured a professional practice outcome after a similar time interval. Similar to the systematic review, the baseline compliance in our study did not appear to explain the differences in changed practice as a result of the implementation intervention;13 pre-intervention prescription of IMT was zero (Table 6) in both the behavioural-based and information-based intervention groups. Demographic differences of health professionals in the behavioural-based compared to the information-based intervention group, do not appear to explain the positive outcome of the behavioural-based implementation intervention (Table 6). Firstly, with respect to discipline (p=0.045), there were a greater number of respiratory therapists and fewer PTs in the behavioural group compared to the information-based group (Table 6). Due to a paucity of literature on respiratory therapists‘ use of evidence based practice and IMT, a review of the PT and nursing literature informed the selection of target variables for the behaviouralbased intervention (Table 3). Our lack of consideration of respiratory therapists during the development of the intervention would be expected to have reduced the effectiveness of the behavioural based implementation intervention to these practitioners, but this does not appear 33  to be the case. A second demographic difference, with respect to previous training in IMT (p=0.021), was that the information-based group reported previous continuing education and practical training in IMT at the work site whereas the behavioural-based group did not (Table 6). Although, previous practice related courses may influence choice of interventions by PTs,26 evidence on IMT was questionable in the earlier days (see Chapter 2 Table 2), such that prior education could have created a bias for or against IMT prescription. Some trends in the demographic data worthy of mention are that a small group of health professionals in the information-based group had more experience in pulmonary rehabilitation (p=0.069) and more years in practice (p=0.094) compared to the behaviouralbased group. A national study of PTs providing services to people with stroke found that those with less than five years experience were almost ten times more likely than those with greater than fifteen years of practice experience to apply research findings to clients and they reported greater evidence-based practice self-efficacy.30 We did not assess whether the behavioural-based intervention group was more compelled and/or may have felt more capable to apply IMT in COPD. In summary, bias due to demographic differences could have influenced outcomes in both groups in either direction. In future, a theory-based process evaluation77 performed in conjunction with a larger, randomized clinical trial is suggested to explore causal mechanisms and effect modifiers. The behavioural-based intervention may have been more effective than the information-based intervention because the former was a tailored strategy that prospectively identified and targeted barriers to change. The literature suggests that tailored interventions are more likely to improve professional practice than no intervention or dissemination of guidelines.58 The most effective methods for tailoring have not been identified; however, several argue in favour of using behavioural theories, 13, 14, 19 such as the TPB used in this 34  study (Figure 3). A literature review of barriers to EBP and barriers specific to IMT use identified behavioural, normative, and control belief targets. For example, lack of equipment11 was classified as relating to control beliefs; therefore, the behavioural-based intervention included provision of a respiratory pressure meter and Threshold trainers to increase perceived behavioural control. Future research should use a TPB questionnaire which measures the variables in the TPB model. Construction of the questionnaire involves several steps, some brief and some requiring a lengthy process of empirical investigation, including defining the population of interest, defining the behaviour under study, deciding how to best measure TPB constructs, piloting, revising, and assessing test-retest reliability.63 Documenting baseline and post-intervention perspectives of health professionals using a TPB questionnaire is required to determine whether or not beliefs changed as a result of the behavioural-based intervention and may assist in identifying the active ingredient of the intervention. Our didactic information-based intervention failed to show any effect on practice which is contrary to the 6.9% change noted for didactic educational meetings in a recent systematic review that primarily focused on physicians.13 Although didactic educational meetings are often used to increase knowledge, in our study the baseline results of the multiple choice questionnaire (mean scores of 6.1 and 6.0, out of 9.0) suggest that deficiency in knowledge may not have been a factor. This finding may indicate that factors other than the practitioner‘s knowledge should be considered when developing interventions that seek to change practice. Of two studies that examined the practice style traits of PTs, 78, 79 the most prevalent was that of a pragmatist, which is defined as someone who, ―focuses on practicality and is likely to change practice based on workload demands, patient flow and patient satisfaction, rather than on scientific validity.‖79 In our post-hoc debriefing with participants, it appeared that those who did not implement IMT, tended to have pragmatic concerns about 35  the sustainability of the practice. Issues mentioned including where to purchase equipment in the future and how to clean the force meter between uses. It appears the behavioural-based intervention which targeted control beliefs was more successful than the information-based invention in addressing pragmatic concerns. Little is known about factors that modify the effectiveness of educational meetings; more direct comparisons of differing education, such as different group sizes and content, are needed.13 While a 10% increase in IMT prescription with an interactive workshop (behavioural-based intervention) was better than no change with a didactic meeting (information-based intervention); at least two factors may have negatively impacted the effectiveness of the behavioural-based intervention. Firstly, given the cyclical nature of pulmonary rehabilitation, typically six to eight weeks in duration,80 programs may have only gone through two full cycles during the six month post-intervention period. Interventions that involve patients on a shorter treatment cycle or those that are administered to greater volume of patients within a similar six month time frame may demonstrate a greater effect. Secondly, the behavioural-based implementation intervention was directed primarily at the level of the health professional. Neither the information-based nor the behavioural-based intervention addressed lack of time, a known organizational barrier to evidence-based practice.25, 28, 38 It appeared from our post-hoc debriefing that health professionals, who did not implement IMT, had time limitations or difficulties implementing a new treatment in their on-going program. Organizational barriers might have contributed to the uptake of IMT, however, there is limited evidence on the effectiveness of organizational interventions to target these barriers.81 Wensing and colleagues81 found that professional performance was improved by computer systems for reminding and decision support and by enhancement of professional roles of non-physicians. Future research might examine whether any in a range of organizational approaches, including those currently under review such as organizational 36  culture interventions82 might improve prescription of an exercise intervention among a multidisciplinary team. It is likely that there was a greater than 10% change in the prescription rate of IMT due to the behavioural-based intervention. Defining the people with COPD that would benefit from IMT, based on criteria outlined in research articles 8 and systematic reviews,5, 7 (see criteria outlined on page 77) would provide a more appropriate denominator for determining the prescription rate of IMT. Ideally, the prescription rate should be expressed as the number of people with COPD that were prescribed IMT divided by those people with COPD that would benefit from IMT that participated in the pulmonary rehabilitation program rather than a denominator of the total number of people with COPD that participated in the pulmonary rehabilitation program. Given that there is no consensus on the proportion of COPD patients that should be prescribed IMT, it is currently difficult to estimate this number. Study Limitations Some limitations were identified in this study which could be used to improve the design of a future trial. A major limitation is that the level of randomization (centre) differs from the level of analysis (patient). A greater number of centers in each cluster would permit multi-level analysis; however, given the scarcity of pulmonary rehabilitation programs in Canada3 this may require an international sample. Also, due to restrictions placed on the chart audit by the ethics review board, self-selected auditors from each centre performed the chart audit, which may have resulted in over or under reporting. In future, auditors should be blinded and trained to follow a standardized protocol which would increase the reliability of this measure. Moreover, some may propose the behavioural-based implementation intervention was theory ―informed‖ rather than a theory-based design. Our study was partially informed based on a survey that was administered nationwide to physiotherapists. 11 37  We did not examine the mediating effect of the TPB constructs on the behavioural outcome as it was not feasible to design and administer a TPB questionnaire. Ideally, a TPB questionnaire63, 64 to identify barriers to the target behaviour should be administered prior to the development of the intervention and after the intervention in order to illuminate the mechanism of behaviour change. Future studies should also evaluate effectiveness of prescription, such as frequency and intensity of training and related outcomes, which would better assess changes in quality of care delivered. Conclusions We have demonstrated that a behavioural-based implementation intervention is feasible and is beneficial for improving health care professionals` prescription of IMT to people with COPD in out-patient pulmonary rehabilitation. It may provide a model for other implementation interventions directed at health professionals for prescribing different interventions. Future study is required to assess the mediating effects of the TPB constructs on the prescribing behaviour as well as effectiveness and cost-effectiveness of the intervention. Suppliers a  Threshold® Trainers Roxon Medical, 151 E. Columbia St. New Westminster, B.C. V3L3V9 b  MicroRPM (Respiratory Pressure Meter ), Micro Medical Limited, PO BOX 6, Rochester, Kent, ME1 2AZ, UK Telephone 01634 893500 Fax 01634 893600 International +44 1634 893500 Email micromedical@viasyshc.com www.micromedical.co.uk  38  Table 4 Protocol and Comparison of Behavioural-based and Information-based Intervention Timing of Intervention Prior to 1st Day 1st Day  4-6 weeks after first session Ongoing After 6 months  Behavioural-based Intervention Information-Based Intervention Arrange two 45 minute Arrange one 90 minute session sessions 4 to 6 weeks apart Questionnaire (Demographics and Use of IMT) and Multiple Choice Questionnaire 45 minute interactive session 35 minute lecture followed by that provided step-by-step 10 minute demonstration of instruction during hands-on testing device and trainers practice of testing device and trainers Slide Kit Different Slide Kit Handout Different Handout No Publications provided 2 Publications provided Respiratory Pressure Meter Threshold trainers provided No Threshold trainers provided Semi-Structured Problem No planned activity Solving Session Log of queries to expert outside of intervention session(s) Obtain Consent from Health Care Professionals Repeat Multiple Choice Questionnaire Obtain chart audit information  Gold shaded elements were applied in both the behavioural-based and information-based intervention in a similar manner.  39  Table 5 Multiple Choice Questionnaire Inspiratory Muscle Training - Multiple Choice Questions Please circle the best answer 1. Primary muscles of inspiration a. Include the diaphragm, scalenes and parasternal intercostals b. Are only recruited during exercise in healthy people c. Are only recruited during tidal breathing in people with chronic respiratory disease d. Produce a positive pressure in the thoracic cavity during inspiration 2.  Inspiratory muscle force a. Can be measured during a maximal expiratory manoeuvre b. Can be measured at total lung capacity c. Can be measured at functional residual capacity and residual volume d. Is increased in people with high spinal cord lesions e.g. C3 or higher  3.  The best training device of inspiratory muscle training in people with chronic obstructive pulmonary disease is a. The DHD device (that has interchangeable coloured discs with different sized holes), without an incentive spirometer b. The P-flex device (that has a dial to adjust the diameter of the inspiratory hole) without an incentive spirometer c. The Powerlung, that is made of blue plastic and can add adjustable loads to inspiration and expiration d. The Threshold trainer, that is made of clear plastic and can add inspiratory threshold loads by adjusting the spring loaded inspiratory valve.  4.  Maximal inspiratory pressure a. Can be abbreviated as Pdi b. Can be abbreviated as MIP or PImax c. Should not be tested while the person is wearing nose plugs d. Will be the same magnitude when the person is in different body positions  5.  Normative values of inspiratory muscle strength are based on a. Height, weight and gender b. Height, weight, age, and gender c. Gender and height d. Only gender  6.  Prescription parameters for inspiratory muscle training should a. follow American College of Sports Medicine guidelines b. include a training intensity of 60-80% for all training sessions c. should be prescribed cautiously to avoid excessive fatigue and injury d. should be performed a minimum of 30 minutes per session  7.  Signs and symptoms of overtraining the inspiratory muscles of people with chronic respiratory disease are a. Excessive dyspnea b. Discoordinated chest wall movement c. Muscle soreness d. All of the above  8.  People that might benefit from inspiratory muscle training are a. Those individuals who are dyspneic or have weak inspiratory muscles b. Patients post-operatively who have atelectasis c. Patients with pneumonia d. Patients in acute respiratory failure. e. Inspiratory muscle training is contra-indicated or should be prescribed with caution for a. People involved in elite athletic sports b. Neuromuscular disorders c. Stable people with COPD with a maximal inspiratory pressure that is slightly less the normative value. d. Stable patients with COPD who are coping well with an exercise program involving upper and lower extremity aerobic exercise.  9.  40  Table 6 Demographic Characteristics of the Behavioural-based and Information-based Intervention groups BehaviouralBased  InformationBased  3 31  3 30  Number of Programs Number of Health Professionals n Discipline of participating health professionals Physiotherapist Respiratory Therapist Nurse Speech-Language Pathologist Not indicated Degree Diploma Bachelors Masters Years in Practice < 5 years 5-10 years 11-20 years > 20 years Employment Status Full-time Part-Time Casual/Locum Caseload of Patients with COPD Acute Rehabilitation Both Experience in Pulmonary Rehabilitation < 5 years 5-10 years 11-20 years > 20 years Previous Education in Inspiratory Muscle Training Entry Level Continuing Education Practical Training at worksite  Valid %  n  ChiSquare  Valid % 8.05  15 12 0 1 3 11 15 2 7 2 10 9 18 6 3 11 12 3 21 4 3 0  12 0 0  48.4 38.7 0 3.2 9.7 39.3 53.6 7.1 25.0 7.1 35.7 32.1 66.7 22.2 11.1 42.3 46.2 11.5 75.0 14.3 10.7 0  38.7 0 0  20 3 2 1 4 5 19 3 2 4 6 16 18 7 3 7 13 1 19 4 0 4  12 6 4  P  0.045*  66.7 10.0 6.7 3.3 13.3 2.90  0.230  6.4  0.094  0.06  0.97  1.41  0.49  7.08  0.069  7.73  0.021*  18.5 70.4 11.1 7.1 14.3 21.4 57.1 64.3 25.0 10.7 33.3 61.9 4.8 63.3 13.3 0 13.3  40.0 20.0 13.3  * indicates statistically significant  41  Table 7 Analysis by Patient Count Group  Behavioural –based intervention Informationbased intervention  Number of COPD patients in Pulmonary Rehabilitation Programs  Number of patients who received a prescription of IMT  % change in prescription of IMT (95% CI)  6 mos. Preintervention  6 mos. Postintervention  6 mos. Preintervention  6 mos. Postintervention  102  118  0  12  10.2 (5.7; 17.1)  123  145  0  0  0 (0; 2.2)  Abbreviations: CI, confidence interval; COPD, chronic obstructive pulmonary disease; IMT, inspiratory muscle training  42  Figure 3 Behavioural-based interventions for improving IMT prescription, guided by the Theory of Planned Behaviour  Legend: The elements of the Theory of Planned Behaviour (TPB) are shown in the rounded rectangles. The TPB provided a framework for developing strategies to influence beliefs in order to change behaviour. The actions outlined are a partial list of how the various strategies in the behavioural-based intervention were linked to the TPB.  43  Figure 4 Study Flow Chart  44  CHAPTER 4 SUMMARY AND FUTURE DIRECTIONS Discussion This thesis research project involved a number of steps: 1) conducting a literature review of barriers to evidence-based practice (EBP) in physical therapy and/or respiratory therapy (see Chapter 2); 2) conducting a literature review on implementation interventions (see Chapter 2); 3) developing a behavioural-based intervention to improve the uptake of IMT (see Chapter 2); 4) conducting a pragmatic, cluster randomized clinical trial (see Chapter 3). The literature review on barriers to EBP in physical therapy revealed that barriers may exist at the individual, research, and organizational levels,25-30, 36, 38-43 some of which appear to be associated with the poor uptake of IMT in COPD. Some of the research on barriers to EBP was multi-disciplinary in nature. It appears that similar barriers to EBP are experienced among physical therapists, nurses, and speech language pathologists. 37-39 Despite using search terms and databases analogous to those used for physical therapy, no published literature on barriers to EBP in respiratory therapy was found. The literature review on implementation interventions revealed that a number of interventions have been developed and tested.13, 19, 31, 32, 55-58, 83 Most of the interventions that aim to change practice behaviours have been directed at a single profession, usually physicians.19 Very few interventions have been directed at improving the quality of practice in physical therapy.56 In general, implementation interventions produced a median improvement of 6% to 14% in process outcomes57 or patient outcomes.13, 19, 31, 32, 55 Moreover, there was no clear pattern of findings favouring one particular method, or the context in which the intervention is effective. 19 This may be due to the lack of a theoretical basis for most interventions that are developed to improve practice behaviours. 14, 16 45  Proponents of this view argue that behavioural theories, such as the Theory of Planned Behaviour (TPB), offer a generalizable framework to understand and predict practice behaviours,15, 33, 34 and therefore, they can be used to guide the development of interventions for improving clinical practice, such as using inspiratory muscle training (IMT) in the management of chronic obstructive pulmonary disease (COPD). Given the TPB‘s ability to predict health professional‘s clinical intention and behaviour,15 we believed it would provide a strong model to inform the development of an implementation intervention to improve health professionals prescription of IMT in the management of COPD in out-patient pulmonary rehabilitation. A behavioural-based intervention, grounded in the TPB, was developed. We defined the behaviour in terms of target, action, and context as per the TPB.63, 64 Beliefs, identified through the literature review of barriers to EBP in physical therapy and barriers to IMT use identified in a national survey,11 were categorized as behavioural, normative, or control beliefs (Table 3). Based on our categorization and the previous TPB studies of health behaviour,20 we determined the primary cognitive targets20 to be attitude (via behavioural beliefs) and perceived behavioural control (via control beliefs) whereas subjective norm (via normative beliefs) was deemed a minor construct. Table 3 outlines the type of interventions we selected to modify or introduce beliefs and the rationale for the choice of the intervention. The TPB does not offer a set way to change existing beliefs20 and Ajzen suggests investigators use experience and creativity in designing the intervention.64 We followed this tact and also incorporated the evidence from the aforementioned literature review of implementation interventions. Finally, we conducted a cluster, randomized clinical trial to assess the feasibility of the design and to compare the effectiveness of a behavioural-based implementation intervention versus an information-based implementation intervention for increasing health 46  professionals‘ prescription of IMT in the management of COPD in out-patient pulmonary rehabilitation settings. Limitations and Strengths of Thesis Research Project A number of authors have outlined steps to consider when designing an intervention to translate knowledge to action.84-86 Van Bokhoven, Kok, and Van Der Weijen have outlined a design process to improve quality of care.84 In this instance, I will be using the steps they outline to map the process of my research and as framework to highlight the limitations and strengths of my thesis research project. The steps outlined in Table 8 have been described as a cyclical process.84 A systematic approach was followed to develop the behavioural-based implementation intervention (see Table 8) employed in our study. Despite using multiple sources to inform the development of the intervention, problem analysis and design of the behavioural-based intervention would have been enhanced by using a TPB questionnaire.63, 64 A TPB questionnaire can be used to assess the influence of each predictor (attitude, subjective norm, perceived behavioural control) with a view to designing an intervention to modify the most powerful predictor.63 Francis et al.63 have developed a manual for constructing questionnaires based on the TPB. The construction of a TPB questionnaire proceeds in a series of phases and requires a significant amount of time and resource;63 therefore, it was not administered in our study for practical reasons. Also, the design of the implementation intervention was such that one investigator (WDR) served as the expert for the all educational meetings. This may have introduced experimental bias in the form of experimenter effects. In future, a possible solution is to observe, the expert delivering the interventions, to detect and reduce expectancy-inducing behaviour related to his or her active (i.e. smiling) or passive (i.e. appearance) behaviours. It may be also be possible to train an expert to deliver the interventions who is blinded to the research hypothesis. 47  The experimental design selected was a cluster, randomized clinical trial.73 The strength of a randomized controlled trial comes from its ability to offer causal inferences. This ability is dependent on the internal validity. By including a comparison group we ruled out the single group threats described by Portney and Watkins:73 history, maturation, attrition, testing, instrumentation and regression. When selecting among possible levels of randomization a number of factors were considered (see Table 9) before randomizing at the level of the centre (see Chapter 3 and Figure 4). Random assignment is meant to equalize groups.73 Our two groups (behaviouralbased group and information-based group) were compared on demographic characteristics considered to be relevant to the dependent variable; some factors did not balance out (see Table 6). As such, some may argue the groups were not equivalent at the start of the study. Therefore, a plausible alternative explanation for the relationship between IMT prescription rate and behavioural-based intervention, namely, selection-history effects exists. Social threats like ―diffusion and imitation of treatments,‖ ―compensatory equalization of treatment,‖ ―compensatory rivalry,‖ and ―resentful demoralization‖73 were controlled or eliminated by randomizing at the level of the centre and blinding the participating health professionals. In summary, the assumption of causality requires three components: 1) temporal precedence 2) covariation of cause and effect and 3) no plausible alternative explanation;73 the first two of these were documented. This trial was a pragmatic cluster randomized clinical trial (see Chapter 3). Pragmatic studies aim to test whether an intervention is likely to be effective in routine practice by comparing a new practice, our behavioural-based intervention, against the current method, information-based intervention. Pragmatic studies attempt to approximate normal conditions and do not usually try to equalize contextual factors and other effect modifiers;86 we acknowledge potential for attention bias is inherent to the study design due to differences 48  between the behavioural-based and information-based interventions. However, to minimize potential bias and equalize personnel costs we standardized the amount of time allocated to each of the implementation interventions. With regards to randomization, it was feasible to randomized three clusters to each arm instead of the suggested 5 or more clusters per arm. 87 With relatively few clusters there is an increased danger of imbalance between the behavioural-based group and informationbased group due to chance. However, baseline measurements of the primary outcome, rates of IMT prescription, were uniformly zero. Thus, even with 3 clusters in each arm, their baseline measure of IMT prescription rate revealed equal allocation and much room for improvement (no ceiling effect). There are several acceptable approaches to consider in the analysis of cluster randomized trials: 1) analysis at the cluster level, 2) the adjustment of standard tests, and 3) advanced statistical techniques using data recorded at both the individual and cluster level. 86 In order to select the most pertinent approach, the research team should consider a number of factors such as the research question, the type and distribution of outcome measure, statistical resources available in the research team, etc. in selecting the most appropriate analysis option.86 A major limitation of this study is that there is a unit of analysis error -the level of randomization (centre) differs from the level of analysis (patient). In the future, the main cluster randomized control trial should at ensure sufficient sample size and that choice of outcomes permits collecting and analyzing data at the cluster level. We found that the behavioural-based intervention increased the prescription of IMT by health professionals to people with COPD in out-patient pulmonary rehabilitation settings by approximately 10%, whereas an information-based implementation intervention did not. The results of the study should be interpreted with caution due small cluster number and size. Furthermore, some may argue, that a threat to statistical conclusion validity, namely 49  unreliability of measures, exists. Due to restrictions placed on the chart audit by the ethics review board, self-selected auditors from each centre performed the chart audits. It is possible reporting may not have been double checked or biased resulting in over or under reporting. In future, auditors should be blinded and trained to follow a standardized protocol to increase reliability of this measure. Future studies should also evaluate the effectiveness of prescription, such as frequency and intensity of training, which would better assess changes in quality of care delivered. There are several factors which limit external validity. Firstly, analysis by centre revealed that 2 out 3 centres receiving the behavioural-based intervention improved IMT prescription rate (Table 7); therefore, there may be an interaction of treatment and setting. Secondly, improvement in IMT prescription rate was observed 6 months after the behavioural-based intervention; we cannot determine if the trend would be maintained over a shorter or longer time period. Our study was conducted in publicly-funded hospitals in Canada and, in our view; the findings are generalizable to similar type of hospitals across the country. It would be imprudent to proceed with the adoption and implementation of the behavioural-based intervention until further study is conducted. It should be noted that this was originally proposed to be a pilot study; however, due to positive feasibility(see Table 10 and further discussion below) and the success of the behavioural-based intervention, it provides a strong basis as a standalone project to further develop future research. This study provides data for a separate calculation of intra-cluster correlation coefficient, which allows for a precise estimate of a sample size for a full cluster, randomized controlled trial. Future Research Directions Future studies might include a ―process evaluation‖ or ―theory-based process evaluation‖ to assist in identifying the causal mechanism that produced the change in IMT 50  prescription observed in the behavioural group. Process evaluation can be used to 1) describe an intervention in detail, 2) check actual exposure to an intervention, and 3) describe the experience of those exposed to an intervention. 77 A process evaluation was not administered in our study due to lack of feasibility but could have provided insight into the mechanisms responsible for the effect in the behavioural-based intervention. A process evaluation which described whether health professionals in the behavioural-based group were satisfied with the intervention method and whether problems arose while implementing changes might explain why two centres exposed to the behavioural-based intervention changed practice while one did not. Theory-based process evaluations collect data on theoretical constructs alongside randomized control trials to explore possible causal mechanisms. For example, this would require development of theory-based surveys using standard methods based on the TPB.63 A sample of health professionals from each arm of the trial would be surveyed several months before and after the information and behavioural-based interventions. Groups would be compared using methods appropriate for comparing independent samples to determine whether there had been changes in the predicted constructs (attitudes, subjective norms, perceived behavioural control or intention) across the study groups. The convergence between the process evaluation results and the main trial results would be assessed. Interpretation of the results of our trial and assessment of its likely generalizability would be enhanced if we had more information, from a theory-based process evaluation, about the causal mechanism through which the behavioural-based intervention worked; however, it was not feasible to conduct such an evaluation with a small project budget and research team. A theory-based process evaluation could accompany a larger, definitive randomized controlled trial in the future.  51  Furthermore, with respect to the measurement of the primary outcome, prescription of IMT, identifying the number of people with COPD that would benefit from IMT that participated in the pulmonary rehabilitation programs, based on the criteria outlined in on page 77 of Appendix D, would provide a more appropriate denominator for determining the success of the behavioural-based intervention. The larger, definitive cluster randomized controlled trial would ideally have the following features that were lacking in this trial: 1) random selection of pulmonary rehabilitation programs, 2) properly powered, 3) a measure to examine the mediating effect of the TPB constructs on the behavioural outcome, 4) measurement of patient outcomes and 5) long-term follow-up of the practice behaviour. Significance of the Study This study is valuable in that it provides evidence with regards to the feasibility of the design (Table 10). Furthermore, it adds to the sparse implementation research that employs theory88 and/or is directed at non-physicians. Arguably, given that in many health care environments such as cardiac, stroke, and pulmonary rehabilitation programs various health professionals are directed to work as a team, implementation interventions which are directed at more than one professional group, as in our study, are needed. As aforementioned, our study, to our knowledge, is the first to assess the effectiveness of a behavioural-based intervention, grounded in the TPB, to change practice patterns of members of a multi-disciplinary team that included physiotherapists, respiratory therapists, nurses and speech language pathologists. Personal Reflection Pursuing a Master of Science in Physical Therapy has been a personal goal for about 10 years. Discussions with Dr. Darlene Reid about a planned knowledge translation study lead to a perfect opportunity to purse this goal while living several hundred kilometres from 52  UBC. I was offered the opportunity to work with leaders in the field of Physical Therapy from Ontario and British Columbia on a trial comparing knowledge translation strategies to enhance the uptake of IMT. My major thesis project was a pragmatic cluster randomized clinical trial comparing two implementation interventions to increase prescription of IMT for people with COPD among health professionals delivering pulmonary rehabilitation. Initially, I had little idea of the steps involved in carrying out a project of this nature. The efforts required in developing a theory-based intervention and obtaining ethics approval from several institutions at times seemed monumental. There were several challenges in scheduling the interventions, in collecting consent, in obtaining data from chart audit, and in selecting an approach to the statistical analysis. The results were exciting but given the small sample and the difficulty in identifying the causal mechanism and effect modifiers in the behavioural-based intervention it poses challenges in drawing a clear conclusion about the effect the of behavioural-based intervention. In spite of this, I was struck by the effect of a novel theory-based implementation intervention and the lack of effect of the traditional, didactic intervention. It made me reflect upon my own experiences with continuing education, where attendance at didactic presentations at local and national conferences, increased my knowledge but did not necessarily lead to the anticipated change towards best practice in my work as a physical therapist at a tertiary care hospital. My Master‘s experience has been enhanced by my thesis supervisors, Drs. Linda Li and Darlene Reid who have guided me through the stages of the thesis. I would not have completed this project without their patience, guidance and ample, gently delivered feedback. I feel a sense of achievement and have experienced tremendous personal growth at having seen this research project from start to finish.  53  Table 8 Mapping Our Research Process Using The Design Process to Improve Quality of Care Proposed by Van Bokhoven, Kok and Van Der Weijden84     STEPS IN THE DESIGN PROCESS Identify problem/target for improvement  Problem Analysis o Describe barriers and facilitators o Describe target population  -  -  -    Design of Intervention o Specify intervention objectives - State expected changes in behaviour - Specify performance objective (specific indicators) - Analyze objective with respect to barriers to change ˗ Category 1: methods to identify barriers to change as reported by professionals, patients and others ˗ Category 2: analysis of the variation in practice with respect to its determinants ˗ Category 3: analysis of the determinants of change after applications of interventions for knowledge translation  -  -  -  o        Select Methods and Strategies - Exploratory - Theory - Combined Exploratory and Theory o Design the Program - Operationalize strategies into plans, considering implementers and sites - Develop and design documents - Produce program materials Pretest o Testing materials o Pilot Test o Trial - Randomized ˗ Individual patient randomized trials ˗ Cluster randomized trials - Non-Randomized  -  ACTION Noted that the results of Canadian survey indicates prescription of IMT in COPD rehabilitation is low despite evidence from systematic reviews indicating IMT may benefit some people with COPD (Chapter 2) Considered barriers to EBP of PTs and other health professionals involved in the delivery of pulmonary rehabilitation programs (Chapter 2) Considered barriers identified in national survey of IMT use (Chapter 2) Defined target population as PTs, RTs, nurses and other health professionals involved in the delivery of pulmonary rehabilitation (Chapter 2) Specified intervention objectives: the expected behaviour was increase prescription of IMT to people with COPD in the context of pulmonary rehabilitation(Chapter 2) Specified the indicator: see definition of primary outcome (Chapter 3) Analyzed objective with respect to barriers to change: the focus was on barriers to change reported in the literature and/or identified generally by the Theory of Planned Behaviour (Chapter 2) Selected Methods and Strategies: theoryinformed strategy (Chapter 2) Designed the Program: Developed the behavioural-based intervention (Chapter 2) and designed documents/ program materials (Appendices B to H)  Circulated study materials to investigators for review and revised as needed( Chapter 3) Selected cluster randomized clinical trial (Chapter 3)  ˗ Uncontrolled before and after studies ˗ Controlled before and after studies ˗ Time series designs  Adoption and Implementation Evaluation Adjustment  -  Further study needed to complete this step Further study needed to complete this step  54  Table 9 The Strengths and Limitations of Performing the Randomization at the Patient, Health Professionals, Centre, and City Levels Level of Randomization Patient  Strengths  Limitations  Recommendation  - Smaller sample size required versus cluster RCT - Simple, more straight forward statistical analysis - Focus of the intervention is individual professionals and therefore individuals may be less likely to drop out  - In practice it would be difficult or even impossible to implement randomizing individual patients to therapist who had received either the behavioural versus information-based intervention  - Consider other options due to practicalities.  - High potential for contamination where professionals allocated to the Information-based intervention inadvertently receive some aspects of the behavioural-based intervention due to proximity/ danger of dilution bias resulting in a Type II error  - Consider other options due to high potential for contamination as therapists working in pulmonary rehabilitation are generally a small group in close contact  Centre  - Practical reasons/ take advantage of pre-existing grouping by work site - To avoid dilution bias/ avoid contamination issues - Decreased potential for biased recruitment of patients as professionals are not aware of the trial or allocation schedule  - Focus of the intervention is the centre and not the professionals; therefore professionals may be more likely to drop out.89 - Consent for participation obtained after randomization therefore potential for refusal for outcome assessment may introduce selection bias 90 - Cannot control for communication across centres, for example, through email or other professional interaction over the 6 month intervention period - Variables of interest at the patient level such as whether IMT improved dyspnea, quality of life will not be assessed - Baseline measurements, in this case such as self-reported prescription rates, can be used to assess adequacy of the allocation process, low prescription rates indicate room for improvement and decrease likelihood of ceiling effect 91 - Ideally 10 or more hospitals should be recruited to allow 5 clusters per arm and therefore cost of delivery of intervention will increase  City  - May avoid contamination issues  - Increased number of hospitals and cities recruited therefore cost of delivery of intervention will increase - Complexity of intervention increases - Number of clusters likely decreases and size of cluster increases; however it is number of clusters rather than the size of cluster that is important in determining power89 - Potential for contamination remains as cannot control for communication across cities, for example, through phone, email or migration of professionals  - The randomization of clusters needs to be undertaken carefully and preferably independently to avoid biased allocation - Report discrepancy between number of subjects (professionals) entering the trial and the number analyzed for each intervention group89 - In planning for large cluster RCT it is necessary to have a priori estimate of the design effect or the intracluster correlation coefficient (ICC)89 - Larger, definitive RCT trial should have 5 or more clusters per arm. At less than 5 there will be an inadequate number to balance out cluster level confounding87 - Requires a significantly larger sample size compared with an individually randomized trial testing the same hypothesis - May need an international study to gather enough cities given the scarcity of pulmonary rehabilitation programs in Canada  Professionals  Abbreviations: ICC, intracluster correlation coefficient; RCT, randomized controlled trial  55  Table 10 Evaluation of Feasibility Criteria Feasibility Criteria Recruitment of centres  80% eligible centres agree to participate Acceptability of randomization  100% of centres agree to randomization Ability to carry out the methodology as proposed  The behavioural-based implementation intervention can be delivered as described  The information-based implementation intervention can be delivered as described  60% of health care professionals agree to data collection Ability to apply outcome measures as proposed  Was the Criteria Met? Yes or No Yes  Comment All recruited centres participated fully  Yes  All centres agreed to randomization  Yes  All interventions delivered as described All centres provided data Consent was obtained from at least 60% of therapists in charge of pulmonary rehabilitation  No  Ethics committee precluded our ability to do chart audits as originally proposed at 2 of 6 centres therefore we were able to apply all outcome measures as proposed with the exception of ‗GOLD‘ criteria and IMT prescription parameters. As a results therapists determined number of patients with diagnosis of COPD and the appropriateness of IMT prescription could not be determined.  Outcome measures applied provide meaningful data  Yes  All centres completed the study Able to address primary hypothesis  56  REFERENCES  1. O'Donnell DE, Aaron SBJ, Bourbeau J, Hernandez N, Marciniuk D, Balter M, Ford G, Gervais A, Goldstein R, Hodder R, Kaplan A, Keenan S, Lacasse Y, Maltais F, Road J, Rocker G, Sin D, Sinuff T, Voduc N. et al. Canadian Thoracic Society recommendations for management of chronic obstructive pulmonary disease - 2007 update. Can Respir J. 2007;14(Suppl B):5B-32B. 2. Global Strategy for the Diagnosis, Management, and Prevention of COPD Updated 2009. 2009. [cited 2010 Aug 12]. Available at http://www.goldcopd.org/Guidelineitem.asp?l1=2&l2=1&intId=2003 3. The Canadian Lung Assoiciation COPD and Smoking Report. 2007. [cited 2007 Dec 28]. Available at http://www.lung.ca/_resources/COPD_and_Smoking_Survey_Results_CLA_2007.pd f 4. Reid WD, Dechman G. Considerations when testing and training the respiratory muscles. Phys Ther. 1995;75:971-82. 5. Geddes E, O'Brien K, Reid W, Brooks D, Crowe J. Inspiratory muscle training in adults with chronic obstructive pulmonary disease: an update of a systematic review. Resp Med. 2008;102:1715-29. 6. Lotters F, van Tol B, Kwakkel G, Gosselink R. Effects of controlled inspiratory muscle training in patients with COPD: a meta-analysis. Eur Respir J. 2002;20:570-7. 7. O Brien K, Geddes E, Reid W, Brooks D, Crowe J. Inspiratory muscle training compared with other rehabilitation interventions in chronic obstructive pulmonary disease: a systematic review update. J Cardiopulm Rehabil. 2008;28:128-41. 8. Hill K, Cecins NM, Eastwood PR, Jenkins SC. Inspiratory muscle training for patients with chronic obstructive pulmonary disease: a practical guide for clinicians. Arch Phys Med Rehab. 2010;91:1466-70. 9. Reid WD, Geddes EL, Brooks D, O'Brien K, Crowe J. Inspiratory muscle training in chronic obstructive pulmonary disease. Physiother Can. 2004;56:128-42. 10. Geddes EL, Reid WD, Crowe J, O‘Brien K, Brooks D. Inspiratory muscle training in adults with chronic obstructive pulmonary disease: a systematic review. Resp Med. 2005;99:1440-58. 11. Crowe J, Geddes EL, Brooks D, Reid WD. Inspiratory muscle training for individuals with cervical spinal cord injury or chronic obstructive pulmonary disease: a survey of Canadian physical therapists. Physiother Can. 2006;58:271-9. 12. Graham I, Logan J, Harrison M, Staus S, Tetroe J, Caswell W, et al. Lost in knowledge translation: Time for a map? J Contin Educ Health. 2006;26:13-24. 57  13. Forsetlund L, Bjørndal A, Rashidian A, Jamtvedt G, O'Brien MA, Wolf F, Davis D, Odgaard-Jensen J, Oxman AD. Continuing education meetings and workshops: effects on professional practice and health care outcomes. Cochrane Db Syst Rev. 2009;2:CD003030. 14. Eccles M, Grimshaw J, Walker A, Johnston M, Pitts N. Changing the behavior of healthcare professionals: the use of theory in promoting the uptake of research findings. J Clin Epidemiol. 2005;58:107-12. 15. Godin G, Belanger-Gravel A, Eccles M, Grimshaw J. Healthcare professionals' intentions and behaviours: a systematic review of studies based on social cognitive theories. Implement Sci [Internet]. 2008 Jul [cited 2010 May 13];3:[about 12 p.].Available from: http://www.implementationscience.com/content/3/1/36 16. Michie S, Johnston M, Abraham C, Lawton R, Parker D, Walker A. Making psychological theory useful for implementing evidence based practice: a consensus approach. Qual Saf Health Care. 2005;14:26-33. 17. Michie S, Johnston M, Francis J, Hardeman W, Eccles M. From theory to intervention: mapping theoretically derived behavioural determinants to behaviour change techniques. Appl Psychol. 2008;574:660-80. 18. The Improved Clinical Effectiveness through Behavioural Research Group (ICEBeRG). Designing theoretically-informed implementation interventions. Implement Sci [Internet]. 2006 Feb [cited 2010 May 19]; 1(4):[about 8 p.].Available from: http://www.implementationscience.com/content/1/1/4 19. Grimshaw JM, Thomas RE, MacLennan G, Fraser C, Ramsay CR, Vale L,Whitty P, Eccles MP, Matowe L, Shirran L, Wensing M, Dijkstra R, Donaldson C. Effectiveness and efficiency of guideline dissemination and implementation strategies. Health Technol Asses. 2004;8:1-72. 20. Conner M, Sparks P. Theory of Planned Behaviour and health behaviour. In: Conner M, Norman P, editors. Predicting health behaviour: research and practice with social cognition models. 2nd ed. Maidenhead, England: Open University Press;2003. p. 170-222. 21. University of Massachusetts, Department of Psychology. TPB model. [cited 2009 Dec 22]. Available at: http;//www.people.umass.edu/aizen/tpb.diag.html#null-link. 22. Armitage CJ, Conner M. Efficacy of the theory of planned behaviour: a meta-analytic review. Brit J Soc Psychol.2001;40:471-99. 23. Sheeran P. Intention-behaviour relations: a conceptual and empirical review. Eur Rev Soc Psychol.2002;12:1-36. 24. Sackett D, Rosenberg W, Gray J, Haynes R, Richardson W. Evidence based medicine: what it is and what it isn't. Brit Med J. 1996;312: 71-2. 58  25. Iles R, Davidson M. Evidence based practice: a survey of physiotherapists' current practice. Physiother Res Int. 2006;11:93-103. 26. Turner P, Whitfield TW. Physiotherapists' use of evidence based practice: a crossnational study. Physiother Res Int. 1997;2:17-29. 27. Kamwendo K. What do Swedish physiotherapists feel about research? A survey of perceptions, attitudes, intentions and engagement. Physiother Res Int. 2002;7:23-34. 28. Jette DU, Bacon K, Batty C, Carlson M, Ferland A, Hemingway RD, Hill JC, Ogilvie L, Volk D. Evidence-based practice: beliefs, attitudes, knowledge, and behaviors of physical therapists. Phys Ther. 2003;83:786-805. 29. Schreiber J, Stern P, Marchetti G, Provident I. Strategies to promote evidence-based practice in pediatric physical therapy: a formative evaluation pilot project. Phys Ther. 2009;89:918-33. 30. Salbach NM, Jaglal SB, Korner-Bitensky N, Rappolt S, Davis D. Practitioner and organizational barriers to evidence-based practice of physical therapists for people with stroke. Phys Ther. 2007;87:1284-303. 31. O'Brien MA, Rogers S, Jamtvedt G, Oxman AD, Odgaard-Jensen J, Kristoffersen DT, Forsetlund L, Bainbridge D, Freemantle N, Davis DA, Haynes RB, Harvey EL. Educational outreach visits: effects on professional practice and health care outcomes. Cochrane Db Syst Rev. 2007;4:CD003786. 32. Doumit G, Gattellari M, Grimshaw J, O'Brien MA. Local opinion leaders: effects on professional practice and health care outcomes. Cochrane Db Syst Rev. 2007;4:CD000125. 33. Eccles MP, Hrisos S, Francis J, Kaner EF, Dickinson HO, Beyer F, Johnston M. Do self- reported intentions predict clinicians' behaviour: a systematic review. Implement Sci [Internet]. 2006 Nov [cited 2010 May 13];1:[about 10p.]. Available from: http://www.implementationscience.com/content/1/1/28 34. Perkins MB, Jensen PS, Jaccard J, Gollwitzer P, Oettingen G, Pappadopulos E, Hoagwood KE. Applying theory-driven approaches to understanding and modifying clinicians' behavior: what do we know? Psychiat Serv. 2007;58:342-8. 35. Sackett D, Straus S, Richardson W, Rosenberg W, Haynes R. Evidence-based medicine: How to practice and teach EBM. 2nd ed. New York: Churchill Livingstone; 2000. 36. De Vera Barredo R. Reflection and evidence based practice in action: a case based application. Internet J Allied Health Sci Pract. 2005;3:1-4.  59  37. Pain K, Magill-Evans J, Darrah J, Hagler P, Warren S. Effects of profession and facility type on research utilization by rehabilitation professionals. J Allied Health. 2004;33:3-9. 38. Metcalfe C, Lewin R, Wisher S, Perry S, Bannigan K, Moffett JK. Barriers to implementing the evidence base in four NHS therapies: dietitians, occupational therapists, physiotherapists, speech and language therapists. Phys Ther. 2001;87:43341. 39. Palfreyman S, Tod A, Doyle J. Comparing evidence-based practice of nurses and physiotherapists. Br J Nurs. 2003;12:246-53. 40. Rappolt S, Tassone M. How rehabilitation therapists gather, evaluate, and implement new knowledge. J Contin Educ Health Prof. 2002;22:170-80. 41. Jones M, Grimmer K, Edwards I, Higgs J, Trede F. Challenges in applying best evidence to physiotherapy. Internet J Allied Health Sci Pract. 2006;4:1-8. 42. Salbach N, Guilcher S, Jaglal S, Davis D. Factors influencing information seeking by physical therapists providing stroke management. Phys Ther. 2009;89:1039-50. 43. Salbach N, Veinot P, Rappolt S, Bayley M, Burnett D, Judd M, Jaglal SB. Physical therapists' experiences updating the clinical management of walking rehabilitation after stroke: a qualitative study. Phys Ther. 2009;89:556-68. 44. Guyatt G, Keller J, Singer J, Halcrow S, Newhouse M. Controlled trial of respiratory muscle training in chronic airflow limitation. Thorax. 1992;47:598-602. 45. Chen H, Dukes R, Martin BJ. Inspiratory muscle training in patients with chronic obstructive pulmonary disease. Am Rev Respir Dis. 1985;131:251-5. 46. Noseda A, Carpiaux JP, Vandeput W, Prigogine T, Schmerber J. Resistive inspiratory muscle training and exercise performance in COPD patients. A comparative study with conventional breathing retraining. B Eur Physiopath Res. 1987;23:457-63. 47. Smith K, Cook D, Guyatt GH, Madhavan J, Oxman AD. Respiratory muscle training in chronic airflow limitation: a meta-analysis. Am Rev Respir Dis. 1992;145:533-9. 48. O'Donnell DE, Aaron S, Bourbeau J, Hernandez N, Marciniuk D, Balter M, Ford G, Gervais A, Goldstein R, Hodder R, Maltais F, Road J. Canadian Thoracic Society recommendations for management of chronic obstructive pulmonary disease--2003. Can Respir J. 2003;10:11A-65A. 49. Nici L, Donner C, Wouters E, Zuwallack R, Ambrosino N, Bourbeau J et al. American Thoracic Society/European Respiratory Society statement on pulmonary rehabilitation. Am J Resp Crit Care. 2006;173:1390-413. 50. The Lung Association. Women and COPD: a national report. 2006.[cited 2009 Dec 14]. Avaialable at: http://www.lung.ca/_resources/Women_COPD_Report_2006.pdf. 60  51. Crowe J, Reid WD, Geddes EL, O'Brien K, Brooks D. Inspiratory muscle training compared with other rehabilitation interventions in adults with chronic obstructive pulmonary disease: a systematic literature review and meta-analysis. COPD. 2005;2:319-29. 52. Reid WD, Samrai B. Respiratory muscle training for patients with chronic obstructive pulmonary disease. Phys Ther. 1995;75:996-1005. 53. Reid WD, Sharma A. Respiratory muscle training in people with chronic obstructive pulmonary disease. Physiotherapy Singapore. 2000;3:113-26. 54. Thomson O'Brien MA, Freemantle N, Oxman AD, Wolf F, Davis DA, Herrin J. Continuing education meetings and workshops: effects on professional practice and health care outcomes. Cochrane Db Syst Rev. 2001;2:CD003030. 55. Jamtvedt G, Young JM, Kristoffersen DT, O‘Brien MA, Oxman AD. Audit and feedback: effects on professional practice and health care outcomes. Cochrane Db Syst Rev. 2006;2:CD000259 56. Menon A, Korner-Bitensky N, Kastner M, McKibbon K, Straus S. Strategies for rehabilitation professionals to move evidence-based knowledge into practice: A systematic review. J Rehabil Med. 2009;41:1024-32. 57. Farmer AP, Légaré F, Turcot L, Grimshaw J, Harvey E, McGowan JL, Wolf F. Printed educational materials: effects on professional practice and health care outcomes. Cochrane Db Syst Rev 2008;3:CD004398. 58. Baker R, Camosso-Stefinovic J, Gillies C, Shaw EJ, Cheater F, Flottorp S, Robertson  N. Tailored interventions to overcome identified barriers to change: effects on professional practice and health care outcomes. Cochrane Db Syst Rev. 2010;3:CD005470. 59. Sanson-Fisher RW, Grimshaw JM, Eccles MP. The science of changing providers'  behaviour: the missing link in evidence-based practice. Med J Aust. 2004;1805:2056. 60. Grol R. Beliefs and evidence in changing clinical practice. Brit Med J. 1997;315:418-  21. 61. Bhattacharyya O, Reeves S, Garfinkel S, Zwarenstein M. Designing theoreticallyinformed implementation interventions: fine in theory, but evidence of effectiveness in practice is needed. Implement Sci [Internet]. 2006 Feb[cited 2010 Nov 24];1;[about 3p]. Available from http://www.implementationscience.com/content/1/1/5 62. Fishbein M, Ajzen I. Belief, attitude, intention, and behavior: an introduction to theory and research. New York: Wiley; 1975. 61  63. University of Massachusetts, Department of Psychology. TPB Research Manual J. J. Francis et al. [cited 2010 Jan 25]. Available at: http://www.people.umass.edu/aizen/pdf/Francis%20etal.TPB%20research%20manual .pdf. 64. University of Massachusetts, Department of Psychology. Designing a TPB intervention.[cited 2009 Dec 22] Available at: http://www.people.umass.edu/aizen/tpb.html 65. O'Brien MA, Rogers S, Jamtvedt G, Oxman AD, Odgaard-Jensen J, Kristoffersen  DT, Forsetlund L, Bainbridge D, Freemantle N, Davis DA, Haynes RB, Harvey EL. Educational outreach visits: effects on professional practice and health care outcomes. Cochrane Db Syst Rev 2007;4:CD000409. 66. Eccles M, Hrisos S, Francis J, Steen N, Bosch M, Johnston M. Can the collective intentions of individual professionals within healthcare teams predict the team's performance: developing methods and theory. Implement Sci [Internet] 2009 May [cited 2010 Nov 24];4[about 10p].Available from http://www.implementationscience.com/content/4/1/24 67. Berwick DM. Disseminating Innovations in Health Care. J Amer Med Assoc.  2003;289:1969-75. 68. Seddon M, Marshall M, Campbell S, Roland M. Systematic review of studies of quality of clinical care in general practice in the UK, Australia and New Zealand. Qua Health Care. 2001;10:152-58. 69. World Health Organization. [cited 2010August 7] Available at http://www.who.int/features/qa/48/en/index.html. 70. Foy R, Eccles M, Grimshaw J. Why does primary care need more implementation research? Fam Pract. 2001;18(4):353-55. 71. Rennie D. Disclosure to the reader of institutional review board approval and  informed consent. J Amer Med Assoc.1997;277:922-23 72. Simms AM, Li LC, Reid WD. Development of a theory-based intervention to increase prescription of inspiratory muscle training by health professionals in the management of chronic obstructive pulmonary disease. Physiother Can. In press. 73. Portney LG, Watkins MP. Foundations of clinical research applications to practice. 3rd ed. New Jersey: Pearson Education; 2009. 74. Hintze, J. (2007). NCSS 2007. NCSS, LLC. Kaysville, Utah, USA. www.ncss.com 75. Confidence Interval Calculator for a Completion Rate: Measuring Usability. [Cited 2010 August 7] Available from: URL: http://www.measuringusability.com/wald.htm. 62  76. SPSS 16.0. 2007.Chicago: SPSS Inc. 77. Hulscher M LM, Grol R. Process Evaluations of quality improvement interventions. In: Grol R BR, Moss F, editors. Quality Improvement Reseach: Understanding the Science of Change in Health Care. London: BMJ Books; 2004. p 165-84. 78. Mikhail C, Korner-Bitensky N, Rossignol M, Dumas J. Physical therapists' use of interventions with high evidence of effectiveness in the management of a hypothetical typical patient with acute low back pain. Phys Ther. 2005;85:1151-67. 79. Korner-Bitensky N, Menon-Nair A, Thomas A, Boutin E, Arafah A. Practice Style Traits: Do they help explain practice behaviours of stroke rehabilitation professionals? J Rehabil Med 2007;39:685-92. 80. Marciniuk DD, Brooks D, Butcher S, Debigare R, Dechman G, Ford G, Pepin V, Reid D, AW, Stickland MK, Todd DC, Walker SL, Aaron SD, Balter M, Bourbeau J, Hernandez P, Maltais F, O'Donnell DE, Bleakney D, Carlin B, Goldstein R, Muthur SK; Optimizing pulmonary rehabilitation in chronic obstructive pulmonary disease practical issues: A Canadian Thoracic Society clinical practice guideline . Can Resp J. 2010;17:159-68. 81. Wensing M, Wollersheim H, Grol R. Organizational interventions to implement improvements in patient care: a structured review of reviews. Implement Sci [Internet]. 2006 Febl [cited 2010 Sept 9];2:[ about 9 p.].Available from: URL: http://www.implementationscience.com/content/1/1/2 82. Parmelli E, Flodgren G, Schaafsma EM, Baillie NN, Dickinson HO, Beyer FR, Eccles MP. The effectiveness of strategies to change organisational culture to improve healthcare performance (protocol). Cochrane Db Syst Rev. 2010;4:CD008315 83. Bero L, Grilli R, Grimshaw J, Harvey E, Hanines A, Donald A. Getting research findings into practice: closing the gap between research and practice: an overview of systematic reviews of interventions to promote the implementation of research findings. Brit Med J.1998;317:465-68. 84. Van Bokhoven M KG, Van Der Weijden T. Designing a quality improvement intervention: a systematic approach. In: Grol R BR, Moss F, editors. Quality improvement research: understanding the science of change in health care. London: BMJ Books;2004.p.147-64. 85. Wensing M, Bosch M, Grol R. Developing and selecting interventions for translating knowledge to action. Can Med Assoc J. 2010;182:E85-E88.  63  86. Eccles M GJ, Campbell M, Ramsay C. Research Designs for studies evaluating the effectivenss of change and improvement strategies. In: Grol R BR, Moss F, editors. Quality Improvement Research: understanding the science of change in health care. London: BMJ Books;2004.p.97-114. 87. Puffer S, Torgerson D, Watson J. Cluster randomized controlled trials. J Eval Clin Pract. 2005;11(5):479-83. 88. Davies P, Walker A, Grimshaw J. A systematic review of the use of theory in the design of guideline dissemination and implementation strategies and interpretation of the results of rigorous evaluations. Implement Sci. [Internet]. 2010 Feb [cited 2010 Nov 24]; 5(1):[about 6p.]. Available from http://www.implementationscience.com/content/pdf/1748-5908-5-14.pdf 89. Simpson J, Klar N, Donnor A. Accounting for cluster randomization: a review of primary prevention trials, 1990 through 1993. Am J Public Health.1995;85(10):137883. 90. Hahn S, Puffer S, Torgerson D, Watson J. Methodological bias in cluster randomised trials. BMC medical research methodology. [Internet]. 2005 Mar;5 [cited 2010 Nov 24]; 1;[about 8p.] Available at http://www.biomedcentral.com/1471-2288/5/10 91. Eccles M, Grimshaw J, Campbell M, Ramsay C. Research designs for studies evaluating the effectiveness of change and improvement strategies. Qual Saf Health Care. 2003;12(1):47-52.  64  Appendix A: Informed Consent Document THE UNIVERSITY OF BRITISH COLUMBIA  School of Rehabilitation Sciences Faculty of Medicine T325-2211 Wesbrook Mall Vancouver, British Columbia V6T 2B5 Phone: 604.822.7392 Fax: 604.822.7624 Web: www.rehab.ubc.ca  Crossing the Chasm: More Inspiratory muscle training for people with COPD Principal Investigator:  Co- Investigators:  Dr. Darlene Reid, University of British Columbia  Dr. Lynne Geddes, McMaster University Dr. Dina Brooks, University of Toronto Alison Hoens, University of British Columbia  A study funded by the Canadian Respiratory Health Professionals of The Lung Association An Invitation to Participate in a Research Study Over the last 6 months you participated in a continuing education exercise on the effects of Inspiratory Muscle Training (IMT) for COPD. During this education, you participated in focus groups and completed questionnaires designed to get feedback on your knowledge of IMT, your thoughts regarding the obstacles and challenges to prescribing IMT and how often you prescribed IMT to your patients with COPD. We are currently conducting a research study to determine if different teaching strategies to increase the use of breathing exercise are more effective in changing how you prescribe this exercise to your patients with COPD. The study is being conducted in 6 hospitals in 3 metropolitan centers across Canada. We are interested in determining if the way in which you received this training, subsequently changed the way you provide care to patients with COPD. Your completion and return of this consent form indicates your consent to submit the feedback and responses you provided during the training intervention to be included in this study. For example this includes the surveys you completed, focus groups discussion, as well as the clinical care you provided to patients during and after the training period (obtained via chart audit and surveys). 65  Confidentiality: All information which would permit your identification will be deleted where possible after your consent to participate. Signed consent forms will be kept in a locked filing cabinet. Please do not remove the identification number on the consent form. This number will be assigned to the questionnaire you completed, thereby enabling us to remove identifying information for all further data analysis. Thereafter data will be assigned a code number in place of your name and stored on password–protected computer. Your name will not be used to identify any of the information that you completed. Please note that only limited confidentiality can be offered in focus group sessions. We encourage all participants to refrain from disclosing the contents of the discussions outside of the focus group; however, we cannot control what other participants do with the information discussed. Personal identifying information will be eliminated from the transcripts of the recorded focus group sessions. No individual outside the research team will have access to the data. No information that could identify you will be shared with your colleagues, manager or employer. The name of the hospitals included in the studies will not be included in the publication. Only group data, discussing trends and comparisons across hospitals for example, will be published. Contact: If you have any questions or desire further information with respect to this study, you can contact Dr. Darlene Reid at (604) 875-4111 ext 66056. If you have any concerns about your participation as a research subject, you may contact the Research Subject Information Line at the UBC Office of Research Services at the University of British Columbia (604) 822-8598. Subject Consent: I understand that my participation in this study is entirely voluntary and that I may refuse to participate or I may withdraw from the study at any time without any consequences to my employment. I have received a copy of this consent form for my own records. I consent to participate in this study  Subject Signature  Print Name  Date  66  Appendix B: Survey - Use and Knowledge of Inspiratory Muscle Training in the management of patients with Chronic Obstructive Pulmonary Disease Section A. (please place an X in the most appropriate box) Have you prescribed Inspiratory Muscle Training (IMT) for patients with COPD during the last 6 months?  □ No – not during the last 6 months – please go to Section B, C and D. □ Yes – for some patients with COPD during the last 6 months– please complete section A 1- 7, C and D. A 1. Which device do you use?  PFLEX ™ Inspiratory Muscle Trainer  DHD Inspiratory Muscle Trainer  Threshold ® Inspiratory Muscle Trainer  Power breathe  Normocapneic hyperpnea  Modified targeted resistive breather like pflex ? If so, describe details  _______________________________________________________  Other – please specify ____________________________________ A 2. Please specify the parameters you use to prescribe IMT as requested below. a. Please specify the number of training sessions ______ sessions per day ______ days per week ______ weeks b. Please specify the length of each session c. Each session is interval , continuous  ______ minutes  or both   d. Within each session, is the pattern of breathing fixed?  Yes  No e. How is the intensity selected for each session? (please describe)  f. How is the intensity of training progressed? (please describe)  g. How is the decision made to end the IMT program? (please describe)  67  h. Which outcome measure(s) do you use? □ None  Pe max/MEPS (peak/maximal expiratory pressure)  Pi max / MIPS (peak/maximal inspiratory pressure)  Quality of life measure (specify which one)  __________________________________________  Dyspnea scale (specify which one)  _______________________________________________  General exercise capacity (specify if bike test, treadmill test or walk test)  Inspiratory muscle endurance Other (please specify) _________________________ A 3. Do you prescribe a IMT maintenance program?  □  No  □  Yes (please describe)  _________________________________________________________ _____________________________________________________ A 4. For which patients with COPD would you prescribe IMT? Please list 3-5 factors (eg do you consider disease severity, use of supplemental oxygen, acute/rehab)?  1. 2. 3. 4. 5.  _____________________________________________________ _____________________________________________________ _____________________________________________________ _____________________________________________________ _____________________________________________________  A 5. Are there patients with COPD for whom you WILL NOT prescribe IMT?  No   Yes (please describe)  _______________________________________________________ A 6. Are there any precautions to using IMT with this population?  No   Yes (specify)  _________________________________________________________ _____________________________________________________ A 7. Are there any contraindications to using IMT with this population?  No  Yes (specify)  _______________________________________________________ _______________________________________________________ Please go to sections C (next page )  68  Section B (For those PTs NOT presently using IMT in the management of patients with COPD) Did you ever use IMT for this population? No – specify why NOT.  _________________________________________________________ _____________________________________________________ Yes – used previously but not currently – please specify why you stopped.  _________________________________________________________ _____________________________________________________ Section C.  We would like to know some details about you and your facility.  C 1 What is your highest educational qualification ?  □  Diploma □ Baccalaurate degree □ Masters Degree Year of completion for last degree _______ C 2 How long since you graduated as a PT? ______ years  □  Doctorate  C 3 Is your caseload of patients with COPD mostly: acute  rehabilitation  C 4 Are you involved in the clinical education of PT students?  Yes  No  ______ beds  C 5 How many beds does your facility have?  C 6 Is your hospital a designated teaching hospital?  Yes  No C 7 Have you had previous education on inspiratory muscle training?  □ Entry level C8  □ Continuing education  □ Practical training at worksite  Full time/Part Time/Casual or other:  □ C9  □ Part-time  Full-time  □ Casual/Locums  Health Care Profession  □ Physiotherapist □ Respiratory Therapist □ Nurse □ Other: Please specify ______________________ C 10 How many years have you practiced your profession  □ < 5 years C 11  □ 5- 10 years  □ 11-20 years  □ > 20 years  Years experience in Pulmonary Rehabilitation  □ < 5 years  □  5- 10 years  □11-20 years  □  > 20 years  Other comments below Please complete Multiple Choice Questions on next page  69  Inspiratory Muscle Training - Multiple Choice Questions – Please circle the best answer a. b. c. d.  1. Primary muscles of inspiration Include the diaphragm, scalenes and parasternal intercostals Are only recruited during exercise in healthy people Are only recruited during tidal breathing in people with chronic respiratory disease Produce a positive pressure in the thoracic cavity during inspiration  2. Inspiratory muscle force a. Can be measured during a maximal expiratory maneuver b. Can be measured at total lung capacity c. Can be measured at functional residual capacity and residual volume d. Is increased in people with high spinal cord lesions e.g. C3 or higher 3. The best training device of inspiratory muscle training in people with chronic obstructive pulmonary disease is: a. The DHD device (that has interchangeable coloured discs with different sized holes), without an incentive spirometer b. The P-flex device (that has a dial to adjust the diameter of the inspiratory hole) without an incentive spirometer c. The Powerlung, that is made of blue plastic and can add adjustable loads to inspiration and expiration d. The Threshold trainer that is made of clear plastic and can add inspiratory threshold loads by adjusting the spring-loaded inspiratory valve. 4. Maximal inspiratory pressure a. Can be abbreviated as Pdi b. Can be abbreviated as MIP or PImax c. Should not be tested while the person is wearing nose plugs d. Will be the same magnitude when the person is in different body positions 5. Normative values of inspiratory muscle strength are based on a. Height, weight and gender b. Height, weight, age, and gender c. Gender and height d. Only gender 6. Prescription parameters for inspiratory muscle training should a. follow American College of Sports Medicine guidelines b. include a training intensity of 60-80% for all training sessions c. should be prescribed cautiously to avoid excessive fatigue and injury d. should be performed a minimum of 30 minutes per session 7. Signs and symptoms of overtraining the inspiratory muscles of people with chronic respiratory disease are a. Excessive dyspnea b. Discoordinated chest wall movement c. Muscle soreness d. All of the above 8. a. b. c. d. 9. a. b. c. d.  People that might benefit from inspiratory muscle training are Those individuals who are dyspneic or have weak inspiratory muscles Patients post-operatively who have atelectasis Patients with pneumonia Patients in acute respiratory failure. Inspiratory muscle training is contra-indicated or should be prescribed with caution for People involved in elite athletic sports Neuromuscular disorders Stable people with COPD with a maximal inspiratory pressure that is slightly less the normative value. Stable patients with COPD who are coping well with an exercise program involving upper and lower extremity aerobic exercise.  70  Appendix C: Behavioural Based Group - Slide Presentation  71  72  73  74  Appendix D: Behavioural Group Handout - How to Prescribe Inspiratory Muscle Training to People with COPD Much of the information in this handout is based on the articles: Reid WD, Geddes EL, Brooks D, O‘Brien K, Crowe J. Inspiratory Muscle Training in Chronic Obstructive Pulmonary Disease (COPD). Special Series on Skeletal Muscle Training. Physiotherapy Canada 2004;56(3):128-142 Geddes, E.L., Reid, W.D., Crowe, J., O'Brien, K., Brooks, D. Inspiratory muscle training in adults with chronic obstructive pulmonary disease: A systematic review. Respir Med. 2005;99:1440-1458. Evidence: Excellent evidence exists to support the use of inspiratory muscle training in order to improve inspiratory muscle strength and endurance, and to decrease dyspnea. An Overview of How to Prescribe IMT for People with COPD: 1. Obtain reliable measures of Maximal Inspiratory Pressure (short formed as MIP or PI max), and Maximal Expiratory Pressure (short formed as either MEP or PEmax) either by having a physician order them from a pulmonary function laboratory or by performing them in a reliable, valid manner using an electronic force meter (see below for details). 2. Obtain a reliable measure of inspiratory muscle endurance by performing an incremental, progressive loading test using a threshold loading device (see below for details). 3. Training using a threshold trainer a. Begin with a short training session (< 5 min) and progress over two – three weeks to a training duration of two – fifteen minute periods or one thirty minute period. b. Instruct patient to train 4-5 days per week with at least two days off to rest. c. Begin at a low intensity (20-30% of MIP) and progress to 50% of MIP over three to four weeks as tolerated. May progress to 70% in very fit patients but use caution. Progress slowly and monitor carefully. 4. Monitor the following during each supervised training session a. oxygen saturation, b. BP, HR, RR c. other signs & symptoms of respiratory distress or inability to tolerate exercise load. 5. Retest MIP and the measure of inspiratory muscle endurance every 4-6 weeks.  MICRORPM ELECTRONIC FORCE METER  75  Strength Testing of Respiratory Muscles How to measure Maximal Inspiratory Pressure (MIP) using the MicroRPM electronic force meter  Assemble the MicroRPM with the inspiration pressure valve assembly (see page 5 of the Respiratory Pressure Meter Operating Manual)  Slide the switch on the face of the meter from „off‟ position to the MIP/MEP position  Have the subject sit in an erect position with feet flat on the floor  Give the following instructions to the client: Please put the nose clips on. Breathe all your air out. Put the mouthpiece in your mouth. Seal your lips around the mouthpiece as tightly as possible. At the very bottom and suck in as hard as possible… like you are trying to suck up a very thick milkshake. Hold for at least 2 seconds.   Ensure that the mouthpiece flange is positioned over the gums and inside the lips and that the “bite blocks” are between the teeth.  Ensure that the subject does not lean forward and that they hold the pressure constant for 1-2 seconds. The pressure for each test is the average of at least 1 second not the peak pressure  The best result from 3 tests, with a suitable 1 or 2 minute recovery period between efforts, is used as the value of inspiratory muscle strength. How to measure Maximal Expiratory Pressure ( MEP) using the MicroRPM electronic force meter  Assemble the MicroRPM with the expiratory pressure valve assembly (see page 5 of the Respiratory Pressure Meter Operating Manual)  Slide the switch on the face of the meter from „off‟ position to the MIP/MEP position  The test is performed in the identical fashion as that for MIP except the instructions to the client are as follows: Please put the nose clips on. Take a slow deep breath in and fill to the very top of your lungs. Put the mouthpiece in your mouth. Seal your lips around the mouthpiece as tightly as possible. At the very top, and blow out as hard as possible. Hold for at least 2 seconds.   The best result from 3 tests, with a suitable 1 or 2 minute recovery period between efforts, is used as the value of expiratory muscle strength.  General Principles  Lung volumes should be standardized when measuring MIPs and MEPs, using residual volume for MIP and total lung capacity for MEP.  MIP and MEP values are variable based on age and sex – larger in men than in women 1,2 and declining with age. 1,2  MIP and MEP values that are lower than age-predicted values may reflect generalized muscle weakness whereas a decreased MIP and normal MEP is indicative of specific inspiratory muscle weakness. However, determination of whether the patient‟s values are abnormally low may be difficult because there is a very large normal range (as much as  40 cm H2O) and some patients such as the elderly who are of ill health may have as much as a 25% lower value with no specific respiratory muscle abnormality. In addition, some clients require many learning trials before performing the MIP and MEP effectively. 1  Black LF, Hyatt RE. Maximal static respiratory pressures: normal values and relationship to age and sex. Am Rev Respir Dis 1969; 99: 696-702. 2 Enright PL, Kronmal RA, Manolio TA, Schenker MB, Hyatt RE. Respiratory muscle strength in the elderly: correlates and reference values. Am J Respir Crit Care Med 1994; 149: 430-438.  76  How to Determine if Inspiratory Muscle Weakness is Present 1) Compare best test result for MIP to the normative values 3 in the table below. Weakness is present if the values is less than the 5 th percentile. Age (yrs) Men 18-30 31-40 41-50 51-60 61-70 >70 Women 18-30 31-40 41-50 51-60 61-70 >70  MIP (cm H2O) 5th Mean Percentile 107 59 105 54 106 58 105 65 86 57 82 50 81 76 79 77 67 68  Best Result Age (yrs)  ________  Height (cm)  ________  Weight (kg)  ________  2  _________  BMI (kg/M )  45 47 43 48 37 38  ________  BMI = weight ÷ height  2  2) Calculate predicted values based on the regression equations4 that provide the age predicted value + the standard error of the estimate. Compare best test result to predicted value. Men: MIP = 126 – 1.029 × age + 0.343 × weight (kg) + 22.4 Women: MIP = 171 – 0.694 × age + 0.861 × weight (kg) – 0.743 × height(cm) + 18.5  Endurance Testing of the Inspiratory Muscles Stage Time 1  MIP (cm H2O) RR  2  0-3 9 min 6 min 13  3  9 min 17  4  12 min 21  5  15 min 25  6  18 min 29  7  21 min 33  8  24 min 37  9  27 min 41   Subject wears nose clips and the therapist observes closely for air leaks occur, especially near maximal loads.  This test is a progressive, incremental test that has the threshold load increased every three minutes.  Begin at 9 cm H2O for the first stage. Ask the subject to breathe in and out using a relaxed breathing pattern against the load for three minutes.  Every three minutes, ask the subject to stop. Quickly remove the mouthpiece, increase the load by 4 cm H20 and continue with the test for the next 3 minute stage.  The test ends when the patient can no longer continue because the effort is too great, the patient completes the maximal stage, or the patient desaturates or has any other untoward response to inspiratory muscle loading.  Hautmann H, Hefele S, Schotten K, Huber RM. Maximal inspiratory mouth pressures (PIMAX) in healthy subjects – what is the lower limit of normal. Resp Med 2000;94:689-693. 4 Harik-Khan RI, Wise RA, Fozard JL. Determinants of maximal inspiratory pressure. The Baltimore longitudinal study of aging. Am J Respir Crit Care Med 1998; 158:1459-1464 3  77  Selection Criteria for Patients Selection Criteria  Proceed with Caution  Contraindicated  Patients with chronic respiratory disease who meet one or more of the following might benefit from IMT  Highly motivated and patient will perform IMT in addition to a wellrounded exercise program;  Aerobic exercise of extremities at moderate intensities is risky and supervised training is not available;  Very dyspneic;  Weak inspiratory muscles Patient should be well managed in other aspects of rehabilitative care including medications, oxygen therapy (if required), adequate nourishment  Inspiratory muscle weakness of unknown etiology  Patient on medications with known myopathic side-effects e.g. corticosteroids and statins  Long-standing chronic hypercapnic ventilatory failure  Inspiratory muscle weakness of neuromuscular etiology  Acute respiratory failure  Ongoing Assessment Considerations: Fatigue, Injury, Safety Issues, and other Precautions          Before initiating a training program, the therapist should assess the client in a similar fashion as would be performed for exercise training. Indications similar to those for stopping exercise of the extremities should be used to discontinue inspiratory muscle testing and training. Baseline measures of oxygen saturation, heart rate, blood pressure, and interviewing of the client should be performed in order to ensure that they are stable and fit to do IMT. Monitoring of oxygen saturation (SpO2) and respiratory rate may provide good outcomes to ensure that the client's level of ventilation is adequate to maintain arterial blood gases within an appropriate range. The specific cut-off SpO2 will vary between clients but the absolute cut-off for discontinuing inspiratory muscle testing or training would be the inability to maintain the SpO 2 above 85 mm Hg. Similarly untoward signs such as lightheadedness, confusion, and headache as outlined by Fletcher et al.5 needs to be looked for to ensure that the patient is coping with the inspiratory IMT. Extreme fatigue and exertion-induced muscle injury should be avoided. Unfortunately, good clinical tools to evaluate fatigue and injury of the inspiratory muscles are lacking. Discoordinated chest wall movement during breathing is a sign of fatiguing inspiratory muscles. Delayed onset muscle soreness (DOMS) of the neck and chest wall musculature may be indicative of exertioninduced muscle injury, which usually occurs 24 to 48 hours after the exercise. Muscles are sore upon palpation and some of the soreness may be alleviated by gentle exercise. Because clinical assessment of fatigue and exertion-induced muscle injury is very difficult to evaluate in clients at the present time, the therapist should be very cautious in prescribing the intensity and progressing the intensity of training. One needs to be especially judicious when prescribing training to clients who show signs of inspiratory muscle weakness or hypercapnea.  5  Fletcher GF, Balady G, Froelicher VF, Harley LH, Haskell WL, Pollock ML. Exercise standards. A statement for health care professionals from the American Heart Association. Circulation 1995:91:580-615.  78  Prescription and Monitoring Parameters for Inspiratory Muscle Training (IMT)  Prescription Parameters To ensure adequate training load  Intensity of Load  Defined as a % of MIP. Begin at a low % of MIP (20-30%). Progress as tolerated at no more than 5% per week. Threshold trainer For threshold trainer: let patient self-select their breathing frequency Begin at low duration as tolerated (5-15 min). Monitor the patient‘s sense of air hunger when beginning the IMT program. Add 1 minute every third day to tolerance. Continue increasing duration until patient is able to sustain two 15 minute periods or one 30 minute period. 4-5 times per wk for endurance effect. 1-2 days rest per week to avoid staleness, fatigue, and muscle injury Indefinitely  Type of Load  Duration  Frequency Length of Training  Variables to Monitor Why To avoid fatigue  To avoid muscle injury  To avoid hypercapnea  Parameter Discoordinated chest wall movement Excessive dyspnea during training Long-lasting fatigue after training Signs of delayed onset muscle soreness Reduced strength Reduced endurance End-tidal CO2 oxygen saturation Signs of headache, confusion  How to do? Observation; monitoring respiratory rate Interview Interview Interview Decreased MIP on reassessment Inability to tolerate usual training load i.e. intensity or duration End-tidal CO2 monitor Pulse oximeter Interview  IMT OUTCOMES TO ASSESS FOR PEOPLE WITH COPD Maximal inspiratory Pressures: 3 best test within 5% before and after trial st nd rd Date 1 test 2 test 3 test  Other details: 6 minute walk test distance & Borg’s dyspnea rating on 10 point scale at end of 6 minute walk test Date  1st test Distance (m) Borg‟s Rating  2nd test Distance (m) Borg‟s Rating  3rd test Distance (m) Borg‟s Rating  Other details:  79  Chronic Respiratory Questionnaire Scores  Date  Domain Scores ( out of possible score of 7) Dyspnea Fatigue Emotional Mastery  Component Scores Physical Emotional  Total Score  Total Score Other Details:  Example of Home Prescription Sheet  Inspiratory Muscle Training (IMT) Prescription Sheet Name:______________________ The F.I.T.T Principle  Frequency = How Often? Intensity = How Hard?  Date:__________________  Initial Recommendations for you  General Guidelines       Time = How Long?       Type = Threshold® IMT    4 to 5 days per week 1 to 2 rest days per week Set by Therapist 20 to 50% MIP Progress as tolerated at no more than 5% per week Can be as little as 5 minutes Progress slowly Add 1 minute every 3rd day to tolerance Goal two 15 minute sessions or one 30 minutes session Threshold or targeted IMT  Comments/Progression:  Staff Signature________________________ Your Next IMT Review date is:______________ Time:___________ SAFETY POINTS - REMEMBER TO STOP TRAINING …  If you feel unwell  If you feel very breathless during training  If you have rested but still feel fatigued  If your chest or neck muscles feel unusually sore  If you experience headaches or confusion with training TALK TO THE THERAPIST BEFORE RESTARTING YOUR PROGRAM  80  Appendix E: Behavioural-Based Group Handout - Inspiratory Muscle Training Information Sheet INSPIRATORY MUSCLE TRAINING – WHAT IS IT? This type of training enables Participants to exercise the inspiratory muscles by breathingagainst a threshold or resistive load. The Threshold trainer shownin the diagram can provide variable inspiratory loads by tightening or loosening the spring. WHAT DOES THE LITERATURE SAY ABOUT IT’S EFFICACY? TARGETED/THRESHOLD IMT VS SHAM Systematic reviews have demonstrated that IMT has the following effects: 1. Respiratory muscle strength - improved maximal inspiratory pressure (PImax) by 11.6 cm H2O and PImax % predicted by 23.2%    2. Respiratory muscle endurance - increased inspiratory threshold loading by 1.36 kPa and endurance time by 4.43 min - increased maximum minute ventilation by 6.55 L/min 3. Exercise capacity – Borg score for effort decreased by 1.76 (0 -10 grade scale) – 6 Minute Walk Distance increased 32.1 M 4. Dyspnea - Focal score of Transitional Dyspnea Index increased by 2.55 5. Quality of Life - improvement in Chronic Respiratory Questionnaire 6. Increase in Inspiratory Flow Rate – to that required for some dry powder inhalers IMT WITH NO TARGET o Most studies (4/6) showed no improvements o Only one study showed improved dyspnea and increased endurance time on cycle ergometer o The primary limitation of this device is that patients can slow down their breathing rate when using this device so the major outcome of training is a slower breathing rate rather than training at a higher resistive load.  Conclusions From the literature o – – – –  IMT is effective in the management of people with COPD to improve inspiratory muscle strength and endurance; decrease dyspnea; increase peak inspiratory flow to the minimum threshold level for use of some dry powder inhalers. improves quality of life and 6 minute walk distance o IMT must use targeted or threshold device o IMT is under-utilized in practice PATIENT SELECTION – stable COPD o Studies included mostly moderate to severe COPD (some included mild) o Not during acute exacerbation o Not immediately following exacerbation o Extreme caution should be used for those with stable hypercapnic ventilatory failure RISKS REPORTED o One incident of ear ache. SUMMARY  Like other skeletal muscle, inspiratory muscles can be trained.  People with stable COPD can benefit from IMT.  IMT is under-utilized by physiotherapists, respiratory therapists, and other pulmonary practitioners.  Appropriate parameters (FITT) are needed, including a targeted or threshold device.  Ideally IMT should be in conjunction with pulmonary rehabilitation.  81  REFERENCES REPORTS USING THRESHOLD OR TARGETED DEVICES 1. Belman MJ, Shadmehr R. Targeted resistive ventilatory muscle training in chronic obstructive pulmonary disease. J Appl Physiol. 1988; 65(6):2726-35. 2. Harver A, Mahler DA, Daubenspeck JA. Targeted inspiratory muscle training improves respiratory muscle function and reduces dyspnea in patients with chronic obstructive pulmonary disease. Ann Intern Med.1989; 111(2):117-24. 3. Heijdra YF, Dekhuijzen PN, van Herwaarden CL, Folgering HT. Nocturnal saturation improves by target-flow inspiratory muscle training in patients with COPD. Am J Respir Crit Care Med. 1996; 153(1):260-5. 4. Hsiao SF, Wu YT, Wu HD, Wang TG. Comparison of effectiveness of pressure threshold and targeted resistance devices for inspiratory muscle training in patients with chronic obstructive pulmonary disease. J Formos Med Assoc. 2003; 102(4):240-5. 5. Kim MJ, Larson JL, Covey MK, Vitalo CA, Alex CG, Patel M. Inspiratory muscle training in patients with chronic obstructive pulmonary disease. Nurs Res. 1993; 42(6):356-62. 6. Larson JL, Kim MJ, Sharp JT, Larson DA. Inspiratory muscle training with a pressure threshold breathing device in patients with chronic obstructive pulmonary disease. Am Rev Respir Dis.1988; 138(3):689-96. 7. Lisboa C, Villafranca C, Leiva A, Cruz E, Pertuze J, Borzone G. Inspiratory muscle training in chronic airflow limitation: effect on exercise performance. Eur Respir J. 1997; 10(3):537-42. 8. Patessio A, Rampulla C, Fracchia C, Ioli F, Majani U, De Marchi A, Donner CF. Relationship between the perception of breathlessness and inspiratory resistive loading: report on a clinical trial. Eur Respir J Suppl.1989; 7:587s-591s. 9. Preusser BA, Winningham ML, Clanton TL. High versus low-intensity inspiratory muscle interval training in patients with COPD. Chest 1994; 106(1):110-117. 10. Ramirez-Sarmiento A, Orozco-Levi M, Guell R, Barreiro E, Hernandez N, Mota S, Sangenis M, Broquetas JM, Casan P, Gea J. Inspiratory muscle training in patients with chronic obstructive pulmonary disease: structural adaptation and physiologic outcomes. Am J Respir Crit Care Med. 2002; 166(11):1491-7. 11. Reid WD, Warren CPW. Ventilatory muscle strength and endurance training in elderly subjects and patients with chronic airflow limitation: a pilot study. Physiother Can 1984; 36(6):305-311 12. Sanchez Riera H, Montemayor Rubio T, Ortega Ruiz F, Cejudo Ramos P, Del Castillo Otero D, Elias Hernandez T, Castillo Gomez J. Inspiratory muscle training in patients with COPD: effect on dyspnea, exercise performance, and quality of life. Chest. 2001; 120(3):748-56. 13. Villafranca C, Borzone G, Leiva A, Lisboa C. Effect of inspiratory muscle training with an intermediate load on inspiratory power output in COPD. Eur Respir J. 1998; 11(1):28-33. REPORTS USING NON-TARGETED TRAINING DEVICES 14. Bjerre-Jepsen K, Secher NH, Kok-Jensen A. Inspiratory resistance training in severe chronic obstructive pulmonary disease. Eur J Respir Dis 1981;62:405-411. 15. Guyatt G, Keller J, Singer J, Halcrow S, Newhouse M. Controlled trial of respiratory muscle training in chronic airflow limitation. Thorax 1992; 47(8): 598-602. 16. Jones DT, Thomson RJ, Sears MR. Physical exercise and resistive breathing training in severe chronic airways obstruction – are they effective? Eur J Respir Dis 1985; 67: 159-166. 17. Richardson J, Dunn L, Pardy R. Inspiratory resistive endurance training in patients with chronic obstructive pulmonary disease: a pilot study. Physiother Can 1989; 41(2): 85-92. 18. Falk P, Eriksen AM, Kølliker K, Andersen JB. Relieving dyspnea with an inexpensive and simple method in patients with severe chronic airflow limitation. Eur J Respir Dis 1985; 66(3): 181-186. 19. McKeon JL, Turner J, Kelly C, Dent A, Zimmerman PV. The effect of inspiratory resistive training on exercise capacity in optimally treated patients with severe chronic airflow limitation. Aust N Z J Med 1986; 16(5): 648652. SYSTEMATIC AND NARRATIVE REVIEWS 20. Crowe J, Reid WD, Geddes EL, O‟Brien K, Brooks D. Inspiratory muscle training compared with other rehabilitation interventions in adults with chronic obstructive pulmonary disease: A systematic literature review and meta-analysis. Journal of Chronic Obstructive Pulmonary Disease. 2005; 3:1-11. 21. Geddes EL, Reid WD, Crowe J, O‟Brien K, Brooks D: Inspiratory muscle training in adults with chronic obstructive pulmonary disease: A systematic review. Respiratory Medicine 2005;99:1440-1458. 22. Reid WD, Geddes EL, Brooks D, O‟Brien K, Crowe J: Inspiratory muscle training in chronic obstructive pulmonary disease. Special Series on Skeletal Muscle Training. Physiotherapy Canada 2004; 56(3): 128-142. 23. Lotters F. van Tol B. Kwakkel G. Gosselink R. Effects of controlled inspiratory muscle training in patients with COPD: a meta-analysis. Eur Respir J 2002; 20: 570-6.  82  Appendix F: Behavioural-based Group Session 2 Guide - Problem Solving Session  Inspiratory Muscle Training Debrief – to provide insight into why IMT was not implemented 1. Do you have any questions about the research evidence presented? 2. Do you require clarification about how to do the technique: o Selection of appropriate individuals for IMT o Testing respiratory muscle strength or endurance - Maximal inspiratory pressure - Threshold Test o Using the MicroRPM with multiple individuals - Obtaining spare or disposable parts for the MircoRPM - Sterilizing the MicroRPM between uses o Establishing the initial IMT prescription o Teaching an individual to use the Threshold ® trainer - Keeping the Threshold ® device clean o Monitoring vitals and IMT tolerance o Progression of frequency, intensity, or time o Outcomes measures for IMT  3. Are there any organizational challenges to implementing IMT you would like to discuss? o Time pressures o Availability of resources o Soliciting support from physicians, management, or co-workers 4. What challenges are you having in implementing IMT?  83  Appendix G: Information-Based Group Slides – Inspiratory Muscle Training for Adults with Chronic Obstructive Pulmonary Disease: Evidence and Clinical Recommendations  84  85  86  87  88  89  90  91  Appendix H: Information -Based Group Handout - How to Prescribe Inspiratory Muscle Training to People with COPD  How to Prescribe Inspiratory Muscle Training to People with COPD Much of the information in this handout is based on the articles: Reid WD, Geddes EL, Brooks D, O‘Brien K, Crowe J. Inspiratory Muscle Training in Chronic Obstructive Pulmonary Disease (COPD). Special Series on Skeletal Muscle Training. Physiotherapy Canada 2004;56(3):128-142 Geddes, E.L., Reid, W.D., Crowe, J., O'Brien, K., Brooks, D. Inspiratory muscle training in adults with chronic obstructive pulmonary disease: A systematic review. Respir Med. 2005;99:1440-1458. Evidence: Excellent evidence exists to support the use of inspiratory muscle training in order to improve inspiratory muscle strength and endurance, to decrease dyspnea, increase 6 minute walk distance and quality of life. An Overview of How to prescribe IMT for People with COPD: 1. Obtain reliable measures of MIP or PImax, and MEP or PEmax either by having a physician order them from a pulmonary function laboratory or by performing them in a reliable, valid manner (see below for details). 2. Obtain a reliable measure of inspiratory muscle endurance by performing an incremental, progressive loading test using a threshold loading device (see below for details). 3. Begin training a. using a threshold trainer or inspiratory resistive trainer connected to an incentive spirometer. b. begin for a short training session (< 5 min) and progress over two – three weeks to a training duration of two – fifteen minute periods or one thirty minute period. c. instruct patient to train 4-5 days per week with at least two days off to rest. d. begin at a low intensity (20-30% of MIP or PImax) and progress to 50% of MIP or PImax over three to four weeks as tolerated. May progress to 70% in very fit patients but use caution. Progress slowly and monitor carefully. 4. Monitor the following during each supervised training session: a. oxygen saturation, b. BP, HR, RR c. other signs & symptoms of respiratory distress or inability to tolerate exercise load. 5. Retest MIP or PImax, and the measure of inspiratory muscle endurance every 4-6 weeks. Strength Testing of Respiratory Muscles How to measure Maximal Inspiratory Pressure (short formed as either MIP or PImax) • Have the subject sit in an erect position with feet flat on the floor. • Rest the pressure gauge on the table so the tester and the subject can clearly see the dial. • Pivot the red marker arrow. Depending on the specific brand being used, either move red arrow so it rests under the black arrow or place it adjacent to the black arrow in the direction of the desired movement of the arrows. • Give the following instructions to the subject: Please put the nose clips on. Breathe all your air out. At the very bottom, put the mouthpiece in your mouth, seal your lips around the mouthpiece as tightly as possible and suck in as hard as possible… like you are trying to suck up a very thick milkshake. Hold for at least 1-2 seconds. • As the subject completes the maneuver, ensure the thumb port is occluded.  92  • Ensure that the subject does not lean forward and that they hold the pressure constant for 1-2 seconds. The pressure for each test is the average of at least 1 second not the peak pressure • At least 5 tests should be performed until three measures are within 5% of each other. Usually 10 or more tests are required in order for the subject to achieve 3 measures with this small amount of variability. • The MIP or PImax is taken as the average of three measures. How to measure Maximal Expiratory Pressure (short formed as either MEP or PEmax) • The test is performed in the identical fashion as that for MIP or PI max except the instructions to the subject are as follows: Please put the nose clips on. Take a slow deep breath in and fill to the very top of your lungs. At the very top, put the mouthpiece in your mouth, seal your lips around the mouthpiece as tightly as possible and blow out against the pressure manometer as hard as possible. Hold for at least 1-2 seconds. General Principles • Lung volumes should be standardized when measuring MIPs and MEPs, using residual volume for MIP and total lung capacity for MEP. • MIP and MEP values are variable based on age and sex – larger in men than in women and declining with age1,2. • MIP and MEP values that are lower than age-predicted values1,2 may reflect generalized muscle weakness whereas a decreased MIP and normal MEP is indicative of specific inspiratory muscle weakness. However, determination of whether the patient‟s values are abnormally low may be difficult because there is a very large normal range (as much as ± 40 cm H2O) and some patients such as the elderly who are of ill health may have as much as a 25% lower value with no specific respiratory muscle abnormality. In addition, some clients require many learning trials before performing the MIP and MEP effectively.  Types of Devices  1 Black  LF, Hyatt RE. Maximal static respiratory pressures: normal values and relationship to age and sex. Am Rev Respir Dis 1969; 99: 696-702. 2 Enright PL, Kronmal RA, Manolio TA, Schenker MB, Hyatt RE. Respiratory muscle strength in the elderly: correlates and reference values. Am J Respir Crit Care Med 1994; 149: 430-438.  93  Test Results 1. ______2. ________ 3. _______ 4. ________ 5. ________ 6. _______ 7. _______ 8. ______9. _______ 10. _______11. ________12. ________13. ______14. ______ 1) Were 3 of the best test results within 5%? 2) How does the best test result compare to the normative values in the table below (Hautmann et al.)? They are defined as weakness if the values are less than the 5th percentile  3) Calculate predicted values based on the regression equations from the article from Harik-Khan et al. that provide the age predicted value + the standard error of the estimate Men: MIP = 126 – 1.029 × age + 0.343 × weight (kg) + 22.4 Women: MIP = 171 – 0.694 × age + 0.861 × weight (kg) – 0.743 × height(cm) + 18.5 Hautmann H, Hefele S, Schotten K, Huber RM. Maximal inspiratory mouth pressures (PIMAX) in healthy subjects – what is the lower limit of normal. Resp Med 2000;94:689-693. Harik-Khan RI, Wise RA, Fozard JL. Determinants of maximal inspiratory pressure. The Baltimore longitudinal study of aging. Am J Respir Crit Care Med 1998; 158:1459-1464  Ongoing Assessment Considerations: Fatigue, Injury, safety issues, and other Precautions • Before initiating a training program, the physiotherapist should assess the patient in a similar fashion as would be performed for exercise training. • Indications similar to those for stopping exercise of the extremities should be used to discontinue inspiratory muscle testing and training. • Baseline measures of oxygen saturation, heart rate, blood pressure, and interviewing of the patient should be performed in order to ensure that they are stable and fit to do IMT • monitoring of SaO2 and respiratory rate may provide good outcomes to ensure that the patient's level of ventilation is adequate to maintain arterial blood gases within an appropriate range. The specific cut-off SaO2 will vary between patients but the absolute cut-off for discontinuing inspiratory muscle testing or training would be the inability to maintain the SaO2 above 85 mm Hg Similarly untoward signs such as lightheadedness, confusion, and headache as outlined by Fletcher et al.1 needs to be looked for to ensure that the patient is coping with the inspiratory IMT. • Extreme fatigue and exertion-induced muscle injury should be avoided. Unfortunately, good clinical tools to evaluate fatigue and injury of the inspiratory muscles are lacking. Discoordinated chest wall movement during breathing is a sign of fatiguing inspiratory muscles. Delayed onset muscle soreness (DOMS) of the neck and chest wall musculature may be indicative of exertion-induced  94  muscle injury, which usually occurs 24 to 48 hours after the exercise. Muscles are sore upon palpation and some of the soreness may be alleviated by gentle exercise. • Because clinical assessment of fatigue and exertion-induced muscle injury is very difficult to evaluate in patients at the present time, the physiotherapist should be very cautious in prescribing the intensity and progressing the intensity of training. One needs to be especially judicious when prescribing training to patients who show signs of inspiratory muscle weakness or hypercapnea. Selection Criteria for Patients  Prescription and monitoring parameters for inspiratory muscle training (IMT)  1  Fletcher GF, Balady G, Froelicher VF, Harley LH, Haskell WL, Pollock ML. Exercise standards. A statement for health care professionals from the American Heart Association. Circulation 1995:91:580-615.  95  Suppliers for testing and training apparatus: 1. Negative inspiratory force meter – +/- 60 cm H2O NIF Kit – contains pressure gauge, 25 sets of tubing, and 25 sets of mouthpieces ~ $251 Cdn DHD Supplier, eg. MacArthur Medical, Rockton ON 2. Respiratory Force Pressure Gauge – Bourdon-type manometer- +/- 120 cm H2O Vacumetrics Inc, Vacumed Division, 4538 Westinghouse Street, Ventura, CA, 93003 1-800-235-3333 Web site: http://www.vacumed.com/zcom/product/Product.do?compid=27&prodid=266 3. Electronic inspiratory/expiratory force meter – ~ $995 US Vacumetrics Inc, Vacumed Division, 4538 Westinghouse Street, Ventura, CA, 93003 1-800-235-3333 Web site: http://www.vacumed.com/zcom/product/Product.do?compid=27&prodid=909 4. Threshold® inspiratory muscle trainer trainer – ~$22 US - 38 Cdn HealthScan Products Inc, 908 Pompton Ave, Unit B2, Cedar Grove, NJ 07009-1292 or Vacumetrics Inc, Vacumed Division, 4538 Westinghouse Street, Ventura, CA, 93003 1-800-235-3333 Web site: http://www.vacumed.com/zcom/product/Product.do?compid=27&prodid=399  Case History - 69 yo woman with COPD case A 69 year old woman who has been previously very active is referred to your program for exercise. She has COPD which has worsened during the last year. She is highly motivated to improve her exercise tolerance. She has been participating in a walking and cycling program for 5 weeks. This consists of attending the pulmonary rehabilitation program at St. Paul‟s Hospital twice weekly and performing her home walking program 2-3 times weekly. She continues to complain of shortness of breath. Her pulmonary function tests show – MIP = 36 cm H2O MEP = 60 cm H2O Prescribe an inspiratory muscle training program. What should be the starting intensity, duration, and breathing frequency? How quickly should the training load be progressed?  96  IMT OUTCOMES TO ASSESS FOR PEOPLE WITH COPD  97  Appendix I: Information-Based Group – List of Publications Geddes EL, Reid WD, Crowe J, O‘Brien K, Brooks D. Inspiratory muscle training in adults with chronic obstructive pulmonary disease: a systematic review. Resp Med 2005;99:14401458. Reid WD, Geddes EL, Brooks D, O‘Brien K, Crowe J. Inspiratory muscle training in chronic obstructive pulmonary disease. Physiother Can 2004;56:128-142.  98  

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