Health Promotion and Arthroplasty….really….when have we got the time?

1. Health Promotion and Arthroplasty….really….when have we got the time? Dr Toby Smith University of East Anglia, UK

2. Objectives • Determine current practices • Top-Ten Global Health Challenges • Health Indicators • MECC • Health Promotion in Arthroplasty • Health Promotion in other clinical areas • Implementation into practice

3. What are current practices amongst ACPA members in the room?

4. Possible responses??? Advice in pre-op/in-patient/post-op consultations on: • Physical activity • Diet • Smoking • Alcohol consumption • Substance misuse • Self-harm • Mental Health • Hygiene

5. Top-Ten Global Health Challenges 1) The growing role of frontline health workers 2) The need for more community health workers 3) The rebirth of family planning 4) Helping even more children to live longer 5) AIDS: getting to zero 6) The continuing fight against malaria 7) Eradicating polio 8) The global burden of non-communicable diseases 9) Safety for health workers during conflicts 10) Mobile health and new technologies

6. Health Indicators • Life expectancy is rising – females = 80yrs; males 74 yrs. • Similar health problems between the genders (i.e. high CVR and CVA pathologies) • Across EU 62% regard themselves in very good health

7. What are the common co-morbidities for people post-arthroplasty? • Osteoporosis • Diabetes • Hypertension • COPD • Asthma • Dementia • TIA/CVA • Cancers • Peripheral vascular disease • MI • Cardiac failure • Gastric ulcers • DVTs • Osteoarthritis

8. What is MECC? MECC means making the best of every appropriate opportunity to raise the issue of healthy lifestyle • Systematically promoting the benefits of healthy living across the organisation • Asking individuals about their lifestyle and changes they may wish to make • Responding appropriately to the lifestyle issue/s once raised • Taking the appropriate action to either give information, signpost or refer service users to the support they need.

9. What MECC is not • It is not about adding another job to your already busy working day • It is not about you becoming a specialist in a certain lifestyle area • It is not about you becoming a counsellor or providing ongoing support to particular individuals • It is not about you telling somebody what to do and how to live their live • It is about you helping other people to know how they can improve their own health and wellbeing.

10. An example of MECC Impact In East Midlands • 288,000 staff • Millions of patient contacts a year • If staff MECC with just ten people • Less than one hour a year for each staff member = 2.88 million opportunities to influence behaviour change.

11. The Elephant in the Room We might find it difficult to raise a lifestyle issue with a client if we… • smoke • drink too much • eat an unhealthy diet • don’t exercise enough • have emotional health problems • …ourselves! Making Every Contact Count 2010 (NHS West Midlands. Adapted)

12. Is Health Promotion Needed in Arthroplasty Care? • No studies have investigated different health promotion strategies following TKR or TKR • Physical activity • Patients following THR and TKR do not do the recommended levels of physical activity as suggested in national guidelines - (Peiris et al, 2013) • Physical activity does not reach the same level as age- and sex-matched cohorts without joint pain, even talking into account people with no further joint pain following arthroplasty (Brandes et al, 2011). • Physical activity does improve following THR - but still low levels of vigorous physical activity (Fujita et al, 2013). • Hypertension • Increases risk of DVT and greater post-operative complications for people with hypertension (Chen et al, 2013; Mwachukwu et al, 2013).

13. Examples of problematic co-morbidities in arthroplasty care Diabetes • Well documented diabetes affects short and longer-term arthroplasty outcomes (Zhao et al, 2014; Singh and Lewallen, 2013; Adams et al, 2013). Depression • Higher levels of depression are associated with poorer outcome (Browne et al, 2014; Duivenvoorden et al, 2013; Perez-Prieto et al, 2014). Obesity • Well documented obesity affects short and longer-term arthroplasty outcomes (Belmont et al, 2014, Maradit Kremers et al, 2014; Liliensue et al, 2013). Malnutrition • Malnutrition has an impact on early post-operative recovery and overall physical activity (Cross et al, 2014).

14. Current Health Promotion Strategies in Arthroplasty Care Research • None…but…what we currently do.... • Rehabilitation exercises following TKR can sufficiently increase Heart Rate to training levels (Naylor et al, 2013) • Weekend physiotherapy increased habitual physical activity...although not up to an accepted recommended level (Peiris et al, 2012)

15. Models of Health Promotion in Other Fields http://www.jeanjullien.com/img/work/1231110714-catastrophe-/catastrophe.jpg

16. Models Cardiac rehab • Dunn S, Lark S, Fallows S. Identifying Similar and Different Factors Effecting Long-Term Cardiac Exercise Rehabilitation Behaviour Modification Between New Zealand and the United Kingdom. J Phys Act Health. 2013 Jun 24. • Rodgers WM, Murray TC, Selzler AM, Norman P. Development and impact of exercise self-efficacy types during and after cardiac rehabilitation. Rehabil Psychol. 2013 May;58(2):178-84. • Baghianimoghadam MH, Shogafard G, Sanati HR, Baghianimoghadam B, Mazloomy SS, Askarshahi M. Application of the health belief model in promotion of self-care in heart failure patients. Acta Med Iran. 2013;51(1):52-8. Cancer • Jarden M, Møller T, Kjeldsen L, Birgens H, Christensen JF, Bang Christensen K, Diderichsen F, Hendriksen C, Adamsen L. Patient Activation through Counseling and Exercise--Acute Leukemia (PACE-AL)--a randomized controlled trial. BMC Cancer. 2013 Oct 2;13:446. • Weaver KE, Danhauer SC, Tooze JA, Blackstock AW, Spangler J, Thomas L, Sutfin EL. Smoking cessation counseling beliefs and behaviors of outpatient oncology providers. Oncologist. 2012;17(3):455-62. • Kobetz E, Menard J, Dietz N, Hazan G, Soler-Vila H, Lechner S, Diem J, Auguste P. Contextualizing the survivorship experiences of Haitian immigrant women with breast cancer: opportunities for health promotion. Oncol Nurs Forum. 2011 Sep;38(5):555-60. General Physical Activity • Exercise for the over 65 could have a significant financial gain for the NHS at a low cost relatively speaking (Munro J, Brazier J, Davey R, Nicholl J. Physical activity for the over-65s: could it be a cost-effective exercise for the NHS? J Public Health Med. 1997 Dec;19(4):397-402.)

17. What can we do as Nurses, Surgical Practitioners, AHPs etc etc and all ACPA members? • Reflect on current practice. • Consider what health promotion strategies are important to YOUR patient group. • Trial introduction of MECC principles into practice • Audit and reflect on this change of practice…is it meaningful and effective? • Spread the message and disseminate

18. Take Home Messages • Patients who undergo arthroplasty frequently present with multiple co-morbidities. • These can significantly affect outcomes and their general health. • Can arthroplasty be a catastrophising event? • Arthroplasty Care Practitioners are in a great position to try to increase awareness of health promotion. • Reflect on this on your own practices.

19. Thank You

20. Peiris CL, Taylor NF, Shields N. Patients receiving inpatient rehabilitation for lower limb orthopaedic conditions do much less physical activity than recommended in guidelines for healthy older adults: an observational study. J Physiother. 2013 Mar;59(1):39-44. di: 10.1016/S1836-9553(13)70145-0.) Brandes M, Ringling M, Winter C, Hillmann A, Rosenbaum D. Changes in physical activity and health-related quality of life during the first year after total knee arthroplasty. Arthritis Care Res (Hoboken). 2011 Mar;63(3):328-34. Fujita K, Makimoto K, Tanaka R, Mawatari M, Hotokebuchi T. Prospective study of physical activity and quality of life in Japanese women undergoing total hip arthroplasty. J Orthop Sci. 2013 Jan;18(1):45-53. Chen J, Cui Y, Li X, Miao X, Wen Z, Xue Y, Tian J. Risk factors for deep infection after total knee arthroplasty: a meta-analysis. Arch Orthop Trauma Surg. 2013 May;133(5):675-87. Nwachukwu BU, Collins JE, Nelson EP, Concepcion M, Thornhill TS, Katz JN. Obesity & hypertension are determinants of poor hemodynamic control during total joint arthroplasty: a retrospective review. BMC Musculoskelet Disord. 2013 Jan 14;14:20. Zhao Z, Wang S, Ma W, Kong G, Zhang S, Tang Y, Zhao Y. Diabetes mellitus increases the incidence of deep vein thrombosis after total knee arthroplasty. Arch Orthop Trauma Surg. 2014 Jan;134(1):79-83. Singh JA, Lewallen DG. Diabetes: a risk factor for poor functional outcome after total knee arthroplasty. PLoS One. 2013 Nov 13;8(11):e78991. Adams AL, Paxton EW, Wang JQ, Johnson ES, Bayliss EA, Ferrara A, Nakasato C, Bini SA, Namba RS. Surgical outcomes of total knee replacement according to diabetes status and glycemic control, 2001 to 2009. J Bone Joint Surg Am. 2013 Mar 20;95(6):481-7. Belmont PJ Jr, Goodman GP, Waterman BR, Bader JO, Schoenfeld AJ. Thirty-day postoperative complications and mortality following total knee arthroplasty: incidence and risk factors among a national sample of 15,321 patients. J Bone Joint Surg Am. 2014 Jan 1;96(1):20-6. Browne JA, Sandberg BF, D'Apuzzo MR, Novicoff WM. Depression is associated with early postoperative outcomes following total joint arthroplasty: a nationwide database study.J Arthroplasty. 2014 Mar;29(3):481-3.

21. Duivenvoorden T, Vissers MM, Verhaar JA, Busschbach JJ, Gosens T, Bloem RM, Bierma-Zeinstra SM, Reijman M. Anxiety and depressive symptoms before and after total hip and knee arthroplasty: a prospective multicentre study.Osteoarthritis Cartilage. 2013 Dec;21(12):1834-40. Pérez-Prieto D, Gil-González S, Pelfort X, Leal-Blanquet J, Puig-Verdié L, Hinarejos P. Influence of depression on total knee arthroplasty outcomes.J Arthroplasty. 2014 Jan;29(1):44-7. Belmont PJ Jr, Goodman GP, Waterman BR, Bader JO, Schoenfeld AJ. Thirty-day postoperative complications and mortality following total knee arthroplasty: incidence and risk factors among a national sample of 15,321 patients. J Bone Joint Surg Am. 2014 Jan 1;96(1):20-6. Maradit Kremers H, Visscher SL, Kremers WK, Naessens JM, Lewallen DG. Obesity increases length of stay and direct medical costs in total hip arthroplasty. Clin Orthop Relat Res. 2014 Apr;472(4):1232-9. Liljensøe A, Lauersen JO, Søballe K, Mechlenburg I. Overweight preoperatively impairs clinical outcome after knee arthroplasty: a cohort study of 197 patients 3–5 years after surgery. Acta Orthop. 2013 Aug;84(4):392-7. Cross MB, Yi PH, Thomas CF, Garcia J, Della Valle CJ Evaluation of malnutrition in orthopaedic surgery. J Am Acad Orthop Surg. 2014 Mar;22(3):193-9. Naylor JM, Ko V. Heart rate response and factors affecting exercise performance during home- or class-based rehabilitation for knee replacement recipients: lessons for clinical practice.J Eval Clin Pract. 2012 Apr;18(2):449-58. Peiris CL, Taylor NF, Shields N. Additional Saturday allied health services increase habitual physical activity among patients receiving inpatient rehabilitation for lower limb orthopedic conditions: a randomized controlled trial. Arch Phys Med Rehabil. 2012 Aug;93(8):1365-70.

22. Dunn S, Lark S, Fallows S. Identifying Similar and Different Factors Effecting Long-Term Cardiac Exercise Rehabilitation Behaviour Modification Between New Zealand and the United Kingdom. J Phys Act Health. 2013 Rodgers WM, Murray TC, Selzler AM, Norman P. Development and impact of exercise self-efficacy types during and after cardiac rehabilitation. Rehabil Psychol. 2013 May;58(2):178-84. Baghianimoghadam MH, Shogafard G, Sanati HR, Baghianimoghadam B, Mazloomy SS, Askarshahi M. Application of the health belief model in promotion of self-care in heart failure patients. Acta Med Iran. 2013;51(1):52-8. Jarden M, Møller T, Kjeldsen L, Birgens H, Christensen JF, Bang Christensen K, Diderichsen F, Hendriksen C, Adamsen L. Patient Activation through Counseling and Exercise--Acute Leukemia (PACE-AL)--a randomized controlled trial. BMC Cancer. 2013 Oct 2;13:446. Weaver KE, Danhauer SC, Tooze JA, Blackstock AW, Spangler J, Thomas L, Sutfin EL. Smoking cessation counseling beliefs and behaviors of outpatient oncology providers. Oncologist. 2012;17(3):455-62. Kobetz E, Menard J, Dietz N, Hazan G, Soler-Vila H, Lechner S, Diem J, Auguste P. Contextualizing the survivorship experiences of Haitian immigrant women with breast cancer: opportunities for health promotion. Oncol Nurs Forum. 2011 Sep;38(5):555-60. Munro J, Brazier J, Davey R, Nicholl J. Physical activity for the over-65s: could it be a cost-effective exercise for the NHS? J Public Health Med. 1997 Dec;19(4):397-402.