Award Title: The development and feasibility of a post-operative rehabilitation programme to improve walking in older people with neurogenic claudication.
Funder: Dunhill Medical Trust

Abstract: Neurogenic claudication (NC) affects 1:10 older people and reduces walking and quality of life. It is the main indication for spinal surgery in older people yet following surgery, up to 40% report walking disability and 90% do not achieve physical activity recommendations. Changing behaviour is challenging without appropriate guidance and support. Rehabilitation could improve walking but current provision is inconsistent and ineffective. Modifiable factors that influence post-operative walking in people with NC are unclear but if identified and targeted with theoretically-informed rehabilitation post-operative walking may be improved.
Aims: This fellowship was developed collaboratively with patient advisors and aims to i) identify the determinants of post-operative walking; ii) co-design and test the feasibility including acceptability of a theoretically-informed post-operative rehabilitation programme to improve walking in older people post-surgery for NC.
Methods:
Stage one:
This prospective observational study will recruit 122 adults aged ≥60 years, waiting for surgery for NC. Measures (six-minute walk distance (6MWD, dependent variable), daily step count and objective and self-reported physical and psychosocial factors will be assessed pre-operatively and at 6 and 12 weeks post-operatively. Multivariate linear regression analysis will identify predictors of 6MWD at 12 weeks.
Stage two:
This qualitative interview study will enrol 20 adults aged ≥60 years, 3 months post-surgery for NC. Audio-recorded, semi- structured interviews will explore the experience of walking in the post-operative period. Data will be analysed thematically.
Stage three:
Building on the findings of the first two stages, patients and other stakeholders will co-design a post-operative rehabilitation programme to target salient determinants of walking in a series of workshops, using an experience based co-design approach.
Stage four:
A single arm feasibility study will enroll up to 30 adults ≥60 years old, post-surgery for NC. Measures (e.g. 6MWD, daily step count) will be collected before and after participants complete the rehabilitation programme. Recruitment, measure completion rates, and programme attendance will be summarised descriptively. Participants’ experience of the rehabilitation programme and research processes will be explored in an audio-recorded focus group of 8-12 participants and data analysed thematically.
Dissemination: A PhD thesis will be produced. Professional journals, clinical and public meetings, scientific conferences, social media, podcasts and patient summaries will be used to disseminate the findings. Patient advisors will help disseminate results. The findings will inform the design of a randomised controlled trial investigating the effect the programme.

Lay Abstract: Background
Lumbar spinal stenosis causes symptoms called neurogenic claudication and prevents people from walking. Lumbar spinal stenosis is the most common reason for spinal surgery but many people do not increase their walking after their operation. We don’t know why this happens. Post-operative rehabilitation may improve walking, but it is not always available and it is not clear what should be included in the rehabilitation programme.
Aims:
•To identify the key factors which affects walking after surgery in older people with neurogenic claudication;
•To develop a post-operative rehabilitation programme that helps these factors;
•To assess if the new programme is acceptable and see if it is possible to carry out a larger study in the future looking at whether the rehabilitation programme works.

Methods:
This fellowship comprises four stages
Stage one: 122 adults waiting for surgery for neurogenic claudication, aged over 60 years old, will be invited to attend two appointments, one 8 weeks before surgery and one 12 weeks after surgery. They will be asked to complete a walking test, leg strength and balance tests, complete some questionnaires and wear a step counter on their thigh for 7 days. In addition, people will be asked to complete some questionnaires at home 6 weeks after their operation. The things that have the greatest influence on walking will be identified and used to develop a post-operative rehabilitation programme.

Stage two: Up to 20 adults who are over 60 years old, at least 3 months after they have had surgery for neurogenic claudication will be interviewed. Interviews will explore people’s beliefs and their experience of walking after surgery and things that help or hinder walking. Common themes will be identified from the interviews and used to help develop a rehabilitation programme.

Stage three: Patients and clinicians will be invited to attend three day workshops over 3 months to co-design a post-operative rehabilitation programme based on the things that influence walking identified in the previous stages.

Stage four: In this feasibility study up to 30 adults, who are at least 60 years old and have had surgery for neurogenic claudication, will complete questionnaires and walking tests before and after completing the new programme. Twelve people will be invited to share their experiences of the programme in an audio-recorded focus group. Common themes will be identified and used to refine the programme and inform a trial into the effect of the programme.

Research Activity Codes: 6.7 PHYSICAL
Health Categories: GENERIC HEALTH RELEVANCE