Title: BOOST Implementation Study
Funder: Department of Health and Social Care

Abstract: Background The BOOST programme is a 12-week physiotherapist delivered group intervention for older people with neurogenic claudication, a condition which substantially affects walking ability. It was tested in a large clinical trial and resulted in clinically important improvements in walking, quality of life and falls. It was cost-effective. The impact on pain was less substantial with smaller short-term improvements. Patient representatives and clinicians strongly support implementation due to the importance of the improvements observed and the lack of alternative effective treatments. However, pain relief is important to patients and reducing pain could potentially improve walking further. Some participants had difficulty continuing exercise long term potentially impacting outcomes. We will use methods from the quality improvement field and implementation science to optimise the BOOST programme by targeting pain and exercise adherence and then develop and test a strategy to facilitate translation into routine clinical practice before finalising a wider implementation strategy. Optimisation will include adding additional behavioural pain management techniques using approaches shown to be effective and establishing a framework to support participants to transition from the groups to sustained independent exercise utilising community programmes and focusing on physical activity. Development work questions Does optimising the pain management and exercise adherence elements of BOOST programme result in improved outcomes compared to the main trial? Can we train physiotherapists to effectively deliver the BOOST programme in routine practice using a Massive Open Online Course (MOOC)? Aims [1] To optimise the BOOST programme [2] To design the MOOC, train physiotherapists and evaluate delivery of the programme [3] Establish the implementation strategy Development work plan Throughout the study we will work with a Community of Practice (patients, clinicians, managers) to coproduce the optimised programme, MOOC and implementation strategy. Stage 1: We will optimise the BOOST programme and evaluate changes by running three groups at three sites (24 participants). At baseline and 6 months, we will collect the Oswestry Disability Index, Spinal Stenosis Scale Symptom Subscale and 6-minute walk test. We will use a synthetic control method to evaluate the probability that the optimised programme results in better outcomes. We will interview the physiotherapists delivering the programme to ensure changes are worthwhile. Stage 2: We will develop the MOOC, train 30 physiotherapists and measure learning outcomes (confidence and capability to deliver the programme). Physiotherapists will deliver the programme as part of routine care. Clinical outcomes will be measured and analysed as above for 60 participants. We will interview physiotherapists delivering the programme. We will conduct fidelity assessments of group sessions during both stages. Timelines for delivery Stage 1: Month 1-3: optimisation, training Month 4-9: Run groups, collect data Month 10: analyse data to inform Stage 2. Stage 2: Month 4-11: Develop and run BOOST MOOC Month 12-17: Run groups, collect data. Month 16-18: Analyse data, produce implementation plan, prepare publications Anticipated Impact and Dissemination An optimised BOOST programme ready for widespread implementation using a MOOC and enabling routine access to the programme by patients. We will disseminate finding via publications, conference presentations and clinical networks.

Lay abstract: Background We have completed a large clinical trial of physiotherapy for older people with a type of back and leg pain called neurogenic claudication. This condition commonly affects older people and occurs when age-related narrowing within the spine puts pressure on nerves and blood vessels. It particularly affects a person s ability to walk. Treatment options are limited. In the trial, we tested a 12-week group physiotherapy programme (The BOOST programme). On completion of the programme, we asked participants to exercise at home twice a week. BOOST programme participants had important improvements in walking and health related quality of life and a substantial reduction in falls at 12-month follow up compared to the control group and the BOOST programme was good value for the NHS. The BOOST programme had a smaller, short term impact on pain and some participants had difficulty continuing to exercise after completing the programme. Researchers, clinicians and patient representatives strongly feel the programme should be offered to patients in the NHS as improvements in walking and quality of life, and reduction in falls are very important outcomes to older people. We want to make some changes to the programme (referred to as optimisation) before making it widely available to see if it can have a larger impact on pain and help participants to exercise independently. We will develop an online course to train clinicians to deliver the programme as part of a longer-term plan to make the programme available to patients. Aims [1] To optimise the BOOST programme [2] Design and evaluate the online course [3] Establish a long-term plan to make the BOOST programme widely available Development work plan In Stage 1, we will make changes to the programme focusing on pain management and helping participant to exercise long-term. We will work with physiotherapists involved in the trial to make sure changes are worthwhile by running and evaluating 3 BOOST groups. In Stage 2, we will develop the online course, train 30 physiotherapists and measure learning outcomes. We will then deliver 10 BOOST groups and collect clinical outcomes. In both stages we will make sure that the clinical outcomes are the same or better than the trial results. Outcomes include pain, walking and physical performance. Patient and Public Involvement We will work with the PPI representatives from the main trial and invite participants who attended the BOOST programme during the trial to share their experiences to help us target pain and support independent exercises. PPI representatives and clinicians will help to develop the long-term plan for widespread provision of the programme. Dissemination and anticipated outcomes Anticipated outcomes are an optimised BOOST programme, an online training course for clinicians and a long-term plan for evaluation and implementation.

Research activity codes: 6.7 PHYSICAL;5.7 PHYSICAL
Health categories: MUSCULOSKELETAL