Intermittent Claudication (IC) is a symptom of peripheral arterial disease (PAD) where pain is experienced in the main muscle groups of the leg when exercising and walking.
Patients with Intermittent Claudication (IC) need to push further into their leg pain when exercising and walking to gain any benefit from physiotherapy – this develops the collateral circulation allowing the blood to follow a natural bypass to the affected muscles and therefore reducing the pain felt thus increasing the pain free walking distance.
NHS Highland (NHSH) is the largest Health Board in Scotland covering 32 500km2 serving a population of 320,000. 2.3% of adults over the age of 16 will be affected by IC – this equates approximately to 4,420 adults in NHSH.
The geography of this area is one of the biggest challenges to delivering patient care.
A large number of patients are very remote and rural, making the journey to Inverness long and tiring. If we can treat and assess these patients in their homes then the geography challenge will no longer be an issue.
With an ever-increasing population there should be no need to review clinically stable claudicants especially if telehealth can be used for remote monitoring.
“If we can treat and assess this cohort of patients in their homes, then the geography challenge will no longer be an issue bringing great benefit to patients and clinicians alike whilst deriving greater value from NHS resources and creating clinic capacity for patients who do require face-to-face review.”
Welcoming Flo
The opportunity for us to use Flo to enable us to remotely gather information regarding their condition and ability, and also to encourage and motivate these patients to continue with their exercise regime and daily walking went live with IC patients in Jan 2016.
At the patient’s initial assessment, they undergo a treadmill test measuring the pain onset distance (POD), maximum walking distance (MWD) and the reason for having to stop walking.
Patients are then given a home exercise programme and advised to push into their pain level a little more than they normally would. Some of these patients will attend a weekly exercise class at Raigmore Hospital (Inverness).
Patients who consent are enrolled with Flo at the end of the initial physiotherapy assessment, The session is extended by 15 minutes to allow for the actions below:
- To explain what Flo is and how she can benefit the patient whilst they are at home
- To provide a patient information leaflet with time to read this
- To explain consent and for the patient to sign the consent form
- To loan the patient a pedometer and show them how it works
- To register the patient with Flo and send consent form to TEC
Flo’s Interactions with our IC Patients
Patients receive regular interaction with Flo’s friendly persona around key elements involved in their treatment plan. This helps to educate and motivate patients to become more confident and engaged with their self care, examples include:
Understanding the number of steps the patient can take before having to stop and the reasons for stopping walking
- Interaction around physiotherapy exercise
- Patient reported impact of symptoms on daily activities
- Medicine compliance for aspirin or clopidogrel
- Smoking status
- Compliance with diabetes management
- Patients report their daily step count registered on their pedometer
Patients are then re-assessed after 3 months when they repeat the initial treadmill test.
The majority of patients enrolled with Flo have felt a great benefit. Patients report that they do not feel so isolated and felt more motivated to carry on the exercise programme despite not coming back for a face-to-face review for 3 months.
“A lot of patients feel they have made a friend in Flo and look forward to her texts.”
We found that the main barrier to patient consent is the use of the mobile phone in what tends to be an elderly age group of patients, and also the lack of signal in certain areas of the Highlands can be problematic.
From a clinician perspective it can be difficult to find the time to assess the Flo results prior to reviewing the patient in an already very busy day.
However when I am able to do this, another dimension to my patient care is added with a more holistic approach to what the patient’s issues actually are.
Flo allows us an insight into the step count of the patient in their own environment and an assessment of their compliance with the programme.
“The motivational aspect of Flo cannot be underestimated as it is very difficult to adhere to an exercise programme which causes pain but not notice any benefit for 5 to 6 weeks – Flo is instrumental in helping patients continue to follow the exercise regime and reap the benefits.”
