Tele-exercise, when implemented specifically in patients who have undergone bariatric surgery, is feasible and well-accepted, and potentially as effective and useful as in-person exercise classes, according to the outcomes from a randomized controlled trial by UK researchers. The findings were reported in the paper, ‘Patients' views and experiences of live supervised tele-exercise classes following bariatric surgery during the COVID-19 pandemic: The BARI-LIFESTYLE qualitative study’, published in Clinical Obesity, by investigators from the Centre for Obesity Research UCL, UCLH, Whittington and Homerton Hospitals.
Although it is known that exercise provides additional health benefits after bariatric surgery, most patients do not meet the recommended level of physical activity. The reasons for unsatisfactory levels of physical activity include geographical accessibility of exercise facilities and lack of time. In addition, the COVID-19 pandemic has impacted the problem by increasing levels of anxiety, decreasing level of physical activity and resulting weight gain.
Therefore, the investigators established the BARI-LIFESTYLE randomised controlled trial to evaluate the efficacy of a post-surgery nutritional and behavioural tele-counselling, and supervised exercise programme to maximise the health benefits of bariatric surgery. As a result of the COVID pandemic, in-person supervised exercise was converted to remote tele-exercise.
A total of 153 participants were enrolled in the BARI-LIFESTYLE observational study since March 2018. On the day of surgery, all participants in this cohort were randomised (1:1 allocation) to either receive post-surgery standard care or standard care plus a lifestyle intervention (BARI-LIFESTYLE intervention study) (Figure 1). By the time the UK government announced the stay-at-home order (March 2020), 16 participants in the intervention group were still actively participating in the gym exercise class. Of all eligible participants approached, 12 participants agreed to be interviewed.
This study group included 12 patients (n=8 female), with a mean age of 46.3 (range 33–63) years, who had undergone either sleeve gastrectomy (n=8) or Roux-en-Y gastric bypass (n=4) surgery. The participated in one-to-one semi-structured interviews following weekly, structured, 60-min supervised exercise classes delivered via Zoom by a trained exercise therapist. Interviews were audio-recorded, transcribed verbatim and analysed using thematic analysis. A total of 45 classes were carried out throughout the lockdown period from April to July 2020. The overall attendance in each class ranged between two to six participants.
The interview questions explored the participants' overall experiences and views of the tele-exercise classes, including the use of technology, the content of the classes, the exercise therapist and supervision; identifying barriers and facilitators of participation, benefits and/or limitations of the classes; and identifying elements for future improvements of the classes.
Four overarching themes were identified, namely:
Coping with the impact of COVID-19 lockdown
Tele-exercise programme was perceived as acceptable
Professional supervision and guidance affecting adherence to tele-exercise
Tele-exercise provided physical, emotional and social benefits
A majority of the participants said the COVID-19 pandemic had impacted many aspects of their daily routines, which made it challenging to adhere to the post-bariatric surgery lifestyle recommendations. They said that enrolment in the tele-exercise classes was perceived to have helped them to cope with the changes brought about by lockdown. They also noted that being part of a small group, as well as knowing the therapist was waiting in class, encouraged them to turn up to sessions for fear of embarrassment that their absence would have been noticed.
Participants found the tele-exercise schedule, content and intensity to be acceptable, and were satisfied with the privacy, security and safety of the technology and classes. None of the participants reported experiencing any major technical difficulties in setting up the Zoom software as the majority of participants had used Zoom during lockdown.
The tele-exercise classes also appeared to increase the accessibility of exercise by removing some of the barriers that are commonly associated when attending in-person gym classes, such as geographical accessibility of exercise facilities, travel time, parking issues and poor weather conditions.
The authors reported that all participants valued the professional supervision and guidance from an exercise therapist, which appeared to increase participants' motivation to exercise and attend the tele-exercise classes. They also found that having a therapist who was aware and knowledgeable of their personal medical issues or injuries was perceived as important, as the exercises could specifically be tailored to meet their needs.
Tele-exercise provided physical, emotional and social benefits
A majority of participants reported physical health benefits including fitness, muscle strength, balance and weight loss. Furthermore, most participants believed that the tele-exercise classes had enhanced their overall psychological wellbeing. Specifically, the classes helped to take their mind off of what was going on in their lives for that hour of the exercise.
A large number of participants said it was beneficial being part of a group of people who had also had bariatric surgery as it gave them the opportunity to share and learn from the experiences of others.
To optimise the delivery of tele-exercise, the investigators recommended:
Using a hospital-based virtual platform to deliver the tele-exercise was a preferred option as this assures participants of their privacy and safety being well-protected
Class size should be limited ideally between five to eight participants per session
In-person session with an exercise therapist prior to enrolment in tele-exercise is needed to assess participants' exercise capacity for tailored exercise prescription and building rapport
A mix of weekdays and weekend options covering morning and evening classes would increase the likelihood of attendance
“These preliminary findings have provided additional insights into much-needed evidence for the potential use of telehealth in the provision of care following bariatric surgery. In today's technologically advanced society, it is foreseeable that telehealth will eventually become a new norm for future healthcare,” the researchers concluded. “Therefore, it is timely and relevant now to undertake more robust research designs to investigate the efficacy and effectiveness of tele-exercise pre- and post-bariatric surgery. The research findings will be not only useful to face the present and future pandemics but can also be translated and integrated into the existing bariatric care pathway to optimize patient outcomes.”
This study was funded by the National Institute for Health Research, the Rosetrees Trust, the Sir Jules Thorn Trust Biomedical Research Award and the University College London Overseas Research Scholarship (UCL-ORS).
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