Development of the BRiMS programme
Health-care policy prioritises the need to empower patients to self-manage through partnership working and self-management programmes,32with emphasis placed on a future NHS that implements interventions
that promote self-care and lifestyle behavioural change and are community based.33
In partnership with service users, providers, other key stakeholders (including commissioners) and
international collaborators, our ongoing research programme systematically developed Balance Right in MS (BRiMS), an innovative, evidence-based, user-focused self-management programme, designed to improve safe mobility and reduce falls for people with MS. The development of BRiMS has been based on the Medical Research Council framework34for the development and evaluation of complex interventions and
supplementary guidance identifying specific tasks to be undertaken in the development process.35It was
informed by input from a number of internationally recognised experts,36which is explicitly acknowledged
in the programme documentation. The programme’s underlying philosophy is based on the premise that interventions must promote lifestyle behavioural change, be community based and focus on prevention and self-care, an approach in line with the future direction of the NHS.33
Overview of the BRiMS programme
BRiMS is a novel 13-week, therapy-led personalised education and exercise programme structured to maximise the development of self-efficacy and support participant engagement (Figure 1). It addresses modifiable risk factors, enabling self-management by individualised mobility, safety and falls risk management strategies.
The programme includes two individual and three group sessions addressing physical, behavioural and environmental aspects of mobility and falls management. These are supplemented by a home-based package delivered via an established web-based interactive resource to ensure integration into daily life
from the outset. As emphasised in the NICE guideline,25this combined approach (which was developed
in collaboration with people with MS, physical therapists, sports scientists, occupational therapists and psychologists) aims to equip the person with MS with the knowledge, skills and motivation to sustain long-term behaviour change. Developing and supporting motivation is addressed throughout using new functional imagery techniques37,38to supplement established motivational techniques.
The BRiMS education component aims to improve exercise self-efficacy and develop individualised falls prevention and management practices through the acquisition and application of relevant knowledge and skills.39This component is delivered through a mix of home and group activities embedded throughout
the programme. It utilises a number of evidence-based self-management practices, specifically group brainstorming, problem-solving and action-planning.40It also applies the principles of cognitive–behavioural
therapy to facilitate self-efficacy enhancement. In group sessions, BRiMS utilises peer modelling, vicarious learning, social persuasion and guided mastery to boost self-efficacy41and encourages the setting and
imagery of short-term exercise goals to boost the desire to achieve them.42
The BRiMS exercise component is designed to achieve a minimum of 120 minutes of individualised, progressive, gait, balance and functional training per week. The content is guided by a comprehensive literature review of MS balance exercise interventions,43while the structure and format are informed by
comprehensive stakeholder input.27
The BRiMS exercise component is designed to be predominantly home-based, with exercise planning and progression undertaken in partnership between the participant and the programme leader. The group sessions include exercise activities to encourage peer support and problem-solving. Motivational support is built into both elements. Additionally, BRiMS integrates an online exercise prescription resource (https://webbasedphysio.com)44to support and guide participants’home-based practice. The resource
can be customised to the participant’s individual exercise prescription and remotely amended during the programme to maintain an appropriate level of challenge.
Intervention description and standardisation
The BRiMS programme has been manualised to provide a detailed description of the intervention and to ensure consistency of content, approach and delivery of sessions across time, region and groups. The manual includes identification of the critical elements of each part of the programme, key objectives of each session and detailed guidance/scripts for programme leaders along with accompanying participant resources.
Figure 2shows the BRiMS‘logic model’,45which maps the programme content and delivery methods,
along with causal assumptions, the mechanisms that are theorised to drive the programme and any expected external factors that may affect the outcomes.Table 1provides an overview of the schedule of content delivery. Assessment Week 1 2 3 4 5 6 BRiMS programme 7 8 9 10 11 12 13 Home visit Group session 1 Group session 2 Home package 1 Home package 2 Home package 3 Home package 4 Group session 3
Home exercise programme (guided by online resource)
FIGURE 1 The BRiMS programme delivery plan.
DOI: 10.3310/hta23270 HEALTH TECHNOLOGY ASSESSMENT 2019 VOL. 23 NO. 27
© Queen’s Printer and Controller of HMSO 2019. This work was produced by Gunnet al.under the terms of a commissioning contract issued by the Secretary of State for Health and Social Care. This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in professional journals provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for commercial reproduction should be addressed to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK.
Problem Evidence base Resources/inputs Activities Outcomes Impact People with MS
fall frequently. Falls are related to injury, activity curtailment and an increased risk of mobility deterioration • Exercise (especially gait, balance and functional training) can improve balance and mobility among people with MS43
• Highly challenging gait, balance and functional training can reduce falls in older people46 • A falls education programme can increase confidence, falls self-efficacy and awareness of falls prevention strategies30 • There are a range of factors that have an impact on the design, content and structure of a MS-specific falls prevention plan27
Programme resources
Specialist programme therapists with MS-specific knowledge and experience
BRiMS programme manual
• Individualised progressive exercise programme • Strategies to support long-term adherence to exercise and physical activity • Identification of personal fall risk factors (using BAASE analysis) • Development of individual plans to reduce fall risk factors (via falls action-planning) • Increasing the individual’s confidence in balance and safe mobility
• Identification of barriers to, and facilitators of, fall prevention plan enactment (via problem-solving activities)
Completion of the programme will lead to: • improved balance • improved mobility • improved falls self-efficacy • reduced incidence of falls • reduced falls- related injuries • reduced resource use for falls-related care
Improvements in mobility and reduction in falls will slow mobility deterioration and improve QoL/ community participation Home package 1 Assessment Home visit Group session 1 Group session 2
Home exercise programme (guided by online resource)
Group session 3 Home package 2 Home package 3 Home package 4 1 2 3 4 5 6 7 8 9 10 11 12 13
FIGURE 2 The BRiMS programme logic model. BAASE, Behaviours and Attitudes, Activities, MS Symptoms, Environment.
INTRODUCTION
NIHR
Journals
Library