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What is the problem?

Find an evidence-based exercise plan for Soneeya that will aspire to help her reach
her fitness goals whilst taking into consideration her cultural beliefs and allergies.
What information do I need to gather/understand to better appreciate the scope and
impact of the concern?
With all types of information available only one click away in this day and age, a
successful research question depends upon how well the investigator formulates the research
question. By incorporating the specialised PICO framework to facilitate my literature search
to answer my clinical question, I will be reducing the amount of irrelevant information that
the search provides, and at the same time increase the chances of finding relevant, reliable
information based on the patient or problem at hand. Therefore, I believe having an
understanding of what each arm of the PICO framework represents, will help me achieve this
task.
My next undertaking is to then formulate a PICO question around my patient’s
specific requirements, that will contribute to answering the clinical question and give
repeatable, consistent results when used to search the database PUBMED. After constructing
the PICO questions “(females) AND (fitness) AND (stamina)” and “(exercise) AND
(activity) AND (eczema)” the search was initiated. This search led to the discovery of the
research papers “Adopting an evidence-based lifestyle physical activity program” by Dunn et
al.1 and “A systematic review of vigorous physical activity in eczema” by Kim and
Silverberg 2. Upon reading these papers, I believe they answered the clinical question asked
by Soneeya, and subsequently formed the basis of my decision-making process in creating
her evidence-based exercise plan to meet her specific requirements.
While the paper by Dunn et al.1 will be the centrepiece for building the exercise
program, I will need to take into consideration her religious beliefs as well as her allergies
she reported during her history taking, and incorporate exercises into her program that are not
violent and will not flair up her symptoms as recommended by Kim and Silverberg 2. The
systematic review by Kim and Silverberg 2 states that patients with eczema should avoid
exercise or vigorous physical activity which are typically accompanied by increased
sweating, to avoid worsening allergies. However, if patients with eczema have a lower
physical activity profile, they could potentially be at higher risk for obesity and
cardiovascular disease. It is, therefore, important to understand the relationship between
eczema and physical activity and to develop clinical interventions to improve the overall
health of patients with eczema.
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How can I critically evaluate the information as it relates to the central concern?
Evidence-based practice recommends that I critique the information by using
evaluating tools such as critical appraisal tools that assess the study on its reliability, validity,
accuracy, authenticity, timeliness, point of view or bias to conclude whether or not the article
is a relevant and reliable source of information to use as a foundation for my research and
outcome.
I have utilised the Critical Appraisal Skills Program (CASP) tool in this situation to
assess whether the study by Dunn et al.1 is an acceptable level of literature to formulate an
evidence-based program, backed with scientific approval for my client. Based on my
investigation of the case-controlled study design with the CASP tool checklist, the results
deem it a credible source to use, to formulate and deliver successful implementation of an
evidence-based exercise program for my client. See appendix for results.
Upon reflection, what concerns may become an impediment to the implementation of
this new synthesis, and how may this be communicated in a patient-centred setting?
The systematic review by Kim and Silverberg 2 states that people who are more
physically active outdoors are at a higher risk to airborne pollutants that could exacerbate
eczema. Consequently, considering this information, creating an outdoor exercise program
would not be in Soneeya’s best interest, allergy wise. Therefore, I will have to design an
indoor based exercise program that would protect her from the elements as well as keeping
sweating and overheating to a minimum. Furthermore, the frequency and types of physical
activity and exercise performed are likely to be limited by several factors, including access to
gyms and recreational spaces, and functional limitation from her medical disorders, with the
quick changes in temperature caused by exercise likely to induce the dreaded skin flare and
itch.
Encouraging my patient to see that this is an opportunity to try something new and
exciting, instead of something negative will allow her to adapt to the recommended low-
impact exercises such as tai chi, Pilates, or yoga, which improve mobility, muscle strength
and stamina as well as reducing stress levels all while keeping sweat levels or overheating to
a minimum. These exercises incorporated alongside a swimming routine in chemical-free
pools with a strict shower protocol will be the basis of the program’s foundation with a view
to change provided the choice of exercise becomes problematic for her skin.
How can I apply this new synthesis research in an ideal patient-centred approach?
King and Hoppe 3 state that if the medical profession wishes to maintain or perhaps
regain trust and respect from the public, it must meet patients' needs with a renewed
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commitment to excellence in the communication skills of physicians. Therefore, not only do I

have to ensure that the exercise program is evidence-based, I also need to be able to portray
the efficacy of good communication skills based on a patient-centred approach.
Consequently, I believe that incorporating the patient’s values to help guide the decision-
making process will motivate the patient’s adoption of the healthcare program providing
there are strategies and support in place to ensure successful implementation.
Can I summarise the newly relevant issues?
The issues that arose throughout this literature search with were dealt with
accordingly. They ranged from what is the best PICO format to answer the clinical question
and which arms of the framework would elicit the most useful information, to what creates an
enhanced clinician-patient relationship where the patient feels that they are in a safe place
where genuine care and respect is shown. From the clinician’s point of view, it is essential to
become invested in Soneeya’s situation to be able to fully grasp an understanding of her
condition all while being able to convey information back to her effectively that is congruent
with her beliefs and circumstances.
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References:

1. Dunn A, Buller D, Dearing J, Cutter G, Guerra M, Wilcox S et al. Adopting an

evidence-based lifestyle physical activity program: dissemination study design and
methods. Translational Behavioural Medicine [Internet]. 2011[cited 2020 Jul
16];2(2):199-208. Available from: doi:10.1007/s13142-011-0063-x

2. Kim A, Silverberg J. A systematic review of vigorous physical activity in eczema.

British Journal of Dermatology [Internet]. 2015 [cited 2020 Jul 16];174(3):660-662.
Available from: doi:10.1111/bjd.14179

3. King A, Hoppe R. “Best Practice” for Patient-Centered Communication: A Narrative

Review. Journal of Graduate Medical Education [Internet]. 2013 [cited 2020 Jul
16];5(3):385-393. Available from: doi:10.4300/jgme-d-13-00072.1

Appendix:
PICO question 1
P (Problem or Patient or
Female, lady, women
Population)
I (intervention/indicator) Exercise “get fit”
C (comparison) Without allergies
O (outcome of interest) Improve fitness and stamina

PICO question 2
P (Problem or Patient or
Patient
Population)
I (intervention/indicator) Eczema, allergies
C (comparison) Activity
O (outcome of interest) Exercise
Figure 1.
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Figure 2.
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