Usability and preliminary effectiveness of an app-based physical activity and education program for people with hip or knee osteoarthritis - a pilot randomized controlled trial.

BACKGROUND: Hip and knee osteoarthritis (OA) are highly prevalent worldwide. The guidelines recommend physical activity and education as the core treatments for osteoarthritis. Digital health has the potential to engage people in physical activity and disease management. Therefore, we conducted a pilot trial to assess the usability and preliminary effectiveness of an app-based physical activity and education program (Join2Move) compared to usual care for people with hip and/or knee OA in Germany. METHODS: A randomized controlled pilot study was conducted. Individuals with diagnosed or self-reported knee and hip OA were included. Allocation to the intervention or control group was randomized. The intervention group received the Join2Move program. The Join2Move program was previously developed as a website and evaluated in the Netherlands. For the current study, the program was translated and adapted to the German context and adjusted from a website to an app. The control group received usual care. The primary outcomes were usability and preliminary effectiveness (pain and physical functioning). Measurements were taken at baseline and at twelve weeks. The data analysis was performed using SPSS (IBM SPSS Statistics 29.0). RESULTS: Sixty participants, with a mean age of 61.9 (SD ± 7.2) years, were allocated to the intervention (n = 32) or the control group (n = 28) and included in the analysis. The majority of participants had knee OA (68%), and 12% had hip and knee OA. The dropout rate was n = 11 (18%). No adverse events were reported. Usability was rated as acceptable (mean System Usability Scale = 71.3/100) with a wide range (32.5 to 100). Statistically significant between-group differences were found only for pain (mean difference 8.52 (95% CI 1.01 to 16.04), p = 0.027). CONCLUSIONS: Join2Move demonstrated acceptable usability. The preliminary results of the pilot trial indicate the potential of a stand-alone app for the treatment of patients with hip or knee OA. However, the acceptable usability of Join2Move limits its recommendation for everyone. There appears to be room for improvement in app usability and in identifying patients for whom the app is suitable and the right time to use a stand-alone app. TRIAL REGISTRATION: German Clinical Trials Register DRKS00027164 .

Development of a goal-directed movement intervention (GOAL) using a movement sensor for hospitalized patients: An intervention mapping approach.

OBJECTIVE: To describe the development of a goal-directed movement intervention in two medical wards, including recommendations for implementation and evaluation. DESIGN: Implementation Research. SETTING: Pulmonology and nephrology/gastroenterology wards of the University Medical Centre Utrecht, The Netherlands. PARTICIPANTS: Seven focus groups were executed including 28 nurses, 7 physical therapists and 15 medical specialists. Patients' perceptions were repeatedly assessed during the iterative steps of the intervention development. INTERVENTION: Interventions were targeted to each ward's specific character, following an Intervention Mapping approach using literature and research meetings. Main measures: Intervention components were linked to Behavior Change Techniques and implementation strategies will be selected using the Expert Recommendation Implementing Change tool. Evaluation outcomes like number of patients using the movement intervention will be measured, based on the taxonomy of Proctor. RESULTS: The developed intervention consists of: insight in patients movement behavior (monitoring & feedback), goal setting (goals & planning) and adjustments to the environment (associations & antecedents). The following implementation strategies are recommended: to conduct educational meetings, prepare & identify champions and audit & provide feedback. To measure service and client outcomes, the mean level of physical activity per ward can be evaluated and the Net Promoter Score can be used. CONCLUSION(S): This study shows the development of a goal-directed movement intervention aligned with the needs of healthcare professionals. This resulted in an intervention consisting of feedback & monitoring of movement behavior, goal setting and adjustments in the environment. Using a step-by-step iterative implementation model to guide development and implementation is recommended.

Characteristics and health outcomes associated with activation for self-management in patients with non-specific low back pain: A cross-sectional study.

BACKGROUND: Research has shown that the course of non-specific low back pain (LBP) is influenced by, among other factors, patients' self-management abilities. Therefore, clinical guidelines recommend stimulation of self-management. Enhancing patients' self-management potentially can improve patients' health outcomes and reduce future healthcare costs for non-specific LBP. OBJECTIVES: Which characteristics and health outcomes are associated with activation for self-management in patients with non-specific LBP? DESIGN: Cross-sectional study. METHOD: Patients with non-specific LBP applying for primary care physiotherapy were asked to participate. Multivariable linear regression analysis was performed to analyze the multivariable relationship between activation for self-management (Patient Activation Measure, range 0-100) and a range of characteristics, e.g., age, gender, and health outcomes, e.g., self-efficacy, pain catastrophizing. RESULTS: The median activation for self-management score of the patients with non-specific LBP (N = 208) was 63.10 (IQR = 19.30) points. The multivariable linear regression analysis revealed that higher self-efficacy scores (B = 0.54), female gender (B = 3.64), and a middle educational level compared with a high educational level (B = -5.47) were associated with better activation for self-management in patients with non-specific LBP. The goodness-of-fit of the model was 17.24% (R2 = 0.17). CONCLUSIONS: Patients with better activation for self-management had better self-efficacy, had a higher educational level, and were more often female. However, given the explained variance better understanding of the factors that influence the complex construct of self-management behaviour in patients who are not doing well might be needed to identify possible barriers to engage in self-management.

Improving physical activity in hospitalized patients: The preliminary effectiveness of a goal-directed movement intervention.

OBJECTIVE: To evaluate the preliminary effectiveness of a goal-directed movement intervention using a movement sensor on physical activity of hospitalized patients. DESIGN: Prospective, pre-post study. SETTING: A university medical center. PARTICIPANTS: Patients admitted to the pulmonology and nephrology/gastro-enterology wards. INTERVENTION: The movement intervention consisted of (1) self-monitoring of patients' physical activity, (2) setting daily movement goals and (3) posters with exercises and walking routes. Physical activity was measured with a movement sensor (PAM AM400) which measures active minutes per day. MAIN MEASURES: Primary outcome was the mean difference in active minutes per day pre- and post-implementation. Secondary outcomes were length of stay, discharge destination, immobility-related complications, physical functioning, perceived difficulty to move, 30-day readmission, 30-day mortality and the adoption of the intervention. RESULTS: A total of 61 patients was included pre-implementation, and a total of 56 patients was included post-implementation. Pre-implementation, patients were active 38 ± 21 minutes (mean ± SD) per day, and post-implementation 50 ± 31 minutes per day (Δ12, P = 0.031). Perceived difficulty to move decreased from 3.4 to 1.7 (0-10) (Δ1.7, P = 0.008). No significant differences were found in other secondary outcomes. CONCLUSIONS: The goal-directed movement intervention seems to increase physical activity levels during hospitalization. Therefore, this intervention might be useful for other hospitals to stimulate inpatient physical activity.

The cost-effectiveness of an indicated blended care intervention in primary care compared to usual care in patients with moderate persistent somatic symptoms.

INTRODUCTION: Appropriate treatment for people with an increased risk for developing chronic Persistent Somatic Symptoms (PSS) is of great importance at an early stage to improve quality of life and prevent high costs for society. OBJECTIVE: To evaluate the cost-effectiveness of an integrated blended care intervention compared to usual care for QALYs, subjective symptom impact and physical and mental health status in patients with moderate PSS. METHODS: This economic evaluation was conducted alongside a 12-month prospective, multicenter cluster randomized controlled trial in Dutch primary care. 80 participants received the intervention and 80 participants received usual care. Seemingly unrelated regression analyzes were performed to estimate cost and effect differences. Missing data were imputed using multiple imputation. Bootstrapping techniques were used to estimate uncertainty. RESULTS: We found no significant difference in total societal costs. Intervention, primary and secondary healthcare and absenteeism costs were higher for the intervention group. The ICER for QALYs demonstrated the intervention was on average less costly and less effective compared to usual care. For the subjective symptom impact and physical health, the ICER indicated that the intervention group was on average less costly and more effective. For mental health, the intervention was on average more costly and less effective. CONCLUSION: We didn't find an integrated blended primary care intervention to be cost-effective compared to usual care. However, when looking on relevant, but specific outcome measures (subjective symptom impact and physical health) for this population, average costs are found to be lower and the effectiveness found to be higher.

Contextual determinants influencing the implementation of fall prevention in the community: a scoping review.

Background: Successful implementation of multifactorial fall prevention interventions (FPIs) is essential to reduce increasing fall rates in community-dwelling older adults. However, implementation often fails due to the complex context of the community involving multiple stakeholders within and across settings, sectors, and organizations. As there is a need for a better understanding of the occurring context-related challenges, the current scoping review purposes to identify what contextual determinants (i.e., barriers and facilitators) influence the implementation of FPIs in the community. Methods: A scoping review was performed using the Arksey and O'Malley framework. First, electronic databases (Pubmed, CINAHL, SPORTDiscus, PsycINFO) were searched. Studies that identified contextual determinants that influence the implementation of FPIs in the community were included. Second, to both validate the findings from the literature and identify complementary determinants, health and social care professionals were consulted during consensus meetings (CMs) in four districts in the region of Utrecht, the Netherlands. Data were analyzed following a directed qualitative content analysis approach, according to the 39 constructs of the Consolidated Framework for Implementation Research. Results: Fourteen relevant studies were included and 35 health and social care professionals (such as general practitioners, practice nurses, and physical therapists) were consulted during four CMs. Directed qualitative content analysis of the included studies yielded determinants within 35 unique constructs operating as barriers and/or facilitators. The majority of the constructs (n = 21) were identified in both the studies and CMs, such as "networks and communications", "formally appointed internal implementation leaders", "available resources" and "patient needs and resources". The other constructs (n = 14) were identified only in the . Discussion: Findings in this review show that a wide array of contextual determinants are essential in achieving successful implementation of FPIs in the community. However, some determinants are considered important to address, regardless of the context where the implementation occurs. Such as accounting for time constraints and financial limitations, and considering the needs of older adults. Also, broad cross-sector collaboration and coordination are required in multifactorial FPIs. Additional context analysis is always an essential part of implementation efforts, as contexts may differ greatly, requiring a locally tailored approach.

Self-management behaviour after a physiotherapist guided blended self-management intervention in patients with chronic low back pain: A qualitative study.

BACKGROUND: Self-management support is considered an important component in the physiotherapeutic treatment of people with chronic low back pain. The stratified blended physiotherapy intervention e-Exercise Low Back Pain is an example of a self-management intervention. More insight may contribute to improving blended interventions to stimulate self-management after treatment and thus hopefully prevent chronicity and/or relapses in patients with chronic low back pain. OBJECTIVES: The aim of this study was to gain an in-depth understanding of the self-management behaviour after a physiotherapist guided blended self-management intervention in people with chronic low back pain. DESIGN: A qualitative study with semi-structured interviews nested within a randomized controlled trial on the (cost-)effectiveness of e-Exercise Low Back Pain was conducted. METHOD: Thematic analysis was used to analyse the transcriptions. A hybrid process of both deductive and inductive approaches was used. RESULTS: After 12 interviews, data saturation was reached. Analysis of the data yielded six themes related to self-management behaviour: illness beliefs, coping, cognitions, social support and resource utilization, physiotherapeutic involvement and motivation. CONCLUSIONS: In our study the majority of the participants seemed to show adequate self-management behaviour when experiencing low back pain. Most participants first try to gain control over their low back pain themselves when experiencing a relapse before contacting the physiotherapist. Participants struggle in continuing health behaviour in pain free periods between relapses of low back pain. Physiotherapists are recommended to encourage long-term behaviour change. Additionally, better facilitation by the physiotherapist or additional functionalities in the app to stimulate social support might have a useful contribution.

Development and internal validation of a machine learning prediction model for low back pain non-recovery in patients with an acute episode consulting a physiotherapist in primary care.

BACKGROUND: While low back pain occurs in nearly everybody and is the leading cause of disability worldwide, we lack instruments to accurately predict persistence of acute low back pain. We aimed to develop and internally validate a machine learning model predicting non-recovery in acute low back pain and to compare this with current practice and 'traditional' prediction modeling. METHODS: Prognostic cohort-study in primary care physiotherapy. Patients (n = 247) with acute low back pain (≤ one month) consulting physiotherapists were included. Candidate predictors were assessed by questionnaire at baseline and (to capture early recovery) after one and two weeks. Primary outcome was non-recovery after three months, defined as at least mild pain (Numeric Rating Scale > 2/10). Machine learning models to predict non-recovery were developed and internally validated, and compared with two current practices in physiotherapy (STarT Back tool and physiotherapists' expectation) and 'traditional' logistic regression analysis. RESULTS: Forty-seven percent of the participants did not recover at three months. The best performing machine learning model showed acceptable predictive performance (area under the curve: 0.66). Although this was no better than a'traditional' logistic regression model, it outperformed current practice. CONCLUSIONS: We developed two prognostic models containing partially different predictors, with acceptable performance for predicting (non-)recovery in patients with acute LBP, which was better than current practice. Our prognostic models have the potential of integration in a clinical decision support system to facilitate data-driven, personalized treatment of acute low back pain, but needs external validation first.

Psychometric evaluation of the Decision Support Tool for Functional Independence in community-dwelling older people.

Background: The aging population is increasingly faced with daily life limitations, threatening their Functional Independence (FI). These limitations extend different life domains and require a broad range of community-care professionals to be addressed. The Decision Support Tool for Functional Independence (DST-FI) facilitates community-care professionals in providing uncontradictory recommendations regarding the maintenance of FI in community-dwelling older people. The current study aims to determine the validity and reliability of the DST-FI. Methods: Sixty community-care professionals completed a twofold assessment. To assess construct validity, participants were asked to assign predefined recommendations to fifty cases of older people to maintain their level of FI. Hypotheses were tested regarding the expected recommendations per case. Content validity was assessed by questions on relevance, comprehensiveness, and comprehensibility of the current set of recommendations. Twelve participants repeated the assessment after two weeks to enable both within- and between rater reliability properties, expressed by an Intraclass Correlation Coefficient. Results: Seven out of eight predefined hypotheses confirmed expectations, indicating high construct validity. As the recommendations were indicated 'relevant' and 'complete', content validity was high as well. Agreement between raters was poor to moderate while agreement within raters was moderate to excellent, resulting in moderate overall reliability. CONCLUSION: The DST-FI suggests high validity and moderate reliability properties when used in a population of community-dwelling older people. The tool could facilitate community-care professionals in their task to preserve FI in older people. Future research should focus on psychometric properties like feasibility, acceptability, and developing and piloting strategies for implementation in community-care.

Healthcare professionals' perspectives on a blended care program in primary care; A qualitative study.

Increasingly, healthcare policies have changed focus from cure and care to behaviour and health. Prevention is becoming more important, which requires a change in the role of healthcare professionals. Healthcare professionals' role is changing from being a therapist to taking on the role of a coach. To prevent chronicity in Medically Unexplained Physical Symptoms (MUPS), an integrated blended care program was developed. To apply this new program in daily practice, it is important to gain insight into the usability. From the healthcare professionals' point of view the concept of usability consists of performance, satisfaction and acceptability. In this qualitative study participants were recruited after participating in the PARASOL program. Demographics were collected. Semi-structured interviews were conducted and analysed using thematic analysis. Ten healthcare professionals (six physical therapists and four mental health nurses) were interviewed. Four themes on usability were identified: (1) Who fits in the program, (2) preparation, (3) experience with the program and (4) interprofessional collaboration. This study gathered healthcare professionals' experiences with and attitudes towards integrating healthcare and offering blended care programs. An integrated blended care program offers the possibility to personalize treatment. Findings show attention should be given to the new responsibilities of healthcare professionals, and their role in integrated and blended care. This new approach of delivering healthcare can facilitate interprofessional collaboration. Achieving sustainable change in patients however still requires instruction and support for healthcare professionals implementing behavioural change techniques.

Decrease of physical fitness during neoadjuvant chemoradiotherapy predicts the risk of pneumonia after esophagectomy.

Although neoadjuvant chemoradiotherapy (nCRT) is frequently used in esophageal cancer patients undergoing treatment with curative intent, it can negatively impact patients' physical fitness. A decline in physical fitness during chemoradiotherapy may be an indication of vulnerability. The aim of this study was to evaluate whether changes in physical fitness, weight, and fat-free mass index (FFMI) during nCRT can predict the risk of postoperative pneumonia. A retrospective longitudinal observational cohort study was performed in patients who received curative treatment for esophageal cancer between September 2016 and September 2018 in a high-volume center for esophageal cancer surgery. Physical fitness (handgrip strength, leg extension strength, and exercise capacity), weight, and FFMI were measured before and after chemoradiotherapy. To be included in the data analyses, pre- and post-nCRT data had to be available of at least one of the outcome measures. Logistic regression analyses were performed to evaluate the predictive value of changes in physical fitness, weight, and FFMI during nCRT on postoperative pneumonia, as defined by the Uniform Pneumonia Scale. In total, 91 patients were included in the data analyses. Significant associations were found between the changes in handgrip strength (odds ratio [OR] 0.880, 95% confidence interval [CI]: 0.813-0.952) and exercise capacity (OR 0.939, 95%CI: 0.887-0.993) and the occurrence of postoperative pneumonia. All pneumonias occurred in patients with declines in handgrip strength and exercise capacity after nCRT. A decrease of handgrip strength and exercise capacity during nCRT predicts the risk of pneumonia after esophagectomy for cancer. Measuring physical fitness before and after chemoradiotherapy seems an adequate method to identify patients at risk of postoperative pneumonia.

Family participation in physiotherapy-related tasks of critically ill patients: A mixed methods systematic review.

PURPOSE: Providing an overview of studies on family participation in physiotherapy-related tasks of critically ill patients, addressing two research questions (RQ): 1) What are the perceptions of patients, relatives, and staff about family participation in physiotherapy-related tasks? and 2) What are the effects of interventions of family participation in physiotherapy-related tasks? MATERIAL AND METHODS: Qualitative, quantitative and mixed-methods articles were identified using PubMed, Embase and CINAHL. Studies reporting on family participation in physiotherapy-related tasks of adult critically ill patients were included. A convergent segregated approach for mixed-methods reviews was used. RESULTS: Eighteen articles were included; 13 for RQ1, and 5 for RQ2. The included studies were quantitative, qualitative and mixed-method, including between 8 and 452 participants. The descriptive studies exhibit a general appreciation for involvement of relatives in physiotherapy-related tasks, although most of the studies reported on family involvement in general care and incorporated diverse physiotherapy-related tasks. One study explored the effectiveness of family participation on a rehabilitation outcome and showed that the percentage of patients mobilizing three times a day increased. CONCLUSION: Positive attitudes were observed among patients, their relatives and staff towards family participation in physiotherapy-related tasks of critically ill patients. However, limited research has been done into the effect of interventions containing family participation in physiotherapy-related tasks.

Quality of life in primary care patients with moderate medically unexplained physical symptoms.

PURPOSE: Medically Unexplained Physical Symptoms (MUPS) have a large impact on patient's quality of life. Most studies have been limited to chronic MUPS and thus, little is known about moderate MUPS. Improved knowledge concerning determinants influencing quality of life in moderate MUPS patients can be helpful in managing MUPS. This study is aimed at describing the common characteristics seen in moderate MUPS patients and compare them with characteristics seen in chronic MUPS patients and general population. We also identified determinants of the physical and mental components of quality of life in moderate MUPS patients. METHODS: In a cross-sectional study, moderate MUPS patients (n = 160) were compared with chronic MUPS patients (n = 162) and general population (n = 1742) based on demographic characteristics and patient's quality of life. Multivariable linear regression analyses were performed to identify determinants associated with a patient's quality of life, assessed with the RAND-36. RESULTS: Moderate MUPS patients experienced a better quality of life than chronic MUPS patients, but a worse quality of life as compared to the general population. Determinants associated with the physical and mental components of quality of life explain 49.1% and 62.9% of the variance, respectively. CONCLUSION: Quality of life of patients with MUPS varies with MUPS disease stage. Based on their quality of life scores, moderate MUPS patients would be adequately distinguished from chronic MUPS patients. Half of the variance in the physical component and almost two thirds of the mental component would be explained by a number of MUPS-related symptoms and perceptions.

Identifying subgroups based on self-management skills in primary care patients with moderate medically unexplained physical symptoms.

OBJECTIVE: Medically Unexplained Physical Symptoms (MUPS) are a major burden on both patients and society and frequently develop into chronic MUPS. Self-management interventions may prevent moderate MUPS from becoming chronic. Tailoring interventions to the patient population is strongly recommended. This can be facilitated by identifying subgroups based on self-management skills. This study aimed to identify these subgroups and their clinical profiles in primary care patients with moderate MUPS. METHODS: A cross-sectional study was performed on baseline measurements from a randomized clinical trial (PARASOL-study). To identify subgroups based on self-management skills, a hierarchical cluster analysis was conducted for adults with moderate MUPS from primary health care centers. Self-management skills were measured with the Health education impact Questionnaire. Cluster variables were seven constructs of this questionnaire. Additionally, specific patient profiles were determined by comparing the identified clusters on the clinical variables pain, fatigue and physical functioning. RESULTS: Four subgroups were identified: High-Self-Management Skills (SMS) (n = 29), Medium-SMS (n = 55), Low-SMS (n = 49) and Active & Low Distress-SMS (n = 20). The latter showed a distinctly different pattern on cluster variables, while the other subgroups differed significantly on means of the cluster variables (p < .001). On clinical variables, significant differences between subgroups were mainly found on fatigue and physical functioning. CONCLUSION: This study found four specific subgroups based on self-management skills in moderate MUPS-patients. One subgroup demonstrated a distinctly different pattern on self-management skills. In other subgroups, more similar patterns on self-management skills were found that negatively correlated with pain and fatigue and positively correlated with physical functioning.

Development and proof of concept of a blended physiotherapeutic intervention for patients with non-specific low back pain.

OBJECTIVE: To develop a blended physiotherapeutic intervention for patients with non-specific low back pain (e-Exercise LBP) and evaluate its proof of concept. DESIGN: Focus groups with patients, physiotherapists, and eHealth and LBP experts were conducted to investigate values according to the development of e-Exercise LBP. Proof of concept was evaluated in a multicentre study. SETTING: Dutch primary care physiotherapy practices (n=21 therapists). PARTICIPANTS: Adults with non-specific LBP (n=41). INTERVENTION: e-Exercise LBP was developed based on clinical LBP guidelines and the focus groups, using the Center for eHealth Research Roadmap. Face-to-face physiotherapy sessions were integrated with a web application consisting of 12 information lessons, video-supported exercises and a physical activity module with the option to gradually increase individuals' level of physical activity. The intervention could be tailored to patients' risk of persistent disabling LBP, according to the STarT Back Screening Tool. MAIN OUTCOME MEASURES: Functional disability, pain, physical activity, sedentary behaviour and fear-avoidance beliefs, measured at baseline and 12 weeks. RESULTS: After 12 weeks, improvements were found in functional disability [Quebec Back Pain Disability Scale: mean difference (MD) -12.2/100; 95% confidence interval (CI) 8.3 to 16.1], pain (Numeric Pain Rating Scale: MD -2.8/10; 95% CI 2.1 to 3.6), subjective physical activity (Short Questionnaire to Assess Health Enhancing Physical Activity: MD 11.5minutes/day; 95% CI -47.8 to 24.8) and objective sedentary behaviour (ActiGraph: MD -23.0minutes/day; 95% CI -8.9 to 55.0). Small improvements were found in objective physical activity and fear-avoidance beliefs. The option to gradually increase physical activity was activated for six patients (15%). On average, patients received seven face-to-face sessions alongside the web application. CONCLUSIONS: The results of this study provide the first indication of the effectiveness of e-Exercise LBP, particularly for disability and pain among patients with LBP. Future studies will focus on end-user experiences and (cost-) effectiveness.

Movement behaviour in adults with haemophilia compared to healthy adults.

BACKGROUND: Limited research has been published regarding movement behaviour of adult persons with haemophilia (PWH). It is hypothesized that avoidance of activities and more sedentary behaviour cause poorer physical functioning. AIM: To determine differences in movement behaviour between PWH and healthy adults. METHODS: Movement behaviour was measured with an accelerometer distinguishing between; lying/non-wear, sitting, standing, walking, running and cycling. Time spent on activities was compared between PWH and healthy adults, using absolute time spent on activities and activities as percentage of wear time. RESULTS: One hundred and five PWH (32 mild/moderate with a mean age of 42.8 ± 15.1, severe 42.1 ± 13.6) and 98 healthy adults (mean age 41.9 ± 15.5) showed that adults with severe haemophilia sit and stand more than healthy adults (4.5 [CI 0.6-8.4] and 4.2 [CI 1.8-6.6] h/wk, respectively) and walk and run less (3.4 [CI 1.4-5.3] hours and 33.6 [CI 19.0-41.7] min/wk, respectively). Patients with mild/moderate haemophilia stand more than healthy adults (3.3 [CI 0.1-6.4] h/wk). Differences in sitting between severe haemophilia and healthy adults and differences in standing between mild/moderate haemophilia and healthy adults disappeared when using activities as percentage of wear time. CONCLUSION: Movement behaviour of adults with severe haemophilia differs from healthy adults, mainly due to less walking and less running. No differences were found in other activities and postures or the distribution of movement behaviour over the day. No significant differences were found between adults with mild/moderate haemophilia and healthy adults.

Evidence for and cost-effectiveness of physiotherapy in haemophilia: a Dutch perspective.

INTRODUCTION: Musculoskeletal impact of haemophilia justifies physiotherapy throughout life. Recently the Dutch Health Care Institute constrained their 'list of chronic conditions', and withdrew financial coverage of physiotherapy for elderly persons with haemophilia (PWH). This decision was based on lack of scientific evidence and not being in accordance with 'state of science and practice'. METHODS: In general, evidence regarding physiotherapy is limited, and especially in rare diseases like haemophilia. 'Evidence based medicine' classifies and recommends evidence based on meta-analyses, systematic reviews and randomized controlled trials, but also means integrating evidence with individual clinical expertise. For the evaluation of physiotherapy - usually individualized treatment - case studies, observational studies and Case Based Reasoning may be more beneficial. RESULTS: Overall annual treatment costs for haemophilia care in the Netherlands are estimated over 100 million Euros, of which 95% is covered by clotting factor concentrates. The cost for physiotherapy assessments in all seven Dutch HTCs (seven centres for adult PWH and seven centres for children) is limited at approximately 500 000 Euros annually. Costs of the actual physiotherapy sessions, carried out in our Dutch first-line care system, will also not exceed 500 000 Euros. Thus, implementation of physiotherapy in haemophilia care the Netherlands in a most optimal way would cost less than 1% of the total budget. AIM: The present paper describes the role of physiotherapy in haemophilia care including available evidence and providing suggestions regarding generation of evidence. Establishing the effectiveness and cost-effectiveness of physiotherapy in haemophilia care is a major topic for the next decennium.

How do patients and professionals differentiate between intra-articular joint bleeds and acute flare-ups of arthropathy in patients with haemophilia?

INTRODUCTION: The overlap in symptoms between joint bleeds and flare-ups of haemophilia arthropathy (HA) creates difficulties in differentiating between the two conditions. Diagnosis of haemarthrosis is currently empirically made based upon clinical presentations. However, no standard diagnostic criteria are available. To offer appropriate treatment, rapid and accurate diagnosis is essential. Additionally, adequate differentiation can decrease health costs significantly. AIM: The aim of this study was to identify signs and symptoms to differentiate between an intra-articular joint bleed and an acute flare-up of HA in patients with haemophilia and make an initial proposal of items to include in a diagnostic criteria set. METHODS: Six focus group interviews with a total of 13 patients and 15 professionals were carried out. The focus groups were structured following the Nominal Group Technique (NGT). RESULTS: The most important signs and symptoms used to differentiate between joint bleeds and HA were (i) course of the symptoms, (ii) cause of the complaints, (iii) joint history, (iv) type of pain and (v) degree of impairments in range of motion. CONCLUSION: This qualitative study provides insight into signs and symptoms that are currently used to differentiate between joint bleeds and flare-ups of HA. Results of this study can be used to develop a valid and standardized clinical diagnostic criteria set to differentiate between these two conditions. Further research is necessary to validate the signs and symptoms found in this study.

Collaboration of general practitioners and exercise providers in promotion of physical activity a written survey among general practitioners.

BACKGROUND: General practitioners have an ideal position to motivate inactive patients to increase their physical activity. Most patients are able to exercise in regular local facilities outside the health care setting. The purpose of this study was to get insight into general practitioners perceptions and current practices regarding referral of patients to local exercise facilities. Furthermore, collaboration with exercise providers in the community was investigated, and motivators and barriers for referral. METHODS: A written questionnaire sent to a representative random sample of 800 Dutch general practitioners. Descriptive statistics and Chi(2) tests were used. RESULTS: All responding general practitioners (340) recommend their patients to take more exercise when necessary and 87 % say to refer patients sometimes. Limited motivation of the patient (44 %) and reduced health status (34 %) are the most mentioned barriers for advising patients to increase physical activity. When referred, most patients are send to a physical therapist (69 %) but also local exercise facilities were mentioned (54 %). The most important barrier for referring patients to local exercise activities are patients limited financial possibilities (46 %). Restricted knowledge of local exercise- or sport facilities was an additional barrier (19 %). There is little structural collaboration between general practitioners and exercise providers, but when collaboration exists general practitioners refer more often. Positive experiences of patients (67 %), affordable offers (59 %) and information of local exercise facilities (46 %) are seen as important promoting factors for referral. Although 32 % of the general practitioners think that good collaboration would be stimulating, regular meetings with sports and exercise providers were considered the least important for increasing referral (3 %). CONCLUSIONS: Dutch physicians have a positive attitude towards stimulating physical activity but referral to local exercise facilities is low. Referral is partly hindered by restricted knowledge of local exercise facilities. Although general practitioners think that collaboration is important for physical activity promotion, it should not cost them much extra time. A coordinator with knowledge of the local situation can facilitate contacts between GP practices and sports providers.

Dietetic treatment lowers body mass index in overweight patients: an observational study in primary health care.

BACKGROUND: Greater insight into the effectiveness of usual dietetic care will contribute to the ongoing development of dietetic services. The present study examined the change in body mass index (BMI) in overweight patients after dietetic treatment in primary care, the sources of variability and factors associated with BMI change. METHODS: This population-based observational study was based on data from a Dutch registration network of dietitians in primary health care. Data were derived from electronic medical records concerning 3960 overweight adult patients (BMI ≥ 25 kg m⁻²) who received usual care from 32 registered dietitians between 2006 and 2012. Multilevel linear regression analyses were conducted. RESULTS: Patients' BMI significantly (P < 0.001) decreased by 0.94 kg m⁻² on average during treatment. An additional reduction of 0.8 kg m⁻² was observed in patients treated for longer than 6 months. BMI decreased by 0.06 kg m⁻² for each additional unit in initial BMI above 31.6. Most (97%) variability in BMI change was attributed to patients and 3% to dietitians. Part of the variance between patients (11%) and dietitians (30%) was explained by patient sociodemographic characteristics, nutrition-related health aspects, initial body weight and treatment duration. CONCLUSIONS: Dietetic treatment in primary care lowers BMI in overweight patients. Patients' change in BMI was rather similar between dietitians. Greater BMI reductions were observed in those with a high initial BMI and those treated for at least 6 months. Future research is necessary to study the long-term effects of weight loss after treatment by primary healthcare dietitians, especially because many patients drop out of treatment prematurely.