Multiple organizations around the world have issued evidence-based exercise guidance for patients with cancer and cancer survivors. Recently, the American College of Sports Medicine has updated its exercise guidance for cancer prevention as well as for the prevention and treatment of a variety of cancer health-related outcomes (eg, fatigue, anxiety, depression, function, and quality of life). Despite these guidelines, the majority of people living with and beyond cancer are not regularly physically active. Among the reasons for this is a lack of clarity on the part of those who work in oncology clinical settings of their role in assessing, advising, and referring patients to exercise. The authors propose using the American College of Sports Medicine's Exercise Is Medicine initiative to address this practice gap. The simple proposal is for clinicians to assess, advise, and refer patients to either home-based or community-based exercise or for further evaluation and intervention in outpatient rehabilitation. To do this will require care coordination with appropriate professionals as well as change in the behaviors of clinicians, patients, and those who deliver the rehabilitation and exercise programming. Behavior change is one of many challenges to enacting the proposed practice changes. Other implementation challenges include capacity for triage and referral, the need for a program registry, costs and compensation, and workforce development. In conclusion, there is a call to action for key stakeholders to create the infrastructure and cultural adaptations needed so that all people living with and beyond cancer can be as active as is possible for them.
Purpose: A structured, tailored exercise therapy strategy was found to significantly improve physical functioning, reduce pain and was safe for patients with knee osteoarthritis (OA) and severe comorbidity. The intervention was performed in a specialized, secondary care center. Before the intervention can be implemented in primary care, appropriate education as well as insight into barriers and facilitators is needed. This study aimed to 1) evaluate the feasibility and effect of an interactive course on the exercise therapy strategy for patients with OA and comorbidity for physiotherapists (PTs) working in primary care; and 2) map barriers for a larger scale implementation of the protocol in primary care.Methods: A pre-posttest study was performed among PTs who were member of a network for rheumatic diseases and PTs from regional subdivisions of the Royal Dutch Society for Physical Therapy (KNGF) in the Netherlands (North-Holland and Mid-Holland) all working in primary care. PTs were offered a postgraduate blended educational course consisting of an e-learning lecture (7 hours study load) and two interactive workshops (each 3 hours study load). Measures of its feasibility and effectiveness included a questionnaire on knowledge (50 multiple choice questions, score ranging from 1 to 50) before (T0) and two weeks after the course (T1)) and a patient vignette to measure clinical reasoning (nine open questions, score ranging from 0 to 5) before the course (T0) and six months after the course (T2). Course satisfaction was administered on a 0-10 point scale (higher score means more satisfaction), directly after the course. Barriers for using the protocol were measured at T2 by means of a 27 item questionnaire, comprising five different dimensions: (i) Design, Content and Feasibility; (ii) Change in working method; (iii) Knowledge and Skills; (iv) Applicability; and (v) Social environment (each item was scored on a 5-point Likert scale, ranging from 0 totally agree to 4 totally disagree).Results: In total, 34 physiotherapists were included. Statistically significant (P < 0.05) improvement was found in knowledge about knee OA and comorbidity between baseline and two- weeks post education, with an average increase of 4.4 points above the baseline score. Also, a statistically significant improvement (P < 0.05) was found for clinical reasoning on adapting knee OA exercise therapy to the comorbid disease between baseline and six- months post education. Overall, the PTs were satisfied with the educational course (7.9 points (SD 0.9) (n ¼ 33)). The majority of PTs found the protocol to be supportive regarding clinical reasoning and clinical decision making. In a period of six months, 15 out of 34 PTs had treated at least one patient with knee OAand comorbidity according to the protocol. Perceived barriers for implementation included the small number of patients with OA and severe comorbidity being referred or referring themselves, treatment time needed to provide care according the protocol, and the limited number of treatments reimbursement by the insurance companies.Conclusions: An interactive educational course on exercise therapy for knee OA patients with comorbidity proved to be effective in improving knowledge and clinical reasoning skills of primary care PTs. Main barriers for larger scale implementation include limited referrals of patients with knee OA and severe comorbidity to PTs and limited number of treatments reimbursement by the insurance companies. Specialists and patients should be encouraged to consider exercise therapy as a treatment option for patients with knee OA and comorbidity.
ObjectiveTo compare cost effectiveness of endovascular revascularisation (ER) and supervised exercise therapy (SET) as primary treatment for patients with intermittent claudication (IC) due to iliac artery obstruction.MethodsCost utility analysis from a restricted societal perspective and time horizon of 12 months. Patients were included in a multicentre randomised controlled trial (SUPER study, NCT01385774, NTR2648) which compared effectiveness of ER and SET. Health status and health related quality of life (HRQOL) were measured using the Euroqol 5 dimensions 3 levels (EQ5D-3L) and VascuQol-25-NL. Incremental costs were determined per allocated treatment and use of healthcare during follow up. Effectiveness of treatment was determined in quality adjusted life years (QALYs). The difference between treatment groups was calculated by an incremental cost utility ratio (ICER).ResultsSome 240 patients were included, and complete follow up was available for 206 patients (ER 111 , SET 95). The mean costs for patients allocated to ER were €4 031 and €2 179 for SET, a mean difference of €1 852 (95% bias corrected and accelerated [bca] bootstrap confidence interval 1 185 – 2 646). The difference in QALYs during follow up was 0.09 (95% bcaCI 0.04 – 0.13) in favour of ER. The ICER per QALY was €20 805 (95% bcaCI 11 053 – 45 561). The difference in VascuQol sumscore was 0.64 (95% bcaCI 0.39 – 0.91), again in favour of ER.ConclusionER as a primary treatment, results in slightly better health outcome and higher QALYs and HRQOL during 12 months of follow up. Although these differences are statistically significant, clinical relevance must be discussed due to the small differences and relatively high cost of ER as primary treatment.
MULTIFILE
Physical rehabilitation programs revolve around the repetitive execution of exercises since it has been proven to lead to better rehabilitation results. Although beginning the motor (re)learning process early is paramount to obtain good recovery outcomes, patients do not normally see/experience any short-term improvement, which has a toll on their motivation. Therefore, patients find it difficult to stay engaged in seemingly mundane exercises, not only in terms of adhering to the rehabilitation program, but also in terms of proper execution of the movements. One way in which this motivation problem has been tackled is to employ games in the rehabilitation process. These games are designed to reward patients for performing the exercises correctly or regularly. The rewards can take many forms, for instance providing an experience that is engaging (fun), one that is aesthetically pleasing (appealing visual and aural feedback), or one that employs gamification elements such as points, badges, or achievements. However, even though some of these serious game systems are designed together with physiotherapists and with the patients’ needs in mind, many of them end up not being used consistently during physical rehabilitation past the first few sessions (i.e. novelty effect). Thus, in this project, we aim to 1) Identify, by means of literature reviews, focus groups, and interviews with the involved stakeholders, why this is happening, 2) Develop a set of guidelines for the successful deployment of serious games for rehabilitation, and 3) Develop an initial implementation process and ideas for potential serious games. In a follow-up application, we intend to build on this knowledge and apply it in the design of a (set of) serious game for rehabilitation to be deployed at one of the partners centers and conduct a longitudinal evaluation to measure the success of the application of the deployment guidelines.
Low back pain is the leading cause of disability worldwide and a significant contributor to work incapacity. Although effective therapeutic options are scarce, exercises supervised by a physiotherapist have shown to be effective. However, the effects found in research studies tend to be small, likely due to the heterogeneous nature of patients' complaints and movement limitations. Personalized treatment is necessary as a 'one-size-fits-all' approach is not sufficient. High-tech solutions consisting of motions sensors supported by artificial intelligence will facilitate physiotherapists to achieve this goal. To date, physiotherapists use questionnaires and physical examinations, which provide subjective results and therefore limited support for treatment decisions. Objective measurement data obtained by motion sensors can help to determine abnormal movement patterns. This information may be crucial in evaluating the prognosis and designing the physiotherapy treatment plan. The proposed study is a small cohort study (n=30) that involves low back pain patients visiting a physiotherapist and performing simple movement tasks such as walking and repeated forward bending. The movements will be recorded using sensors that estimate orientation from accelerations, angular velocities and magnetometer data. Participants complete questionnaires about their pain and functioning before and after treatment. Artificial analysis techniques will be used to link the sensor and questionnaire data to identify clinically relevant subgroups based on movement patterns, and to determine if there are differences in prognosis between these subgroups that serve as a starting point of personalized treatments. This pilot study aims to investigate the potential benefits of using motion sensors to personalize the treatment of low back pain. It serves as a foundation for future research into the use of motion sensors in the treatment of low back pain and other musculoskeletal or neurological movement disorders.
