BACKGROUND: Blended physiotherapy, in which physiotherapy sessions and an online application are integrated, might support patients in taking an active role in the management of their chronic condition and may reduce disease related costs. The aim of this study was to evaluate the cost-effectiveness of a blended physiotherapy intervention (e-Exercise) compared to usual physiotherapy in patients with osteoarthritis of hip and/or knee, from the societal as well as the healthcare perspective.METHODS: This economic evaluation was conducted alongside a 12-month cluster randomized controlled trial, in which 108 patients received e-Exercise, consisting of physiotherapy sessions and a web-application, and 99 patients received usual physiotherapy. Clinical outcome measures were quality-adjusted life years (QALYs) according to the EuroQol (EQ-5D-3 L), physical functioning (HOOS/KOOS) and physical activity (Actigraph Accelerometer). Costs were measured using self-reported questionnaires. Missing data were multiply imputed and bootstrapping was used to estimate statistical uncertainty.RESULTS: Intervention costs and medication costs were significantly lower in e-Exercise compared to usual physiotherapy. Total societal costs and total healthcare costs did not significantly differ between groups. No significant differences in effectiveness were found between groups. For physical functioning and physical activity, the maximum probability of e-Exercise being cost-effective compared to usual physiotherapy was moderate (< 0.82) from both perspectives. For QALYs, the probability of e-Exercise being cost-effective compared to usual physiotherapy was 0.68/0.84 at a willingness to pay of 10,000 Euro and 0.70/0.80 at a willingness to pay of 80,000 Euro per gained QALY, from respectively the societal and the healthcare perspective.CONCLUSIONS: E-Exercise itself was significantly cheaper compared to usual physiotherapy in patients with hip and/or knee osteoarthritis, but not cost-effective from the societal- as well as healthcare perspective. The decision between both interventions can be based on the preferences of the patient and the physiotherapist.TRIAL REGISTRATION: NTR4224 (25 October 2013).
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Physical activity monitoring with wearable technology has the potential to support stroke rehabilitation. Little is known about how physical therapists use and value the use of wearable activity monitors. This cross-sectional study explores the use, perspectives, and barriers to wearable activity monitoring in day-to-day stroke care routines amongst physical therapists. Over 300 physical therapists in primary and geriatric care and rehabilitation centers in the Netherlands were invited to fill in an online survey that was developed based on previous studies and interviews with experts. In total, 103 complete surveys were analyzed. Out of the 103 surveys, 27% of the respondents were already using activity monitoring. Of the suggested treatment purposes of activity monitoring, 86% were perceived as useful by more than 55% of the therapists. The most recognized barriers to clinical implementation were lack of skills and knowledge of patients (65%) and not knowing what brand and type of monitor to choose (54%). Of the non-users, 79% were willing to use it in the future. In conclusion, although the concept of remote activity monitoring was perceived as useful, it was not widely adopted by physical therapists involved in stroke care. To date, skills, beliefs, and attitudes of individual therapists determine the current use of wearable technology.
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The uptake of eRehabilitation programs in stroke care is insufficient, despite the growing availability. The aim of this study was to explore which factors influence the uptake of eRehabilitation in stroke rehabilitation, among stroke patients, informal caregivers, and healthcare professionals. A qualitative focus group study with eight focus groups (6–8 participants per group) was conducted: six with stroke patients/informal caregivers and two with healthcare professionals involved in stroke rehabilitation (rehabilitation physicians, physical therapists, occupational therapists, psychologists, managers). Focus group interviews were audiotaped, transcribed in full, and analyzed by direct content analysis using the implementation model of Grol. Results Thirty-two patients, 15 informal caregivers, and 13 healthcare professionals were included. A total of 14 influencing factors were found, grouped to 5 of the 6 levels of the implementation model of Grol (Innovation, Organizational context, Individual patient, Individual professional, and Economic and political context). Most quotes of patients, informal caregivers, and healthcare professionals were classified to factors at the level of the Innovation (e.g., content, attractiveness, and feasibility of eRehabilitation programs). In addition, for patients, relatively many quotes were classified to factors at the level of the individual patient (e.g., patients characteristics as fatigue and the inability to understand ICT-devices), and for healthcare professionals at the level of the organizational context (e.g., having sufficient time and the fit with existing processes of care). Although there was a considerable overlap in reported factors between patients/informal caregivers and healthcare professionals when it concerns eRehabilitation as innovation, its seems that patients/informal caregivers give more emphasis to factors related to the individual patient, whereas healthcare professionals emphasize the importance of factors related to the organizational context. This difference should be considered when developing an implementation strategy for patients and healthcare professionals separately. https://doi.org/10.1186/s13012-018-0827-5
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Objective: Despite the increasing availability of eRehabilitation, its use remains limited. The aim of this study was to assess factors associated with willingness to use eRehabilitation. Design: Cross-sectional survey. Subjects: Stroke patients, informal caregivers, health-care professionals. Methods: The survey included personal characteristics, willingness to use eRehabilitation (yes/no) and barri-ers/facilitators influencing this willingness (4-point scale). Barriers/facilitators were merged into factors. The association between these factors and willingness to use eRehabilitation was assessed using logistic regression analyses. Results: Overall, 125 patients, 43 informal caregivers and 105 healthcare professionals participated in the study. Willingness to use eRehabilitation was positively influenced by perceived patient benefits (e.g. reduced travel time, increased motivation, better outcomes), among patients (odds ratio (OR) 2.68; 95% confidence interval (95% CI) 1.34–5.33), informal caregivers (OR 8.98; 95% CI 1.70–47.33) and healthcare professionals (OR 6.25; 95% CI 1.17–10.48). Insufficient knowledge decreased willingness to use eRehabilitation among pa-tients (OR 0.36, 95% CI 0.17–0.74). Limitations of the study include low response rates and possible response bias. Conclusion: Differences were found between patients/informal caregivers and healthcare professionals. Ho-wever, for both groups, perceived benefits of the use of eRehabilitation facilitated willingness to use eRehabili-tation. Further research is needed to determine the benefits of such programs, and inform all users about the potential benefits, and how to use eRehabilitation. Lay Abstract The use of digital eRehabilitation after stroke (e.g. in serious games, e-consultation and education) is increasing. However, the use of eRehabilitation in daily practice is limited. As a first step in increasing the use of eRehabilitation in stroke care, this study examined which factors influence the willingness of stroke patients, informal caregivers and healthcare professionals to use eRehabilitation. Beliefs about the benefits of eRehabilitation were found to have the largest positive impact on willingness to use eRehabilitation. These benefits included reduced travel time, increased adherence to therapy or motivation, and better health outcomes. The willingness to use eRehabilitation is limited by a lack of knowledge about how to use eRehabilitation.
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Background: In recent years, the effectiveness and cost-effectiveness of digital health services for people with musculoskeletal conditions have increasingly been studied and show potential. Despite the potential of digital health services, their use in primary care is lagging. A thorough implementation is needed, including the development of implementation strategies that potentially improve the use of digital health services in primary care. The first step in designing implementation strategies that fit the local context is to gain insight into determinants that influence implementation for patients and health care professionals. Until now, no systematic overview has existed of barriers and facilitators influencing the implementation of digital health services for people with musculoskeletal conditions in the primary health care setting. Objective: This systematic literature review aims to identify barriers and facilitators to the implementation of digital health services for people with musculoskeletal conditions in the primary health care setting. Methods: PubMed, Embase, and CINAHL were searched for eligible qualitative and mixed methods studies up to March 2024. Methodological quality of the qualitative component of the included studies was assessed with the Mixed Methods Appraisal Tool. A framework synthesis of barriers and facilitators to implementation was conducted using the Consolidated Framework for Implementation Research (CFIR). All identified CFIR constructs were given a reliability rating (high, medium, or low) to assess the consistency of reporting across each construct. Results: Overall, 35 studies were included in the qualitative synthesis. Methodological quality was high in 34 studies and medium in 1 study. Barriers (–) of and facilitators (+) to implementation were identified in all 5 CFIR domains: “digital health characteristics” (ie, commercial neutral [+], privacy and safety [–], specificity [+], and good usability [+]), “outer setting” (ie, acceptance by stakeholders [+], lack of health care guidelines [–], and external financial incentives [–]), “inner setting” (ie, change of treatment routines [+ and –], information incongruence (–), and support from colleagues [+]), “characteristics of the healthcare professionals” (ie, health care professionals’ acceptance [+ and –] and job satisfaction [+ and –]), and the “implementation process” (involvement [+] and justification and delegation [–]). All identified constructs and subconstructs of the CFIR had a high reliability rating. Some identified determinants that influence implementation may be facilitators in certain cases, whereas in others, they may be barriers. Conclusions: Barriers and facilitators were identified across all 5 CFIR domains, suggesting that the implementation process can be complex and requires implementation strategies across all CFIR domains. Stakeholders, including digital health intervention developers, health care professionals, health care organizations, health policy makers, health care funders, and researchers, can consider the identified barriers and facilitators to design tailored implementation strategies after prioritization has been carried out in their local context
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Introduction: Hip and knee osteoarthritis are associated with functional limitations, pain and restrictions in quality of life and the ability to work. Furthermore, with growing prevalence, osteoarthritis is increasingly causing (in)direct costs. Guidelines recommend exercise therapy and education as primary treatment strategies. Available options for treatment based on physical activity promotion and lifestyle change are often insufficiently provided and used. In addition, the quality of current exercise programmes often does not meet the changing care needs of older people with comorbidities and exercise adherence is a challenge beyond personal physiotherapy. The main objective of this study is to investigate the short- and long-term (cost-)effectiveness of the SmArt-E programme in people with hip and/or knee osteoarthritis in terms of pain and physical functioning compared to usual care. Methods: This study is designed as a multicentre randomized controlled trial with a target sample size of 330 patients. The intervention is based on the e-Exercise intervention from the Netherlands, consists of a training and education programme and is conducted as a blended care intervention over 12 months. We use an app to support independent training and the development of self-management skills. The primary and secondary hypotheses are that participants in the SmArt-E intervention will have less pain (numerical rating scale) and better physical functioning (Hip Disability and Osteoarthritis Outcome Score, Knee Injury and Osteoarthritis Outcome Score) compared to participants in the usual care group after 12 and 3 months. Other secondary outcomes are based on domains of the Osteoarthritis Research Society International (OARSI). The study will be accompanied by a process evaluation. Discussion: After a positive evaluation, SmArt-E can be offered in usual care, flexibly addressing different care situations. The desired sustainability and the support of the participants' behavioural change are initiated via the app through audio-visual contact with their physiotherapists. Furthermore, the app supports the repetition and consolidation of learned training and educational content. For people with osteoarthritis, the new form of care with proven effectiveness can lead to a reduction in underuse and misuse of care as well as contribute to a reduction in (in)direct costs.
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Background: Patient education, home-based exercise therapy, and advice on returning to normal activities are established physiotherapeutic treatment options for patients with nonspecific low back pain (LBP). However, the effectiveness of physiotherapy interventions on health-related outcomes largely depends on patient self-management and adherence to exercise and physical activity recommendations. e-Exercise LBP is a recently developed stratified blended care intervention comprising a smartphone app integrated with face-to-face physiotherapy treatment. Following the promising effects of web-based applications on patients’ self-management skills and adherence to exercise and physical activity recommendations, it is hypothesized that e-Exercise LBP will improve patients’ physical functioning. Objective: This study aims to investigate the short-term (3 months) effectiveness of stratified blended physiotherapy (e-Exercise LBP) on physical functioning in comparison with face-to-face physiotherapy in patients with nonspecific LBP. Methods The study design was a multicenter cluster randomized controlled trial with intention-to-treat analysis. Patients with nonspecific LBP aged ≥18 years were asked to participate in the study. The patients were treated with either stratified blended physiotherapy or face-to-face physiotherapy. Both interventions were conducted according to the Dutch physiotherapy guidelines for nonspecific LBP. Blended physiotherapy was stratified according to the patients’ risk of developing persistent LBP using the Keele STarT Back Screening Tool. The primary outcome was physical functioning (Oswestry Disability Index, range 0-100). Secondary outcomes included pain intensity, fear-avoidance beliefs, and self-reported adherence. Measurements were taken at baseline and at the 3-month follow-up. Results: Both the stratified blended physiotherapy group (104/208, 50%) and the face-to-face physiotherapy group (104/208, 50%) had improved clinically relevant and statistically significant physical functioning; however, there was no statistically significant or clinically relevant between-group difference (mean difference −1.96, 95% CI −4.47 to 0.55). For the secondary outcomes, stratified blended physiotherapy showed statistically significant between-group differences in fear-avoidance beliefs and self-reported adherence. In patients with a high risk of developing persistent LBP (13/208, 6.3%), stratified blended physiotherapy showed statistically significant between-group differences in physical functioning (mean difference −16.39, 95% CI −27.98 to −4.79) and several secondary outcomes. Conclusions: The stratified blended physiotherapy intervention e-Exercise LBP is not more effective than face-to-face physiotherapy in patients with nonspecific LBP in improving physical functioning in the short term. For both stratified blended physiotherapy and face-to-face physiotherapy, within-group improvements were clinically relevant. To be able to decide whether e-Exercise LBP should be implemented in daily physiotherapy practice, future research should focus on the long-term cost-effectiveness and determine which patients benefit most from stratified blended physiotherapy.
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At present, persons with dementia and their family caregivers in the Netherlands are not adequately supported to modify their dwellings to match their personal needs. To facilitate aging-in-place for persons with dementia, a website was designed. The website was designed with persons with dementia and their spouses. In consultation sessions existing websites were discussed. Based on this discussion, a demonstration website was created and then discussed with and judged by the participants. Visits to the website were monitored using Google Analytics.
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A loss of physical functioning (i.e., a low physical capacity and/or a low physical activity) is a common feature in patients with chronic obstructive pulmonary disease (COPD). To date, the primary care physiotherapy and specialized pulmonary rehabilitation are clearly underused, and limited to patients with a moderate to very severe degree of airflow limitation (GOLD stage 2 or higher). However, improved referral rates are a necessity to lower the burden for patients with COPD and for society. Therefore, a multidisciplinary group of healthcare professionals and scientists proposes a new model for referral of patients with COPD to the right type of exercise-based care, irrespective of the degree of airflow limitation. Indeed, disease instability (recent hospitalization, yes/no), the burden of disease (no/low, mild/moderate or high), physical capacity (low or preserved) and physical activity (low or preserved) need to be used to allocate patients to one of the six distinct patient profiles. Patients with profile 1 or 2 will not be referred for physiotherapy; patients with profiles 3–5 will be referred for primary care physiotherapy; and patients with profile 6 will be referred for screening for specialized pulmonary rehabilitation. The proposed Dutch model has the intention to get the right patient with COPD allocated to the right type of exercise-based care and at the right moment.
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Abstract Background Visuospatial neglect (VSN) is a cognitive disorder after stroke in which patients fail to consciously process and interact with contralesional stimuli. Visual Scanning Training (VST) is the recommended treatment in clinical guidelines. At the moment, several mixed reality versions of Visual Scanning Training (VST) are being developed. The aim of this study was to explore the opinions of end-users (i.e., therapists) on the use of Virtual Reality (VR) and Augmented Reality (AR) in VSN treatment. Methods Therapists played one VR and two AR Serious Games, and subsequently flled out a questionnaire on User Experience, Usability, and Implementation. Results Sixteen therapists (psychologists, occupational, speech, and physiotherapists) played the games, thirteen of them evaluated the games. Therapists saw great potential in all three games, yet there was room for improvement on the level of usability, especially for tailoring the games to the patient’s needs. Therapists’ opinions were comparable between VR and AR Serious Games. For implementation, therapists stressed the urgency of clear guidelines and instructions. Discussion Even though VR/AR technology is promising for VSN treatment, there is no one-size-fts-all applicability. It may thus be crucial to move towards a plethora of training environments rather than a single standardized mixed reality neglect treatment. Conclusion As therapists see the potential value of mixed reality, it remains important to investigate the efcacy of AR and VR training tools.
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