Daniël Bossen

Effectiveness of a Web-Based Physical Activity Intervention in Patients With Knee and/or Hip Osteoarthritis: Randomized Controlled Trial

Background Patients with knee and/or hip osteoarthritis (OA) are less physically active than the general population, while the benefits of physical activity (PA) have been well documented. Based on the behavioral graded activity treatment, we developed a Web-based intervention to improve PA levels in patients with knee and/or hip OA, entitled “Join2move”. The Join2move intervention is a self-paced 9-week PA program in which the patient’s favorite recreational activity is gradually increased in a time-contingent way. Objective The aim of the study was to investigate whether a fully automated Web-based PA intervention in patients with knee and/or hip OA would result in improved levels of PA, physical function, and self-perceived effect compared with a waiting list control group. Methods The study design was a two-armed randomized controlled trial which was not blinded. Volunteers were recruited via articles in newspapers and health-related websites. Eligibility criteria for participants were: (1) aged 50-75 years, (2) self-reported knee and/or hip OA, (3) self-reported inactivity (30 minutes of moderate PA, 5 times or less per week), (4) no face-to-face consultation with a health care provider other than general practitioners, for OA in the last 6 months, (5) ability to access the Internet weekly, and (6) no contra-indications to exercise without supervision. Baseline, 3-month, and 12-month follow-up data were collected through online questionnaires. Primary outcomes were PA, physical function, and self-perceived effect. In a subgroup of participants, PA was measured objectively using accelerometers. Secondary outcomes were pain, fatigue, anxiety, depression, symptoms, quality of life, self-efficacy, pain coping, and locus of control. Results Of the 581 interested respondents, 199 eligible participants were randomly assigned to the intervention (n=100) or waiting list control group (n=99). Response rates of questionnaires were 84.4% (168/199) after 3 months and 75.4% (150/199) after 12 months. In this study, 94.0% (94/100) of participants actually started the program, and 46.0% (46/100) reached the adherence threshold of 6 out of 9 modules completed. At 3 months, participants in the intervention group reported a significantly improved physical function status (difference=6.5 points, 95% CI 1.8-11.2) and a positive self-perceived effect (OR 10.7, 95% CI 4.3-26.4) compared with the control group. No effect was found for self-reported PA. After 12 months, the intervention group showed higher levels of subjective (difference=21.2 points, 95% CI 3.6-38.9) and objective PA (difference=24 minutes, 95% CI 0.5-46.8) compared with the control group. After 12 months, no effect was found for physical function (difference=5 points, 95% CI −1.0 to 11.0) and self-perceived effect (OR 1.2, 95% CI 0.6-2.4). For several secondary endpoints, the intervention group demonstrated improvements in favor of the intervention group. Conclusions Join2move resulted in changes in the desired direction for several primary and secondary outcomes. Given the benefits and its self-help format, Join2move could be a component in the effort to enhance PA in sedentary patients with knee and/or hip OA. Trial Registration The Netherlands National Trial Register: NTR2483; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=2483 (Archived by WebCite at http://www.webcitation.org/67NqS6Beq).

Adherence to a Web-Based Physical Activity Intervention for Patients With Knee and/or Hip Osteoarthritis: A Mixed Method Study

Background Web-based interventions show promise in promoting a healthy lifestyle, but their effectiveness is hampered by high rates of nonusage. Predictors and reasons for (non)usage are not well known. Identifying which factors are related to usage contributes to the recognition of subgroups who benefit most from Web-based interventions and to the development of new strategies to increase usage. Objective The aim of this mixed methods study was to explore patient, intervention, and study characteristics that facilitate or impede usage of a Web-based physical activity intervention for patients with knee and/or hip osteoarthritis. Methods This study is part of a randomized controlled trial that investigated the effects of Web-based physical activity intervention. A total of 199 participants between 50-75 years of age with knee and/or hip osteoarthritis were randomly assigned to a Web-based intervention (n=100) or a waiting list (n=99). This mixed methods study used only data from the individuals allocated to the intervention group. Patients were defined as users if they completed at least 6 out of 9 modules. Logistic regression analyses with a stepwise backward selection procedure were executed to build a multivariate prediction usage model. For the qualitative part, semistructured interviews were conducted. Both inductive and deductive analyses were used to identify patterns in reported reasons for nonusage. Results Of the 100 participants who received a password and username, 46 completed 6 modules or more. Multivariate regression analyses revealed that higher age (OR 0.94, P=.08) and the presence of a comorbidity (OR 0.33, P=.02) predicted nonusage. The sensitivity analysis indicated that the model was robust to changes in the usage parameter. Results from the interviews showed that a lack of personal guidance, insufficient motivation, presence of physical problems, and low mood were reasons for nonusage. In addition, the absence of human involvement was viewed as a disadvantage and it negatively impacted program usage. Factors that influenced usage positively were trust in the program, its reliability, functionality of the intervention, social support from family or friends, and commitment to the research team. Conclusions In this mixed methods study, we found patient, intervention, and study factors that were important in the usage and nonusage of a Web-based PA intervention for patients with knee and/or hip osteoarthritis. Although the self-guided components offer several advantages, particularly in relation to costs, reach, and access, we found that older patients and participants with a comorbid condition need a more personal approach. For these groups the integration of Web-based interventions in a health care environment seems to be promising. Trial Registration The Netherlands National Trial Register (NTR): NTR2483; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=2483 (Archived by Webcite at http://www.webcitation.org/67NqS6Beq).

The effectiveness of self-guided web-based physical activity interventions among patients with a chronic disease: a systematic review.

BACKGROUND Despite well-documented health benefits, adults with a physical chronic condition do not meet the recommended physical activity (PA) guidelines. Therefore, secondary prevention programs focusing on PA are needed. Web-based interventions have shown promise in the promotion of PA behavior change. We conducted a systematic review to summarize the evidence about the effectiveness of web-based PA interventions in adults with chronic disease. METHODS Articles were included if they evaluated a web-based PA intervention and used a randomized design. Moreover, studies were eligible for inclusion if they used a non- or minimal-treatment control group and if PA outcomes measures were applied. Seven articles were included. RESULTS Three high-quality studies were statistically significant to the control group, whereas 2 high- and 2 low-quality studies reported nonsignificant findings. CONCLUSION Our best evidence synthesis revealed that there is conflicting evidence on the effectiveness of web-based PA interventions in patients with a chronic disease.

The usability and preliminary effectiveness of a web-based physical activity intervention in patients with knee and/or hip osteoarthritis

BackgroundA large proportion of patients with knee and/or hip osteoarthritis (OA) do not meet the recommended levels of physical activity (PA). Therefore, we developed a web-based intervention that provides a tailored PA program for patients with knee and/or hip OA, entitled Join2move. The intervention incorporates core principles of the behaviour graded activity theory (BGA). The aim of this study was to investigate the preliminary effectiveness, feasibility and acceptability of Join2move in patients with knee and/or hip OA.MethodsA non-randomized pilot study was performed among patients with knee and/or hip OA. Primary outcomes were PA (SQUASH Questionnaire), physical function (HOOS and KOOS questionnaires) and self-perceived effect (7-point Likert scale). Baseline, 6 and 12 week follow-up data were collected via online questionnaires. To assess feasibility and acceptability, program usage (modules completed) and user satisfaction (SUS questionnaire) were measured as secondary outcomes. Participants from the pilot study were invited to be interviewed. The interviews focused on users’ experiences with Join2move. Besides the pilot study we performed two usability tests to determine the feasibility and acceptability of Join2move. In the first usability test, software experts evaluated the website from a list of usability concepts. In the second test, users were asked to verbalize thoughts during the execution of multiple tasks.ResultsTwenty OA patients with knee and/or hip OA between 50 and 80 years of age participated in the pilot study. After six weeks, pain scores increased from 5.3 to 6.6 (p=0.04). After 12 weeks this difference disappeared (p=0.5). Overall, users were enthusiastic about Join2move. In particular, performing exercise at ones own pace without time or travel restrictions was cited as convenient. However, some minor flaws were observed. Users perceived some difficulties in completing the entire introduction module and rated the inability to edit and undo actions as annoying.ConclusionsThis paper outlines the preliminary effectiveness, feasibility and acceptability of a web-based PA intervention. Preliminary results from the pilot study revealed that PA scores increased, although differences were not statistically significant. Interviews and usability tests suggest that the intervention is feasible and acceptable in promoting PA in patients with knee and/or hip OA. The intervention was easy to use and the satisfaction with the program was high.Trial registrationThe Netherlands National Trial Register. Trial number: NTR2483

An Overview of 5 Years of Patient Self-Referral for Physical Therapy in the Netherlands

Background Self-referral for physical therapy was introduced in 2006 in the Netherlands. Internationally, debate on self-referral is still ongoing. Objective The aim of this study was to evaluate the effects of self-referral for physical therapy in the Netherlands, focusing on volume of general practice and physical therapy care (incidence rates and utilization of services). Design The study was based on monitoring data from existing data sources. Methods Longitudinal electronic medical record data from general practitioners (GPs) and physical therapists participating in the NIVEL Primary Care Database were used, as well as public data from Statistics Netherlands. Descriptive statistics and Poisson multilevel regression analyses were used for analyzing the data. Results Incidence rates of back (including low back), shoulder, and neck pain in general practice declined slightly from 2004 to 2009. No linear trends were found for number of contacts in GP care for back (including low back) and neck pain. The number of patients visiting physical therapists and the proportion of self-referrers are growing. Self-referrers receive treatment less often after initial intake than referred patients, and the mean number of visits is lower. Limitations This study was based on data of various patient populations from existing data sources. Conclusions The current study indicates that self-referral in the Netherlands has fulfilled most expectations held prior to its introduction, although no changes to the workload of GP care have been found. Use of physical therapy grew, but due to population aging and increasing prevalence of chronic diseases, it remains unclear whether self-referral affects health care utilization. Therefore, cost-benefit analyses are recommended.

A Blended Intervention for Patients With Knee and Hip Osteoarthritis in the Physical Therapy Practice: Development and a Pilot Study

Background Blended care, a combination of online and face-to-face care, is seen as a promising treatment option. However, actual use of blended interventions in practice is disappointing. Objective The objective of this study was two folded. The first aim was to develop a blended exercise therapy intervention for patients with knee and hip osteoarthritis that matches the values of the users and that can be implemented in the daily routine of physical therapists. The second aim was to investigate the feasibility through interviews and a pilot study. Methods In this paper, we employed the first 3 steps of the CeHRes road map to develop a blended intervention for patients with knee and hip osteoarthritis. We used interviews, a focus group and discussions with stakeholders to explore the needs, values, and requirements with respect to our to-be-developed blended intervention, which we called e-Exercise. The first version of e-Exercise was tested in a pilot study. Feasibility outcomes, including recruitment rates within each practice, website usage (assignments completed and website visits), and user satisfaction, were measured. In addition, therapists and patients from the pilot study were interviewed to investigate users’ experiences. Results The study captured important information about stakeholders’ needs and perspectives. Based on our findings, we created a first version and attuned the application’s content, functionality, and structure. Patients and, to lesser extent, physical therapists were satisfied with the e-Exercise intervention. Eight patients were recruited by 8 physical therapists. Of the 8 patients, 6 completed more than 7 of 12 modules. Conclusions This study outlines the development and feasibility of a blended exercise therapy intervention for patients with knee and hip osteoarthritis. E-Exercise offers an alternative approach in the physical therapy treatment of knee and hip osteoarthritis. This study provides valuable information to conduct a further trial to evaluate the (cost) effectiveness of e-Exercise compared to usual physical therapy. Trial Registration Netherlands Trial Register Number: NTR4224; www.trialregister.nl/trialreg/admin/rctview.asp?TC=4224 (Archived by WebCite at http://www.webcitation.org/6fOK4lrTO).

Determinants of Adherence to the Online Component of a Blended Intervention for Patients with Hip and/or Knee Osteoarthritis: A Mixed Methods Study Embedded in the e-Exercise Trial

BACKGROUND Embedding Web-based interventions within physiotherapy has potential, but knowledge on patient adherence to these interventions is limited. INTRODUCTION This study explores which patient-, intervention-, and environment-related factors are determinants of adherence to the online component of e-Exercise, a 12-week blended intervention for patients with hip and/or knee osteoarthritis. METHODS A convergent mixed methods study was performed, embedded within an ongoing trial. Quantitative data of 109 participants that received e-Exercise were used for negative binomial regression analysis. Adherence was defined as the number of online evaluated weeks. Next, semistructured interviews on factors related to adherence to the online component were analyzed. RESULTS Nineteen participants with missing outcome data because their program was not started were excluded. Of the 90 analyzed participants, 81.1% were evaluated for at least 8 weeks. Adherence was highest for participants with middle education, 1-5-year osteoarthritis duration, and participants who were physiotherapist recruited. The 10 analyzed interviews revealed that sufficient Internet skills, self-discipline, execution of the exercise plan, the interventions usability, flexibility, persuasive design, added value, and acceptable required time, and research participation were linked to favorable adherence. DISCUSSION It is unknown if patients who adhered to the online component also adhered to their exercise plans. The relationship between adherence to the online component and clinical outcomes will be addressed in a future study. CONCLUSIONS The majority of the participants adhered to the online component of e-Exercise, illustrating its applicability. The integration within the physiotherapy setting and interventions persuasive design appear to have an important role in optimizing patient adherence.

Effectiveness of a Blended Physical Therapist Intervention in People With Hip Osteoarthritis, Knee Osteoarthritis, or Both: A Cluster-Randomized Controlled Trial

Background. Integrating physical therapy sessions and an online application (e‐Exercise) might support people with hip osteoarthritis (OA), knee OA, or both (hip/knee OA) in taking an active role in the management of their chronic condition and may reduce the number of physical therapy sessions. Objective. The objective of this study was to investigate the short‐ and long‐term effectiveness of e‐Exercise compared to usual physical therapy in people with hip/knee OA. Design. The design was a prospective, single‐blind, multicenter, superiority, cluster‐ randomized controlled trial. Setting. The setting included 143 primary care physical therapist practices. Participants. The participants were 208 people who had hip/knee OA and were 40 to 80 years of age. Intervention. e‐Exercise is a 3‐month intervention in which about 5 face‐to‐face physical therapy sessions were integrated with an online application consisting of graded activity, exercise, and information modules. Usual physical therapy was conducted according to the Dutch physical therapy guidelines on hip and knee OA. Measurements. Primary outcomes, measured at baseline after 3 and 12 months, were physical functioning and free‐living physical activity. Secondary outcome measures were pain, tiredness, quality of life, self‐efficacy, and the number of physical therapy sessions. Results. The e‐Exercise group (n = 109) received, on average, 5 face‐to‐face sessions; the usual physical therapy group (n = 99) received 12. No significant differences in primary outcomes between the e‐Exercise group and the usual physical therapy group were found. Within‐group analyses for both groups showed a significant improvement in physical functioning. After 3 months, participants in the e‐Exercise group reported an increase in physical activity; however, no objectively measured differences in physical activity were found. With respect to secondary outcomes, after 12 months, sedentary behavior significantly increased in the e‐Exercise group compared with the usual physical therapy group. In both groups, there were significant improvements for pain, tiredness, quality of life, and self‐efficacy. Limitations. The response rate at 12 months was 65%. Conclusions. The blended intervention, e‐Exercise, was not more effective than usual physical therapy in people with hip/knee OA.

Blended Interventions to Change Behavior in Patients With Chronic Somatic Disorders: Systematic Review

Background Blended behavior change interventions combine therapeutic guidance with online care. This new way of delivering health care is supposed to stimulate patients with chronic somatic disorders in taking an active role in their disease management. However, knowledge about the effectiveness of blended behavior change interventions and how they should be composed is scattered. Objective This comprehensive systematic review aimed to provide an overview of characteristics and effectiveness of blended behavior change interventions for patients with chronic somatic disorders. Methods We searched for randomized controlled trials published from 2000 to April 2017 in PubMed, Embase, CINAHL, and Cochrane Central Register of Controlled Trials. Risk of bias was assessed using the Cochrane Collaboration tool. Study characteristics, intervention characteristics, and outcome data were extracted. Studies were sorted based on their comparison group. A best-evidence synthesis was conducted to summarize the effectiveness. Results A total of 25 out of the 29 included studies were of high quality. Most studies (n=21; 72%) compared a blended intervention with no intervention. The majority of interventions focused on changing pain behavior (n=17; 59%), and the other interventions focused on lifestyle change (n=12; 41%). In addition, 26 studies (90%) focused on one type of behavior, whereas 3 studies (10%) focused on multiple behaviors. A total of 23 studies (79%) mentioned a theory as basis for the intervention. The therapeutic guidance in most studies (n=18; 62%) was non face-to-face by using email, phone, or videoconferencing, and in the other studies (partly), it was face-to-face (n=11; 38%). In 26 studies (90%), the online care was provided via a website, and in 3 studies (10%) via an app. In 22 studies (76%), the therapeutic guidance and online care were integrated instead of two separate aspects. A total of 26 outcome measures were included in the evidence synthesis comparing blended interventions with no intervention: for the coping strategy catastrophizing, we found strong evidence for a significant effect. In addition, 1 outcome measure was included in the evidence synthesis comparing blended interventions with face-to-face interventions, but no evidence for a significant effect was found. A total of 6 outcome measures were included in the evidence synthesis comparing blended interventions with online interventions, but no evidence for a significant effect was found. Conclusions Blended behavior change interventions for patients with chronic somatic disorders show variety in the type of therapeutic guidance, the type of online care, and how these two delivery modes are integrated. The evidence of the effectiveness of blended interventions is inconsistent and nonsignificant for most outcome measures. Future research should focus on which type of blended intervention works for whom.

SAT0432 Blended Physical Activity Intervention with Reduced Face-To-Face Contact and Usual Physical Therapy Show Similar Effectiveness in Patients with Knee and Hip Osteoarthritis: A Randomized Controlled Trial

Background Exercise therapy is an effective treatment in patients with knee and hip osteoarthritis. However, face-to-face therapy is an expensive regimen. Blended exercise therapy, in which face-to-face contact is combined with a web-based program, might be a cost-effective alternative. Moreover, a blended intervention supports home-exercises and self-management through technology which is available at any time and place. We developed the blended intervention e-Exercise, a 12-week program in which up to five usual physical therapy sessions are integrated with a web-based program. Objectives The objective of this study was to evaluate the short-term effectiveness of e-Exercise compared to usual physical therapy for patients with knee and/or knee osteoarthritis. Methods A multicentre cluster randomized controlled trial was conducted. A number of 247 physical therapists were randomly allocated to e-Exercise (intervention group) or usual physical therapy (control group). The web-based part of e-Exercise is based on graded activity principles. Individual assignments for a central activity, such as walking or cycling, are gradually increased and supported with strength/stability exercises and information modules. Program progress can be evaluated during the face-to-face sessions. Content of these sessions were in both groups based on the Dutch physiotherapy guideline Osteoarthritis Hip-Knee which recommend education, self-management promotion, exercise therapy and if necessary manual therapy. Primary patient-outcomes, measured at baseline and after 12 weeks, were physical functioning and physical activity. Secondary outcome measures were pain, tiredness, quality of life, self-efficacy and the number of physical therapy sessions. Data were analysed using a mixed linear model. Results Totally, 208 patients were included. There were no significant differences in baseline demographics between the intervention (N=108) and control group (N=100). 176 (85%) participants completed the follow-up questionnaire. After 12 weeks, none of the primary outcome measures were significant different between groups. Within group analyses, however, showed for both groups a significant improvement in physical functioning (IG: +4.1 points/100, p<0.01; CG: +5.3 points/100, p<0.01). Participants in the intervention group reported an increase of 23.7 minutes (p=0.03) physical activity per day, the control group an increase of 13.1 minutes (p=0.21). However, no significant differences were found for physical activity measured with ActiGraph accelerometers. With respect to the other outcomes, tiredness reduced significant (p<0.02) more in the intervention group (-1.3 points/10) compared to the control group (-0.5 points/10). Within both groups there were significant improvements for pain, tiredness, quality of life and self-efficacy. The intervention group received 5 face-to face sessions (range 2–16), the control group 12 (range 2–29). Conclusions In this study we found that e-Exercise is an effective treatment option in patients with knee and hip osteoarthritis. Subgroup-analysis, long-term effectiveness and cost-effectiveness of e-Exercise compared to usual physical therapy are forthcoming. Disclosure of Interest None declared