Geert M. Rutten

Interrupting long periods of sitting: good STUFF

There is increasing evidence that sedentary behaviour is in itself a health risk, regardless of the daily amount of moderate to vigorous physical activity. Therefore, sedentary behaviour should be targeted as important health behaviour.It is known that even relatively small changes of health behaviour often require serious efforts from an individual and from people in their environment to become part of their lifestyle. Therefore, interventions to promote healthy behaviours should ideally be simple, easy to perform and easily available. Since sitting is likely to be highly habitual, confrontation with an intervention should almost automatically elicit a reaction of getting up, and thus break up and reduce sitting time. One important prerequisite for successful dissemination of such an intervention could be the use of a recognisable term relating to sedentary behaviour, which should have the characteristics of an effective brand name. To become wide spread, this term may need to meet three criteria: the “Law of the few”, the “Stickiness factor”, and the “Power of context”. For that purpose we introduce STUFF: Stand Up For Fitness. STUFF can be defined as “interrupting long sitting periods by short breaks”, for instance, interrupting sitting every 30 min by standing for at least five minutes.Even though we still need evidence to test the health-enhancing effects of interrupted sitting, we hope that the introduction of STUFF will facilitate the testing of the social, psychological and health effects of interventions to reduce sitting time.

Adherence to Clinical Practice Guidelines for Low Back Pain in Physical Therapy: Do Patients Benefit?

Background Various guidelines for the management of low back pain have been developed to enhance the effectiveness and efficiency of care. Evidence that guideline-adherent care results in better health outcomes, however, is not conclusive. Objective The main objective of this study was to assess whether a higher percentage of adherence to the Dutch physical and manual therapy guidelines for low back pain is related to improved outcomes. The study further explored whether this relationship differs for the individual steps of the process of care and for distinct subgroups of patients. Design This was an observational prospective cohort study (2005–2006) in the Netherlands that included a sample of 61 private practice therapists and 145 patients. Methods Therapists recorded the process of care and the number of treatment sessions in Web-based patient files. Guideline adherence was assessed using quality indicators. Physical functioning was measured by the Dutch version of the Quebec Back Pain and Disability Scale, and average pain was measured with a visual analog scale. Relationships between the percentage of guideline adherence and outcomes of care were evaluated with regression analyses. Results Higher percentages of adherence were associated with fewer functional limitations (β=−0.21, P=.023) and fewer treatment sessions (β=−0.27, P=.005). Limitations The relatively small self-selected sample might limit external validity, but it is not expected that the small sample greatly influenced the internal validity of the study. Larger samples are required to enable adequate subgroup analyses. Conclusions The results indicate that higher percentages of guideline adherence are related to better improvement of physical functioning and to a lower utilization of care. A proper assessment of the relationship between the process of physical therapy care and outcomes may require a comprehensive set of process indicators to measure guideline adherence.

A Qualitative Application of the Diffusion of Innovations Theory to Examine Determinants of Guideline Adherence Among Physical Therapists

Background: Evidence-based practice has become a major issue in physical therapy. Many evidence-based guidelines, however, are not used extensively after dissemination, and interventions aimed at increasing guideline adherence often have limited effects. Objective: As a prerequisite for changing this situation, the aims of this study were to gain an in-depth understanding of the determinants of guideline adherence among physical therapists in the Netherlands and to evaluate the opportunities of a theoretical framework in this respect. Design and Methods: This observational study consisted of 3 focus group interviews (n=12, 10, and 8) between November 2002 and January 2003. Physical therapists were asked to discuss their opinions about and experiences with the Dutch guidelines for low back pain. Data were analyzed qualitatively using a directed approach to content analysis. Both the interview route and the analysis of the interviews were informed by Rogers’ Diffusion of Innovations Theory. Results: Our study yielded in-depth insights into the various determinants of guideline adherence. Overall, the participants had rather unfavorable opinions about issues related to the dissemination of the guidelines (first phase of the diffusion process) and provided relatively little information on the subsequent adoption process (second phase of the diffusion process). The theoretical framework appeared to be a useful tool to properly structure the focus group interviews, to systematically analyze the data collected, and to determine that supplementary interviews would be necessary to cover the entire diffusion process. Conclusions: Our findings indicated that the diffusion process of guidelines among physical therapists was not yet completed. The use of theory can provide added value to guideline implementation studies.

Development of a theory- and evidence-based intervention to enhance implementation of physical therapy guidelines for the management of low back pain

BackgroundSystematic planning could improve the generally moderate effectiveness of interventions to enhance adherence to clinical practice guidelines. The aim of our study was to demonstrate how the process of Intervention Mapping was used to develop an intervention to address the lack of adherence to the national CPG for low back pain by Dutch physical therapists.MethodsWe systematically developed a program to improve adherence to the Dutch physical therapy guidelines for low back pain. Based on multi-method formative research, we formulated program and change objectives. Selected theory-based methods of change and practical applications were combined into an intervention program. Implementation and evaluation plans were developed.ResultsFormative research revealed influential determinants for physical therapists and practice quality managers. Self-regulation was appropriate because both the physical therapists and the practice managers needed to monitor current practice and make and implement plans for change. The program stimulated interaction between practice levels by emphasizing collective goal setting. It combined practical applications, such as knowledge transfer and discussion-and-feedback, based on theory-based methods, such as consciousness raising and active learning. The implementation plan incorporated the wider environment. The evaluation plan included an effect and process evaluation.ConclusionsIntervention Mapping is a useful framework for formative data in program planning in the field of clinical guideline implementation. However, a decision aid to select determinants of guideline adherence identified in the formative research to analyse the problem may increase the efficiency of the application of the Intervention Mapping process.

A new direction in psychology and health: Resistance exercise training for obese children and adolescents

Obesity is a growing health problem globally (Swinburn et al., 2011). It is an established risk factor for chronic metabolic and cardiovascular diseases (Kelsey, Zaepfel, Bjornstad, & Nadeau, 2014;...

Effectiveness of Peer Assessment for Implementing a Dutch Physical Therapy Low Back Pain Guideline: Cluster Randomized Controlled Trial

Background Clinical practice guidelines are considered important instruments to improve quality of care. However, success is dependent on adherence, which may be improved using peer assessment, a strategy in which professionals assess performance of their peers in a simulated setting. Objective The aim of this study was to determine whether peer assessment is more effective than case-based discussions to improve knowledge and guideline-consistent clinical reasoning in the Dutch physical therapy guideline for low back pain (LBP). Design A cluster randomized controlled trial was conducted. Setting and Participants Ten communities of practice (CoPs) of physical therapists were cluster randomized (N=90): 6 CoPs in the peer-assessment group (n=49) and 4 CoPs in the case-based discussion group (control group) (n=41). Intervention Both groups participated in 4 educational sessions and used clinical patient cases. The peer-assessment group reflected on performed LBP management in different roles. The control group used structured discussions. Measurements Outcomes were assessed at baseline and at 6 months. The primary outcome measure was knowledge and guideline-consistent reasoning, measured with 12 performance indicators using 4 vignettes with specific guideline-related patient profiles. For each participant, the total score was calculated by adding up the percentage scores (0–100) per vignette, divided by 4. The secondary outcome measure was reflective practice, as measured by the Self-Reflection and Insight Scale (20–100). Results Vignettes were completed by 78 participants (87%). Multilevel analysis showed an increase in guideline-consistent clinical reasoning of 8.4% in the peer-assessment group, whereas the control group showed a decline of 0.1% (estimated group difference=8.7%, 95% confidence interval=3.9 to 13.4). No group differences were found on self-reflection. Limitations The small sample size, a short-term follow-up, and the use of vignettes as a proxy for behavior were limitations of the study. Conclusions Peer assessment leads to an increase in knowledge and guideline-consistent clinical reasoning.

Evaluation of the theory-based Quality Improvement in Physical Therapy (QUIP) programme: a one-group, pre-test post-test pilot study

BackgroundGuideline adherence in physical therapy is far from optimal, which has consequences for the effectiveness and efficiency of physical therapy care. Programmes to enhance guideline adherence have, so far, been relatively ineffective. We systematically developed a theory-based Quality Improvement in Physical Therapy (QUIP) programme aimed at the individual performance level (practicing physiotherapists; PTs) and the practice organization level (practice quality manager; PQM). The aim of the study was to pilot test the multilevel QUIP programme’s effectiveness and the fidelity, acceptability and feasibility of its implementation.MethodsA one-group, pre-test, post-test pilot study (N = 8 practices; N = 32 PTs, 8 of whom were also PQMs) done between September and December 2009. Guideline adherence was measured using clinical vignettes that addressed 12 quality indicators reflecting the guidelines’ main recommendations. Determinants of adherence were measured using quantitative methods (questionnaires). Delivery of the programme and management changes were assessed using qualitative methods (observations, group interviews, and document analyses). Changes in adherence and determinants were tested in the paired samples T-tests and expressed in effect sizes (Cohen’s d).ResultsOverall adherence did not change (3.1%; p = .138). Adherence to three quality indicators improved (8%, 24%, 43%; .000 ≤ p ≤ .023). Adherence to one quality indicator decreased (−15.7%; p = .004). Scores on various determinants of individual performance improved and favourable changes at practice organizational level were observed. Improvements were associated with the programme’s multilevel approach, collective goal setting, and the application of self-regulation; unfavourable findings with programme deficits. The one-group pre-test post-test design limits the internal validity of the study, the self-selected sample its external validity.ConclusionsThe QUIP programme has the potential to change physical therapy practice but needs considerable revision to induce the ongoing quality improvement process that is required to optimize overall guideline adherence. To assess its value, the programme needs to be tested in a randomized controlled trial.

Gecombineerde leefstijl interventies in Nederland: ervaringen uit de Beweegkuur

Vanwege de dreiging van onbeheersbare kosten in de gezondheidszorg gaf minister Klink van Volksgezondheid, Welzijn en Sport (VWS) in 2007 aan te willen bezuinigen door middel van preventie. In zijn ‘Kaderbrief 2007-2011, Visie op gezondheid en preventie’, beschreef de minister het belang van preventie en benoemde het als een speerpunt voor het gezondheidsbeleid. Eind 2007 startte het Nederlands Instituut voor Sport en Bewegen (NISB), in opdracht van het ministerie van VWS, met de ontwikkeling van de BeweegKuur ter preventie van diabetes mellitus type 2. De BeweegKuur is een gecombineerde leefstijl interventie waarin deelnemers vanuit de huisartsenpraktijk doorverwezen worden naar een leefstijladviseur (meestal de praktijkondersteuner of een fysiotherapeut), die de deelnemer gedurende een jaar begeleidt naar een gezondere leefstijl. De deelnemer kan zelfstandig gaan bewegen of wordt, indien nodig, door de leefstijladviseur verwezen naar de fysiotherapeut om daar te starten met bewegen. Ook worden alle deelnemers verwezen naar de diëtist voor zowel individuele als groepsbijeenkomsten. De intentie op lange termijn was om de BeweegKuur en in essentie vergelijkbare gecombineerde leefstijlinterventies zoals Bewegen op Recept,1 van Klacht naar Kracht2 en Big!- Move3-4op te nemen in het basispakket van de zorgverzekering. In dit artikel geven we een beschouwing van het implementatieproces van de BeweegKuur, als een sprekend voorbeeld van de ontwikkelingen ten aanzien van gecombineerde leefstijlinterventies in de eerstelijns zorg in Nederland.AbstractCombined lifestyle interventions in the Netherlands: experiences gained with the BeweegKuur intervention This paper gives a reflection on the development, implementation and dissemination processes of the BeweegKuur in primary care. The implementation of the programme took a lot of time and energy on the part of the health care providers. During the implementation process, multidisciplinary networks were formed and the contacts with local exercise facilities improved. Although it is plausible that without BeweegKuur, some of these processes would also have come about, they would probably have taken more time and effort and would have remained more local.

Implementation of the 'BeweegKuur' in practice: Utilization of care of a lifestyle intervention in the Netherlands

This study investigates the delivered care in a multidisciplinary lifestyle intervention by dieticians and physiotherapists compared to the protocol of this intervention. Participants with a body mass index (BMI) between 25 and 40 kg m− 2 were divided over three different programs depending on their BMI and comorbidities. All these programs consisted of individual and group sessions with the dietician, while care by the physiotherapist differed by program. The dieticians and physiotherapists of 30 locations were contacted to provide data about health care use within the intervention from their health records. Data of 379 participants were available and showed that group sessions by dieticians were often not attended. Care by the physiotherapist was delivered according to the protocol to a larger extent. An average of 43–93% of the sessions was attended. The level of attendance is comparable to other interventions, but especially attendance at group sessions with dieticians should be improved.

The Coaching on Lifestyle (CooL) Intervention for Overweight and Obesity: A Longitudinal Study into Participants’ Lifestyle Changes

Combined lifestyle interventions (CLIs) can be effective in reducing weight and improving lifestyle-related behaviours but it is unclear how CLIs can best be implemented in practice in order to achieve sustained lifestyle changes. The Coaching on Lifestyle programme (CooL) is a CLI in the Netherlands, in which professional lifestyle coaches counsel adults and children (and/or their parents) who are obese or at high risk of obesity to achieve a sustained healthier lifestyle. The CooL intervention consists of group and individual sessions addressing the topics of physical activity, dietary behaviours, sleep and stress. Our longitudinal one-group pre-post study aimed to identify lifestyle changes among participants (adults, children and their parents) at 8 and 18 months after initiation. We assessed constructs ranging from motivation and behaviour-specific cognitions to behaviours and health outcomes. Positive and sustained changes among adults were found regarding perceived autonomy, motivation, perceived barriers, lifestyle behaviours, quality of life and weight. Among children and their parents, few improvements were found regarding behaviours and quality of life. CooL has been successful in coaching adult participants towards sustained behavioural change during the intervention period. Mixed results and smaller effect sizes were found for children and their parents.