Petra C. Siemonsma

Therapeutic Validity and Effectiveness of Preoperative Exercise on Functional Recovery after Joint Replacement: A Systematic Review and Meta-Analysis

Background Our aim was to develop a rating scale to assess the therapeutic validity of therapeutic exercise programmes. By use of this rating scale we investigated the therapeutic validity of therapeutic exercise in patients awaiting primary total joint replacement (TJR). Finally, we studied the association between therapeutic validity of preoperative therapeutic exercise and its effectiveness in terms of postoperative functional recovery. Methods (Quasi) randomised clinical trials on preoperative therapeutic exercise in adults awaiting TJR on postoperative recovery of functioning within three months after surgery were identified through database and reference screening. Two reviewers extracted data and assessed the risk of bias and therapeutic validity. Therapeutic validity of the interventions was assessed with a nine-itemed, expert-based rating scale (scores range from 0 to 9; score ≥6 reflecting therapeutic validity), developed in a four-round Delphi study. Effects were pooled using a random-effects model and meta-regression was used to study the influence of therapeutic validity. Results Of the 7,492 articles retrieved, 12 studies (737 patients) were included. None of the included studies demonstrated therapeutic validity and two demonstrated low risk of bias. Therapeutic exercise was not associated with 1) observed functional recovery during the hospital stay (Standardised Mean Difference [SMD]: −1.19; 95%-confidence interval [CI], −2.46 to 0.08); 2) observed recovery within three months of surgery (SMD: −0.15; 95%-CI, −0.42 to 0.12); and 3) self-reported recovery within three months of surgery (SMD −0.07; 95%-CI, −0.35 to 0.21) compared with control participants. Meta-regression showed no statistically significant relationship between therapeutic validity and pooled-effects. Conclusion Preoperative therapeutic exercise for TJR did not demonstrate beneficial effects on postoperative functional recovery. However, poor therapeutic validity of the therapeutic exercise programmes may have hampered potentially beneficial effects, since none of the studies met the predetermined quality criteria. Future review studies on therapeutic exercise should address therapeutic validity.

Reproducibility of plantar pressure measurements in patients with chronic arthritis: a comparison of one-step, two-step, and three-step protocols and an estimate of the number of measurements required.

Background: Plantar pressure measurement may be a helpful evaluation tool in patients with foot complaints. Determination of dynamic pressure distribution under the foot may give information regarding gait, progress of disorders, and the effect of treatment. However, for these measurements to have clinical application, reproducibility, consistency, and accuracy must be ascertained. We compared the reproducibility of measurements among one-step, two-step, and three-step protocols for data collection in patients with arthritis. In addition, the number of measurements needed for a consistent average was determined for the protocol that was found to be the most reproducible. Methods: Twenty patients with foot complaints secondary to arthritis participated in the study. Each patient was tested with a pressure platform system using two of the three testing protocols. Reproducibility of contact time and maximal peak pressure were assessed. Intraclass Correlation Coefficients (ICC) were calculated for measurement results among protocols. In stage two of the study, the number of measurements needed for a consistent average was determined by calculating the first three measurements, the first five measurements, and then all seven measurements for both feet. ICC of three, five, and seven measurements were compared. The two-step protocol (13 patients), which was found in stage one of the study to be the most reproducible, was used for this determination. Results: Reproducibility was found to be reasonable or good for all three measurement protocols. The mean values of contact time for the one-step protocol were found to be higher than the mean values of contact time for the two-step or three-step protocols in both feet. The differences between the one-step and three-step protocols were statistically significant for the left foot only. The mean peak pressure did not show statistically-significant differences among the three protocols. The one-step and three-step protocols were not used for stage two of the study. Using the two-step protocol, three measurements were found to be sufficient for obtaining a consistent average. Conclusions: The results of our study indicated that the one-step, two-step, and three-step protocols of collecting plantar pressure measurements in patients with foot complaints secondary to chronic arthritis were all similar. However, the use of the two-step protocol is recommended over the one-step and three-step protocols; the one-step protocol produced a longer stance phase that did not resemble normal walking and when comparing the two-step and three-step protocols, the two-step protocol was less time consuming and less strenuous for patients with painful feet.

Validity and usability of low-cost accelerometers for internet-based self-monitoring of physical activity in patients with chronic obstructive pulmonary disease

Background The importance of regular physical activity for patients with chronic obstructive pulmonary disease (COPD) is well-established. However, many patients do not meet the recommended daily amount. Accelerometers might provide patients with the information needed to increase physical activity in daily life. Objective Our objective was to assess the validity and usability of low-cost Internet-connected accelerometers. Furthermore we explored patients’ preferences with regards to the presentation of and feedback on monitored physical activity. Methods To assess concurrent validity we conducted a field validation study with patients who wore two low-cost accelerometers, Fitbit and Physical Activity Monitor (PAM), at the same time along with a sophisticated multisensor accelerometer (SenseWear Armband) for 48 hours. Data on energy expenditure assessed from registrations from the two low-cost accelerometers were compared to the well validated SenseWear Armband which served as a reference criterion. Usability was examined in a cross-over study with patients who, in succession, wore the Fitbit and the PAM for 7 consecutive days and filled out a 16 item questionnaire with regards to the use of the corresponding device Results The agreement between energy expenditure (METs) from the SenseWear Armband with METs estimated by the Fitbit and PAM was good (r=.77) and moderate (r=.41), respectively. The regression model that was developed for the Fitbit explained 92% whereas the PAM-model could explain 89% of total variance in METs measured by the SenseWear. With regards to the usability, both the Fitbit and PAM were well rated on all items. There were no significant differences between the two devices. Conclusions The low-cost Fitbit and PAM are valid and usable devices to measure physical activity in patients with COPD. These devices may be useful in long-term interventions aiming at increasing physical activity levels in these patients.

Cognitive Treatment of Illness Perceptions in Patients With Chronic Low Back Pain: A Randomized Controlled Trial

Background Illness perceptions have been shown to predict patient activities. Therefore, studies of the effectiveness of a targeted illness-perception intervention on chronic nonspecific low back pain (CLBP) are needed. Objective The purpose of this study was to compare the effectiveness of treatment of illness perceptions against a waiting list for patients with CLBP. Design This was a prospectively registered randomized controlled trial with an assessor blinded for group allocation. Setting The study was conducted in an outpatient rehabilitation clinic. Participants The participants were 156 patients (18–70 years of age) with CLBP (>3 months). Intervention Patients were randomly assigned to either a treatment group or to a waiting list (control) group. Trained physical therapists and occupational therapists delivered 10 to 14 one-hour treatment sessions according to the treatment protocol. Measurements The primary outcome measure was change in patient-relevant physical activities (Patient-Specific Complaints questionnaire). The secondary outcome measures were changes in illness perceptions (Illness Perceptions Questionnaire) and generic physical activity level (Quebec Back Pain Disability Scale). Measurements were taken at baseline (0 weeks) and after treatment (18 weeks). Results A baseline-adjusted analysis of covariance showed that there were statistically significant differences between intervention and control groups at 18 weeks for the change in patient-relevant physical activities. This was a clinically relevant change (19.1 mm) for the intervention group. Statistically significant differences were found for the majority of illness perception scales. There were no significant differences in generic physical activity levels. Limitations Longer-term effectiveness was not studied. Conclusions This first trial evaluating cognitive treatment of illness perceptions concerning CLBP showed statistically significant and clinically relevant improvements in patient-relevant physical activities at 18 weeks.

Entwinement of Theory and Practice in Physiotherapy

Summary In physiotherapy in general, and in neurological therapy in particular, there is growing awareness that the importance of theory and its use in treatment programmes must be made explicit. The often implicit and poor scientific state of theories underlying their programmes impedes therapists in making informed choices in their clinical and scientific work. Efforts have been made to uncover theories that implicitly guide programmes in common use. Some theorists propose to replace approaches based on out-dated principles in favour of new ones supported by up-to-date scientific material. Others are less radical and suggest revising them by adding the latest scientific knowledge. This raises the question as to which strategy is the most appropriate for developing optimal programme configurations. For the purpose of this article we have explored the different ways in which scientific principles find a place in, and give shape to, the content of two approaches in common use for the rehabilitation of stroke patients: neuro developmental treatment (NDT) and a motor relearning programme (MRP). This analysis shows that both approaches incorporate principles of neural plasticity to support the assumption that it makes sense to train integration of the hemiplegic side in functional tasks. This clinical assumption is further specified into different critical treatable factors and accompanying techniques with the help of patho-neurophysiological principles in NDT and muscle physiological and biomechanical principles in MRP. Both tangles of principles and practices are, in turn, entwined with diverging learning theories and related strategies. Our analysis illustrates that the relationship between scientific principles and therapy practices is complex. Therefore the question of whether programme development should be achieved through the process of substitution or addition of ‘new’ principles reflects an overly simplistic evaluation of the influence of theory on practice.

The benefits of theory for clinical practice : Cognitive treatment for chronic low back pain patients as an illustrative example

Purpose. To demonstrate, with the help of an example of cognitive treatment for patients with chronic low back pain, how a systematic description of the content and theoretical underpinnings of treatment can help to improve clinical practice. Methods. A conceptual analysis, two types of theories, and a programme-theory framework were instrumental in systematically specifying the content of the treatment and the underlying assumptions. Results. A detailed description of the cognitive treatment, including: (i) The intended outcomes; (ii) the related treatment components; (iii) the therapeutic process that is expected to mediate between outcomes and components, (iv) the conditions for optimal application; and (v) the guiding principles. Conclusions. The systematic description of the treatment revealed important issues for clinical practice, such as the patient and therapist characteristics that are needed for optimal provision of cognitive treatment. The discussions on the role of theory in rehabilitation practice are taken one step further in this clinical commentary: instead of simply describing the problems, we also demonstrated a means to tackle them.

BENEFITS OF TREATMENT THEORY IN THE DESIGN OF EXPLANATORY TRIALS: COGNITIVE TREATMENT OF ILLNESS PERCEPTIONS IN CHRONIC LOW BACK PAIN REHABILITATION AS AN ILLUSTRATIVE EXAMPLE

BACKGROUND Evidence-based treatment is not effective for all patients. Research must therefore be carried out to help clinicians to decide for whom and under what circumstances certain treatment is effective. Treatment theory can assist in designing research that will provide results on which clinical decision-making can be based. OBJECTIVE To illustrate how treatment theory can be helpful in the design of explanatory trials that assist clinical decision-making. METHODS The benefit of treatment theory was demonstrated by approaching the design of a clinical trial from two perspectives: one without the use of treatment theory and one with the explicit use of treatment theory. Evaluation of the effectiveness of cognitive treatment of illness perceptions for patients with chronic low back pain was used as an illustrative example. ISSUES With treatment theory as the main focus, the intervention became the starting point for the design of an explanatory trial. Potentially relevant patient selection criteria, essential treatment components, the optimal choice of a control group and the selection of outcome measures were specified. CONCLUSION This paper not only describes problems encountered in research on the effectiveness of treatment, but also ways in which to address these problems.

Determinants influencing the implementation of home-based stroke rehabilitation: a systematic review

Abstract Purpose: Home-based rehabilitation is a promising alternative to regular center-based stroke rehabilitation. The objective of this study was to identify what is currently known about determinants that influence the implementation of home-based stroke rehabilitation (HBSR) in clinical practice. Methods: A systematic review of determinants of HBSR was conducted, using a framework for innovation (including determinants related to the innovation, the user, the organization, and the socio-political context). Reviews, meta-analyses, and qualitative studies were included. Studies were selected if they concerned: home-based rehabilitation of stroke patient’s (motor) function, changes in in-person service delivery (> 24 h to 12 months post-stroke) and determinants of implementation. Results: A total of 88 studies were identified, of which 7 studies met the inclusion criteria. Identified determinants of implementation of HBSR were: intervention effectiveness, the exact nature of the medical condition, satisfaction with services, coordination of services, inter-professional collaborations, availability of appropriate training equipment, and costs. However, none of the studies had the primary aim to identify determinants of implementation. Conclusion: A more complete and detailed overview of existing determinants of HBSR is needed to assist professionals and organizations in decision-making on HBSR implementation and development of suitable strategies for implementation. Implications for Rehabilitation Committed professionals and a smooth transfer to the home-environment are essential elements for home-based rehabilitation or early supported discharge. The determinants related to the client include age, needs, stability and severity of the stroke as well as the living conditions. Clients and care givers should be involved in the recovery process including the decision for early discharge and home-based rehabilitation. It is necessary that essential therapy equipment be provided and that the travel times and costs of therapists are reimbursed.

Overlap of cognitive concepts in chronic widespread pain: An exploratory study

BackgroundA wide variety of cognitive concepts have been shown to play an important role in chronic widespread pain (CWP). Although these concepts are generally considered to be distinct entities, some might in fact be highly overlapping. The objectives of this study were to (i) to establish inter-relationships between self-efficacy, cognitive coping styles, fear-avoidance cognitions and illness beliefs in patients with CWP and (ii) to explore the possibility of a reduction of these cognitions into a more limited number of domains.MethodsBaseline measurement data of a prospective cohort study of 138 patients with CWP were used. Factor analysis was used to study the associations between 16 different cognitive concepts.ResultsFactor analysis resulted in three factors: 1) negative emotional cognitions, 2) active cognitive coping, and 3) control beliefs and expectations of chronicity.ConclusionNegative emotional cognitions, active cognitive coping, control beliefs and expectations of chronicity seem to constitute principal domains of cognitive processes in CWP. These findings contribute to the understanding of overlap and uniqueness of cognitive concepts in chronic widespread pain.

Effects of Aging in Multisensory Integration: A Systematic Review

Multisensory integration (MSI) is the integration by the brain of environmental information acquired through more than one sense. Accurate MSI has been shown to be a key component of successful aging and to be crucial for processes underlying activities of daily living (ADLs). Problems in MSI could prevent older adults (OA) to age in place and live independently. However, there is a need to know how to assess changes in MSI in individuals. This systematic review provides an overview of tests assessing the effect of age on MSI in the healthy elderly population (aged 60 years and older). A literature search was done in Scopus. Articles from the earliest records available to January 20, 2016, were eligible for inclusion if assessing effects of aging on MSI in the healthy elderly population compared to younger adults (YA). These articles were rated for risk of bias with the Newcastle-Ottawa quality assessment. Out of 307 identified research articles, 49 articles were included for final review, describing 69 tests. The review indicated that OA maximize the use of multiple sources of information in comparison to YA (20 studies). In tasks that require more cognitive function, or when participants need to adapt rapidly to a situation, or when a dual task is added to the experiment, OA have problems selecting and integrating information properly as compared to YA (19 studies). Additionally, irrelevant or wrong information (i.e., distractors) has a greater impact on OA than on YA (21 studies). OA failing to weigh sensory information properly, has not been described in previous reviews. Anatomical changes (i.e., reduction of brain volume and differences of brain areas’ recruitment) and information processing changes (i.e., general cognitive slowing, inverse effectiveness, larger time window of integration, deficits in attentional control and increased noise at baseline) can only partly explain the differences between OA and YA regarding MSI. Since we have an interest in successful aging and early detection of MSI issues in the elderly population, the identified tests form a good starting point to develop a clinically useful toolkit to assess MSI in healthy OA.