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BACKGROUND: Access to pain education for healthcare professionals is an International Association for the Study of Pain's key recommendation to improve pain care. The content of preregistration and undergraduate physical therapy pain curricula, however, is highly variable.OBJECTIVE: This study aimed to develop a list, by consensus, of essential pain-related topics for the undergraduate physical therapy curriculum.METHODS: A modified Delphi study was conducted in four rounds, including a Delphi Panel ( N = 22) consisting of in pain experienced lecturers of preregistration undergraduate physical therapy of Universities of Applied Sciences in the Netherlands, and five Validation Panels. Round 1: topics were provided by the Delphi Panel, postgraduate pain educators, and a literature search. Rounds 2-4: the Delphi Panel rated the topics and commented. All topics were analyzed in terms of importance and degree of consensus. Validation Panels rated the outcome of Round 2. RESULTS: The Delphi Panel rated 257, 146, and 90 topics in Rounds 2, 3, and 4, respectively. This resulted in 71 topics judged as "not important," 97 as "important," and 89 as "highly important." In total, 63 topics were rated as "highly important" by the Delphi Panel and Validation Panels.CONCLUSION: A list was developed and can serve as a foundation for the development of comprehensive physical therapy pain curricula.

Achtergrond: De Two-Minute Step Test (TMST) is een meetinstrument gericht op het beoordelen van uithoudingsvermogen. Verscheidene psychometrische eigenschappen van de TMST-NL (Nederlands vertaalde versie) zijn onderzocht bij intramuraal wonende ouderen. De gevoeligheid voor verandering en de responsiviteit is bij deze patiëntenpopulatie nog niet vastgesteld. Doel: Het vaststellen van de gevoeligheid voor verandering en de responsiviteit (Minimal Clinical Important Difference) van de TMST-NL bij intramuraal wonende ouderen. Design: Prospectief responsiviteitsonderzoek. Methode: De onderzoekspopulatie bestond uit intramuraal wonende ouderen. Deelnemers hebben twee meetmomenten (T0 en T1) ondergaan waartussen ze drie maanden fysiotherapie gericht op uithoudingsvermogen ontvingen. Om de gevoeligheid van verandering te meten werd de distributie methode gebruikt waarbij de correlatie met de 6-minuten wandeltest (6MWT) werd getoetst. Via de anker methode met de Receiver Operating Characteristic (ROC) curve werd de MCID bepaald. Metingen voor het aerobe uithoudingsvermogen werden verricht met de TMST-NL en de 6-minuten wandeltest (6MWT). De Global Rating of Change (GRC) en de Borg Category-Ratio10 (BORG-CR10) werden gebruikt als subjectieve vragenlijsten om verandering van de gezondheidssituatie en vermoeidheid te meten. Resultaten: Intramurale ouderen (N=50) met een gemiddelde (SD) leeftijd van 83,96 jaar (6,96) zijn geïncludeerd. De correlatie tussen de verschilscores van de TMST-NL en de 6MWT over de deelnemerspopulatie die T1 ook hebben afgerond (N= 36) kwam uit op r=0.51 (P

Tijdens de coronapandemie kwam de term 'kwetsbaarheid' of 'kwetsbare ouderen' regelmatig in het nieuws. Deze groep liep meer risico om het virus te krijgen en bovendien was het ziektebeloop bij deze groep vaak ernstiger. Maar wat is ‘kwetsbaarheid bij ouderen’, ook wel aangeduid met de Engelse term 'Frailty', nu precies en welke mechanismen liggen eraan ten grondslag? En waarom is het van belang dat u als fysiotherapeut kennis hebt van kwetsbaarheid. Deze cursus gaat daarop in. Oorspronkelijk is kwetsbaarheid een biomedisch concept. De definitie van Fried et al. is een voorbeeld van een dergelijke definitie. Zij definiëren kwetsbaarheid als: een biologisch syndroom waarbij sprake is van een verminderde reserve en weerstand tegen stressoren, dat het resultaat is van dalingen van diverse fysiologische systemen, en het risico verhoogt op negatieve gezondheidsuitkomsten. In meer recente definities wordt kwetsbaarheid integraal benaderd en als multidimensionaal gezien. Naast het fysieke domein is er ook oog voor psychische en sociale problemen die ouderen kunnen hebben. Deze holistische benadering (waarbij systeemdenken van belang is) is essentieel voor een efficiënte en effectieve fysiotherapeutische behandeling. Bovendien hebben fysiotherapeuten de preventieve taak om kwetsbaarheid vroegtijdig te signaleren om d.m.v. gerichte interventies kwetsbaarheid te verminderen of erger te voorkomen.

The ESCAPE trial is a randomized clinical trial comparing meniscus surgery with physical therapy in patients with a degenerative meniscal tear. This thesis is an in-depth analysis and continuation of the ESCAPE trial, aiming to advance evidence-based practice for patients with a degenerative meniscal tear. We investigated the responsiveness and minimal important change of the International Knee Documentation Committee Subjective Knee Form, the primary outcome of the ESCAPE trial. These measurement properties are important for assessing intervention effects in clinical practice and randomized controlled trials. This study showed that the IKDC is responsive to change among patients aged 45 to 70 years with meniscus tears, with an MIC of 10.9 points. This strengthens the value of the IKDC in quantifying treatment effects in this population. Patient-specific activities have not yet been considered as part of the evaluation of treatment effects in those with a meniscus tear. We compared meniscus surgery with physical therapy in patients with a degenerative meniscal tear using the Dutch equivalent of the patient-specific functioning score. measure over a period of 2 years. We also calculated the MIC for the PSFS using an anchor-based method to interpret the results. In our study population, we found a MIC of 2.5 points. The crude overall between-group difference showed a difference of 0.6 points (95% CI, –1.0 to –0.2; p = .004) between both groups. Although statistically significant, this difference between meniscus surgery and physical therapy in terms of patients’ specific activities is not clinically meaningful. In the current guidelines, exercise-based physical therapy is the recommended treatment in patients over 45 years old with a degenerative meniscus tear. However, between 1.9 and 36% of the patients randomized to physical therapy still opt for meniscus surgery. We developed and validated two multivariable prognostic models to identify those patients with a degenerative meniscal tear who will undergo surgery within 6 months and within 24 months following physical therapy. At 24 months, patients were more likely to opt for meniscus surgery when they had worse knee function and a lower level of education at baseline. Both models had a low explained variance (16% and 11%, respectively) and a poor discriminative ability. The non-responders to physical therapy could not accurately be predicted by our prognostic models. To select the best treatment (i.e. meniscus surgery or exercise-based physical therapy) for an individual patient it is important to quantify the expected benefit of one treatment over the other. We introduced a novel approach in musculoskeletal research, a marker-by-treatment analysis. We found that general physical health, pain during activities, knee function, BMI and age were potential treatment selection markers. While some marker-based thresholds could be identified at 3, 12 and 24 months follow-up, none of the baseline characteristics were consistent markers at all three follow-up times. This novel in-depth analysis did not result in clear clinical subgroups of patients who are substantially more likely to benefit from either surgery or physical therapy. Finally, we compared longer term effectiveness of meniscus surgery and exercise-based physical therapy on patient reported knee function and progression of knee osteoarthritis in patients with a degenerative meniscus tear. We assessed patient-reported knee function on the IKDC over 5 years follow-up based on the intention-to-treat principle, with a non-inferiority threshold of 11 points (based on the MIC determined in chapter 2 in our study population). The between-group difference was 2.8 points (95%CI: -0.9 to 6.5; p-value for non-inferiority

The ESCAPE trial is a randomized clinical trial comparing meniscus surgery with physical therapy in patients with a degenerative meniscal tear. This thesis is an in-depth analysis and continuation of the ESCAPE trial, aiming to advance evidence-based practice for patients with a degenerative meniscal tear. We investigated the responsiveness and minimal important change of the International Knee Documentation Committee Subjective Knee Form, the primary outcome of the ESCAPE trial. These measurement properties are important for assessing intervention effects in clinical practice and randomized controlled trials. This study showed that the IKDC is responsive to change among patients aged 45 to 70 years with meniscus tears, with an MIC of 10.9 points. This strengthens the value of the IKDC in quantifying treatment effects in this population. Patient-specific activities have not yet been considered as part of the evaluation of treatment effects in those with a meniscus tear. We compared meniscus surgery with physical therapy in patients with a degenerative meniscal tear using the Dutch equivalent of the patient-specific functioning score. measure over a period of 2 years. We also calculated the MIC for the PSFS using an anchor-based method to interpret the results. In our study population, we found a MIC of 2.5 points. The crude overall between-group difference showed a difference of 0.6 points (95% CI, –1.0 to –0.2; p = .004) between both groups. Although statistically significant, this difference between meniscus surgery and physical therapy in terms of patients’ specific activities is not clinically meaningful. In the current guidelines, exercise-based physical therapy is the recommended treatment in patients over 45 years old with a degenerative meniscus tear. However, between 1.9 and 36% of the patients randomized to physical therapy still opt for meniscus surgery. We developed and validated two multivariable prognostic models to identify those patients with a degenerative meniscal tear who will undergo surgery within 6 months and within 24 months following physical therapy. At 24 months, patients were more likely to opt for meniscus surgery when they had worse knee function and a lower level of education at baseline. Both models had a low explained variance (16% and 11%, respectively) and a poor discriminative ability. The non-responders to physical therapy could not accurately be predicted by our prognostic models. To select the best treatment (i.e. meniscus surgery or exercise-based physical therapy) for an individual patient it is important to quantify the expected benefit of one treatment over the other. We introduced a novel approach in musculoskeletal research, a marker-by-treatment analysis. We found that general physical health, pain during activities, knee function, BMI and age were potential treatment selection markers. While some marker-based thresholds could be identified at 3, 12 and 24 months follow-up, none of the baseline characteristics were consistent markers at all three follow-up times. This novel in-depth analysis did not result in clear clinical subgroups of patients who are substantially more likely to benefit from either surgery or physical therapy. Finally, we compared longer term effectiveness of meniscus surgery and exercise-based physical therapy on patient reported knee function and progression of knee osteoarthritis in patients with a degenerative meniscus tear. We assessed patient-reported knee function on the IKDC over 5 years follow-up based on the intention-to-treat principle, with a non-inferiority threshold of 11 points (based on the MIC determined in chapter 2 in our study population). The between-group difference was 2.8 points (95%CI: -0.9 to 6.5; p-value for non-inferiority

The ESCAPE trial is a randomized clinical trial comparing meniscus surgery with physical therapy in patients with a degenerative meniscal tear. This thesis is an in-depth analysis and continuation of the ESCAPE trial, aiming to advance evidence-based practice for patients with a degenerative meniscal tear. We investigated the responsiveness and minimal important change of the International Knee Documentation Committee Subjective Knee Form, the primary outcome of the ESCAPE trial. These measurement properties are important for assessing intervention effects in clinical practice and randomized controlled trials. This study showed that the IKDC is responsive to change among patients aged 45 to 70 years with meniscus tears, with an MIC of 10.9 points. This strengthens the value of the IKDC in quantifying treatment effects in this population. Patient-specific activities have not yet been considered as part of the evaluation of treatment effects in those with a meniscus tear. We compared meniscus surgery with physical therapy in patients with a degenerative meniscal tear using the Dutch equivalent of the patient-specific functioning score. measure over a period of 2 years. We also calculated the MIC for the PSFS using an anchor-based method to interpret the results. In our study population, we found a MIC of 2.5 points. The crude overall between-group difference showed a difference of 0.6 points (95% CI, –1.0 to –0.2; p = .004) between both groups. Although statistically significant, this difference between meniscus surgery and physical therapy in terms of patients’ specific activities is not clinically meaningful. In the current guidelines, exercise-based physical therapy is the recommended treatment in patients over 45 years old with a degenerative meniscus tear. However, between 1.9 and 36% of the patients randomized to physical therapy still opt for meniscus surgery. We developed and validated two multivariable prognostic models to identify those patients with a degenerative meniscal tear who will undergo surgery within 6 months and within 24 months following physical therapy. At 24 months, patients were more likely to opt for meniscus surgery when they had worse knee function and a lower level of education at baseline. Both models had a low explained variance (16% and 11%, respectively) and a poor discriminative ability. The non-responders to physical therapy could not accurately be predicted by our prognostic models. To select the best treatment (i.e. meniscus surgery or exercise-based physical therapy) for an individual patient it is important to quantify the expected benefit of one treatment over the other. We introduced a novel approach in musculoskeletal research, a marker-by-treatment analysis. We found that general physical health, pain during activities, knee function, BMI and age were potential treatment selection markers. While some marker-based thresholds could be identified at 3, 12 and 24 months follow-up, none of the baseline characteristics were consistent markers at all three follow-up times. This novel in-depth analysis did not result in clear clinical subgroups of patients who are substantially more likely to benefit from either surgery or physical therapy. Finally, we compared longer term effectiveness of meniscus surgery and exercise-based physical therapy on patient reported knee function and progression of knee osteoarthritis in patients with a degenerative meniscus tear. We assessed patient-reported knee function on the IKDC over 5 years follow-up based on the intention-to-treat principle, with a non-inferiority threshold of 11 points (based on the MIC determined in chapter 2 in our study population). The between-group difference was 2.8 points (95%CI: -0.9 to 6.5; p-value for non-inferiority

The ESCAPE trial is a randomized clinical trial comparing meniscus surgery with physical therapy in patients with a degenerative meniscal tear. This thesis is an in-depth analysis and continuation of the ESCAPE trial, aiming to advance evidence-based practice for patients with a degenerative meniscal tear. We investigated the responsiveness and minimal important change of the International Knee Documentation Committee Subjective Knee Form, the primary outcome of the ESCAPE trial. These measurement properties are important for assessing intervention effects in clinical practice and randomized controlled trials. This study showed that the IKDC is responsive to change among patients aged 45 to 70 years with meniscus tears, with an MIC of 10.9 points. This strengthens the value of the IKDC in quantifying treatment effects in this population. Patient-specific activities have not yet been considered as part of the evaluation of treatment effects in those with a meniscus tear. We compared meniscus surgery with physical therapy in patients with a degenerative meniscal tear using the Dutch equivalent of the patient-specific functioning score. measure over a period of 2 years. We also calculated the MIC for the PSFS using an anchor-based method to interpret the results. In our study population, we found a MIC of 2.5 points. The crude overall between-group difference showed a difference of 0.6 points (95% CI, –1.0 to –0.2; p = .004) between both groups. Although statistically significant, this difference between meniscus surgery and physical therapy in terms of patients’ specific activities is not clinically meaningful. In the current guidelines, exercise-based physical therapy is the recommended treatment in patients over 45 years old with a degenerative meniscus tear. However, between 1.9 and 36% of the patients randomized to physical therapy still opt for meniscus surgery. We developed and validated two multivariable prognostic models to identify those patients with a degenerative meniscal tear who will undergo surgery within 6 months and within 24 months following physical therapy. At 24 months, patients were more likely to opt for meniscus surgery when they had worse knee function and a lower level of education at baseline. Both models had a low explained variance (16% and 11%, respectively) and a poor discriminative ability. The non-responders to physical therapy could not accurately be predicted by our prognostic models. To select the best treatment (i.e. meniscus surgery or exercise-based physical therapy) for an individual patient it is important to quantify the expected benefit of one treatment over the other. We introduced a novel approach in musculoskeletal research, a marker-by-treatment analysis. We found that general physical health, pain during activities, knee function, BMI and age were potential treatment selection markers. While some marker-based thresholds could be identified at 3, 12 and 24 months follow-up, none of the baseline characteristics were consistent markers at all three follow-up times. This novel in-depth analysis did not result in clear clinical subgroups of patients who are substantially more likely to benefit from either surgery or physical therapy. Finally, we compared longer term effectiveness of meniscus surgery and exercise-based physical therapy on patient reported knee function and progression of knee osteoarthritis in patients with a degenerative meniscus tear. We assessed patient-reported knee function on the IKDC over 5 years follow-up based on the intention-to-treat principle, with a non-inferiority threshold of 11 points (based on the MIC determined in chapter 2 in our study population). The between-group difference was 2.8 points (95%CI: -0.9 to 6.5; p-value for non-inferiority

The general aim of this dissertation is to gain insight into the physiotherapeutic validity of physiotherapy research in subjects with non-specific neck pain. Chapter 1 describes the background of the research and the research questions and gives an overview of the studies performed. Chapter 2 presents the results of a systematic review (SR) of the completeness of the clinical reasoning process within the methodology of the RCT in patients with non-specific neck pain. For the SR analysis 122 studies were included. In the majority of studies (70%) the described clinical reasoning process was incomplete. There was scarcely any association between the degree of risk of bias and the completeness of the clinical reasoning process, indicating that better methodological quality does not necessarily imply a better description of clinical reasoning process. Chapter 3 presents the results of a SR in which we sought to identify published classification systems with a targeted treatment approach (treatment-based classification systems (TBCSs)) for patients with non-specific neck pain. Thirteen TBCSs were identified. In conclusion, existing treatment-based classification systems are of moderate quality at best. Moreover, these systems were not more effective than alternative treatments. Therefore, we do not recommend the use of these systems in daily physiotherapy practice. Chapter 4 describes a Delphi study of the clinical reasoning process of physiotherapy experts in unimodal interventions in patients with non-specific neck pain. This study had three goals. First, we aimed explore the expert opinions on the indication for physiotherapy when, other than neck pain, there are no positive signs and symptoms, no positive diagnostic tests or complaints of limitations in functioning or restrictions in participation. Second, we focused on the experts' use of measurement tools and when they are used to support and objectify the clinical reasoning process. Finally, we wanted to reach consensus among experts on the use of unimodal interventions in patients with non-specific neck pain. According to all experts, pain alone was not considered to be an indication for physiotherapy. Patient reported outcome measures were mainly used for evaluative purposes and physical tests for diagnostic and evaluative purposes. Only 6 of the 18 variants of sequential linear clinical reasoning reached a consensus of more than 50%. Chapter 5 describes a review that examined the completeness of the description of manipulation and mobilization interventions in randomized controlled trials of subjects with non-specific neck pain. In conclusion, mobilization or manipulation interventions are poorly reported in RCTs, compromising the external validity of RCTs, making it difficult for clinicians and researchers to replicate these interventions. Chapter 6 investigated the diagnostic physiotherapeutic process regarding limited ROM of the neck. It can be concluded that the overall diagnostic accuracy of physical examination is limited (compared to the CROM measurement). Therefore, a measurement device should be used in daily physical therapy practice to assess if a movement direction is restricted. Chapter 7 describes an exploratory, practice-oriented study into matched treatments in patients with non-specific neck pain. The objective of this study was 1) to establish the measurement error of the used accelerometer; 2) To determine which different treatments are used; 3) To explore if the cervical ROM, pain, (perceived) disability and motor control improved after one treatment. The SCT is a reliable accelerometer for measuring neck ROM, with a small measurement error. Eight different treatments were carried out. Pain, disability and left and right rotation showed a clinically relevant improvements (exceeded the measurement error). Chapter 8 comprises the general discussion. The general discussion presents an overview of this dissertation and discusses the strengths and limitations of the studies and possible implications of the results and recommendations for future research.

The general aim of this dissertation is to gain insight into the physiotherapeutic validity of physiotherapy research in subjects with non-specific neck pain. Chapter 1 describes the background of the research and the research questions and gives an overview of the studies performed. Chapter 2 presents the results of a systematic review (SR) of the completeness of the clinical reasoning process within the methodology of the RCT in patients with non-specific neck pain. For the SR analysis 122 studies were included. In the majority of studies (70%) the described clinical reasoning process was incomplete. There was scarcely any association between the degree of risk of bias and the completeness of the clinical reasoning process, indicating that better methodological quality does not necessarily imply a better description of clinical reasoning process. Chapter 3 presents the results of a SR in which we sought to identify published classification systems with a targeted treatment approach (treatment-based classification systems (TBCSs)) for patients with non-specific neck pain. Thirteen TBCSs were identified. In conclusion, existing treatment-based classification systems are of moderate quality at best. Moreover, these systems were not more effective than alternative treatments. Therefore, we do not recommend the use of these systems in daily physiotherapy practice. Chapter 4 describes a Delphi study of the clinical reasoning process of physiotherapy experts in unimodal interventions in patients with non-specific neck pain. This study had three goals. First, we aimed explore the expert opinions on the indication for physiotherapy when, other than neck pain, there are no positive signs and symptoms, no positive diagnostic tests or complaints of limitations in functioning or restrictions in participation. Second, we focused on the experts' use of measurement tools and when they are used to support and objectify the clinical reasoning process. Finally, we wanted to reach consensus among experts on the use of unimodal interventions in patients with non-specific neck pain. According to all experts, pain alone was not considered to be an indication for physiotherapy. Patient reported outcome measures were mainly used for evaluative purposes and physical tests for diagnostic and evaluative purposes. Only 6 of the 18 variants of sequential linear clinical reasoning reached a consensus of more than 50%. Chapter 5 describes a review that examined the completeness of the description of manipulation and mobilization interventions in randomized controlled trials of subjects with non-specific neck pain. In conclusion, mobilization or manipulation interventions are poorly reported in RCTs, compromising the external validity of RCTs, making it difficult for clinicians and researchers to replicate these interventions. Chapter 6 investigated the diagnostic physiotherapeutic process regarding limited ROM of the neck. It can be concluded that the overall diagnostic accuracy of physical examination is limited (compared to the CROM measurement). Therefore, a measurement device should be used in daily physical therapy practice to assess if a movement direction is restricted. Chapter 7 describes an exploratory, practice-oriented study into matched treatments in patients with non-specific neck pain. The objective of this study was 1) to establish the measurement error of the used accelerometer; 2) To determine which different treatments are used; 3) To explore if the cervical ROM, pain, (perceived) disability and motor control improved after one treatment. The SCT is a reliable accelerometer for measuring neck ROM, with a small measurement error. Eight different treatments were carried out. Pain, disability and left and right rotation showed a clinically relevant improvements (exceeded the measurement error). Chapter 8 comprises the general discussion. The general discussion presents an overview of this dissertation and discusses the strengths and limitations of the studies and possible implications of the results and recommendations for future research.

Achtergrond: De Two-Minute Step Test (TMST) is een meetinstrument gericht op het beoordelen van uithoudingsvermogen. Verscheidene psychometrische eigenschappen van de TMST-NL (Nederlands vertaalde versie) zijn onderzocht bij intramuraal wonende ouderen. De gevoeligheid voor verandering en de responsiviteit is bij deze patiëntenpopulatie nog niet vastgesteld. Doel: Het vaststellen van de gevoeligheid voor verandering en de responsiviteit (Minimal Clinical Important Difference) van de TMST-NL bij intramuraal wonende ouderen. Design: Prospectief responsiviteitsonderzoek. Methode: De onderzoekspopulatie bestond uit intramuraal wonende ouderen. Deelnemers hebben twee meetmomenten (T0 en T1) ondergaan waartussen ze drie maanden fysiotherapie gericht op uithoudingsvermogen ontvingen. Om de gevoeligheid van verandering te meten werd de distributie methode gebruikt waarbij de correlatie met de 6-minuten wandeltest (6MWT) werd getoetst. Via de anker methode met de Receiver Operating Characteristic (ROC) curve werd de MCID bepaald. Metingen voor het aerobe uithoudingsvermogen werden verricht met de TMST-NL en de 6-minuten wandeltest (6MWT). De Global Rating of Change (GRC) en de Borg Category-Ratio10 (BORG-CR10) werden gebruikt als subjectieve vragenlijsten om verandering van de gezondheidssituatie en vermoeidheid te meten. Resultaten: Intramurale ouderen (N=50) met een gemiddelde (SD) leeftijd van 83,96 jaar (6,96) zijn geïncludeerd. De correlatie tussen de verschilscores van de TMST-NL en de 6MWT over de deelnemerspopulatie die T1 ook hebben afgerond (N= 36) kwam uit op r=0.51 (P

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.

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.

Op 8 januari 2020 verdedigde ik mijn proef - schrift bij de Rijksuniversiteit Groningen. Het proefschrift richt zich op het vergroten van inzicht in de aard en de omvang van potentiële complicaties na het toepassen van manueeltherapeutische handelingen aan de cervicale wervelkolom bij mensen met nekpijn en/of hoofdpijn. Zowel onder leken als onder zorgprofessionals bestaat de veronderstelling dat manueeltherapeutische handelingen die worden toegepast aan de cervicale wervelkolom, kunnen leiden tot complicaties. Er is tot nu toe geen duidelijk causaal verband gevonden tussen de handelingen en ernstige complicaties. Bovendien wordt slechts sporadisch gepubliceerd over casuïstiek met ernstige complicaties die tijdens of na manuele behandelingen van de cervicale wervelkolom ontstaan zijn. De schattingen van het voorkomen van complicaties variëren enorm. Daarnaast is niet duidelijk welke patiënten een hoger of lager risico lopen op dergelijke complicaties.

Op 8 januari 2020 verdedigde ik mijn proef - schrift bij de Rijksuniversiteit Groningen. Het proefschrift richt zich op het vergroten van inzicht in de aard en de omvang van potentiële complicaties na het toepassen van manueeltherapeutische handelingen aan de cervicale wervelkolom bij mensen met nekpijn en/of hoofdpijn. Zowel onder leken als onder zorgprofessionals bestaat de veronderstelling dat manueeltherapeutische handelingen die worden toegepast aan de cervicale wervelkolom, kunnen leiden tot complicaties. Er is tot nu toe geen duidelijk causaal verband gevonden tussen de handelingen en ernstige complicaties. Bovendien wordt slechts sporadisch gepubliceerd over casuïstiek met ernstige complicaties die tijdens of na manuele behandelingen van de cervicale wervelkolom ontstaan zijn. De schattingen van het voorkomen van complicaties variëren enorm. Daarnaast is niet duidelijk welke patiënten een hoger of lager risico lopen op dergelijke complicaties.

The goal of this thesis is to gain insight in the nature and scale of potential adverse events following manual therapy techniques applied to the cervical spine to patients with neck pain and/ or headache. This thesis describes that most of the patients visiting a manual therapist in a private setting in The Netherlands, does this with complaints of the neck. This research also shows that Dutch manual therapists experience treatments of the upper cervical spine as riskier compared to the rest of the cervical spine. In this thesis potential adverse events have been defined and linked to known classifications. Subsequently, these potential adverse events have been systematically reviewed in published literature. Therewith, it was tried to gain insight in characteristics of involved patients and clinicians. The most frequent described adverse event is a dissection of a cervical artery. Since no profile of patients with an increased or decreased risk could be established, a case control study between patients with a cervical dissection and neck patients without one. No clinically relevant significant differences were established. A systematic literature review has been performed to identify the effect of neck and head positions on cervical blood flow. The findings suggest that neck positions do not alter blood flow as much as previously expected. Finally, treatments and adverse events were nationally inventoried for 12 months. The incidence of major adverse events in The Netherlands is estimated at 1:2,869,020 cervical manipulations.

Achtergrond: Coxartrose wordt vaak in het eindstadium behandeld met een Totale Heup Artroplastiek (THA). In de postoperatieve fase na een THA varieert het fysiotherapeutische beleid. Mogelijk leidt een verhoogd BMI tot een trager functioneel herstel na een THA. Een aangepast revalidatietraject zou dan van belang zijn. Vraagstelling: Is er een verschil in mate van functioneel herstel na een THA, bij patiënten met normaal gewicht, overgewicht en obesitas 12 weken en 6 maanden postoperatief? Daarnaast wordt de mate van associatie bepaald tussen BMI en de mate van functioneel herstel. Methode: In dit longitudinaal, prospectief onderzoek werden patiënten geïncludeerd in het PIUS ziekenhuis in Oldenburg; ze kregen allen eenzelfde revalidatietraject na de THA. Indeling vond plaats in 3 subgroepen, met normaal gewicht (BMI 18,5- 25 kg/m²), overgewicht (BMI 25 - 30 kg/m²) en obesitas (BMI > 30kg/m²). Mate van functioneel herstel werd objectief gemeten met de Timed Up & Go test (TUG) en de 5 Times Sit-to-Stand Test (5TSST), en subjectief met de self-reported vragenlijsten: de Hip disability and Osteoarthritis Outcome Score (HOOS) en de Short Form 36 (SF-36). Metingen werden verricht preoperatief (T0), en 12 weken (T1) en 6 maanden (T2) postoperatief. Met behulp van de Kruskall-Wallis test werden de verschilscores van de uitkomstmaten in de 3 subgroepen tussen T0-T1 en T0-T2 geanalyseerd. De mate van associatie werd berekend met de Spearman correlatiecoëfficiënt (rS). Het significantieniveau was p

To evaluate the construct validity and the inter-rater reliability of the Dutch Activity Measure for Post-Acute Care “6-clicks” Basic Mobility short form measuring the patient’s mobility in Dutch hospital care. First, the “6-clicks” was translated by using a forward-backward translation protocol. Next, 64 patients were assessed by the physiotherapist to determine the validity while being admitted to the Internal Medicine wards of a university medical center. Six hypotheses were tested regarding the construct “mobility” which showed that: Better “6-clicks” scores were related to less restrictive pre-admission living situations (p = 0.011), less restrictive discharge locations (p = 0.001), more independence in activities of daily living (p = 0.001) and less physiotherapy visits (p r= −0.408, p = 0.001), but not between the “6-clicks” and age (r= −0.180, p = 0.528). To determine the inter-rater reliability, an additional 50 patients were assessed by pairs of physiotherapists who independently scored the patients. Intraclass Correlation Coefficients of 0.920 (95%CI: 0.828–0.964) were found. The Kappa Coefficients for the individual items ranged from 0.649 (walking stairs) to 0.841 (sit-to-stand). The Dutch “6-clicks” shows a good construct validity and moderate-to-excellent inter-rater reliability when used to assess the mobility of hospitalized patients.Implications for RehabilitationEven though various measurement tools have been developed, it appears the majority of physiotherapists working in a hospital currently do not use these tools as a standard part of their care.The Activity Measure for Post-Acute Care “6-clicks” Basic Mobility is the only tool which is designed to be short, easy to use within usual care and has been validated in the entire hospital population.This study shows that the Dutch version of the Activity Measure for Post-Acute Care “6-clicks” Basic Mobility form is a valid, easy to use, quick tool to assess the basic mobility of Dutch hospitalized patients. Even though various measurement tools have been developed, it appears the majority of physiotherapists working in a hospital currently do not use these tools as a standard part of their care. The Activity Measure for Post-Acute Care “6-clicks” Basic Mobility is the only tool which is designed to be short, easy to use within usual care and has been validated in the entire hospital population. This study shows that the Dutch version of the Activity Measure for Post-Acute Care “6-clicks” Basic Mobility form is a valid, easy to use, quick tool to assess the basic mobility of Dutch hospitalized patients.

Background:\ud \ud People with intellectual disabilities (ID) experience more health problems and have different lifestyle change needs, compared with the general population.\ud \ud Aims:\ud \ud To improve lifestyle change interventions for people with ID, this review examined how behaviour change techniques (BCTs) were applied in interventions aimed at physical activity, nutrition or physical activity and nutrition, and described their quality.\ud \ud Methods and procedures:\ud \ud After a broad search and detailed selection process, 45 studies were included in the review. For coding BCTs, the CALO-RE taxonomy was used. To assess the quality of the interventions, the Physiotherapy Evidence Database (PEDro) scale was used. Extracted data included general study characteristics and intervention characteristics.\ud \ud Outcomes and results:\ud \ud All interventions used BCTs, although theory-driven BCTs were rarely used. The most frequently used BCTs were ‘provide information on consequences of behaviour in general’ and ‘plan social support/social change’. Most studies were of low quality and a theoretical framework was often missing.\ud \ud Conclusion and implications:\ud \ud This review shows that BCTs are frequently applied in lifestyle change interventions. To further improve effectiveness, these lifestyle change interventions could benefit from using a theoretical framework, a detailed intervention description and an appropriate and reliable intervention design which is tailored to people with ID.

Het wetenschappelijk bewijs voor het effect van fysiotherapie in de langdurige zorg is matig. Echter, interventies zoals beschreven in publicaties betreffen vaak standaardprogramma’s. Dit komt niet overeen met de dagelijkse praktijk in verpleeghuizen waar fysiotherapeuten in een multidisciplinair team zorg op maat leveren. Voor dit onderzoek zijn vijftien fysiotherapeuten geïnterviewd. Alle geïnterviewden zijn werkzaam in de langdurige zorg. Doel van het onderzoek was zowel de specifieke kenmerken als de ervaren waarde van fysiotherapie binnen de langdurige zorg te beschrijven.

Het wetenschappelijk bewijs voor het effect van fysiotherapie in de langdurige zorg is matig. Echter, interventies zoals beschreven in publicaties betreffen vaak standaardprogramma’s. Dit komt niet overeen met de dagelijkse praktijk in verpleeghuizen waar fysiotherapeuten in een multidisciplinair team zorg op maat leveren. Voor dit onderzoek zijn vijftien fysiotherapeuten geïnterviewd. Alle geïnterviewden zijn werkzaam in de langdurige zorg. Doel van het onderzoek was zowel de specifieke kenmerken als de ervaren waarde van fysiotherapie binnen de langdurige zorg te beschrijven.

Met de toenemende vergrijzing in ons land zal er ook een toename plaatsvinden van het aantal ouderen met dementie. Dementie, met als voornaamste oorzaak de ziekte van Alzheimer, wordt in het algemeen vooral gezien als een ziekte waarbij cognitieve problemen optreden. Dat er ook al in een vroeg stadium motorische stoornissen optreden is veel minder bekend. Pas in een laat stadium worden de motorische problemen dusdanig groot dat de fysiotherapeut wordt ingeschakeld. Het is van belang om als fysiotherapeut kennis te hebben van de verschillende vormen van dementie en de daarmee gepaard gaande verschillen in motorische stoornissen. Daarnaast is het van belang om inzicht te krijgen in werkzame interventies en de juiste meetinstrumenten in te kunnen zetten. In deze masterclass wordt inzicht gegeven in de motorische problemen bij dementie (o.a. paratonie) en worden handvatten voor de praktijk gegeven.DoelNa deze masterclass is de deelnemer in staat de verschillen in motorische stoornissen te herkennen en hier de passende meetinstrumenten op in te zetten. Daarnaast heeft de deelnemer handvatten voor de praktische consequenties gekregen.

BACKGROUND: Manual therapy interventions targeting the neck include various positions and movements of the craniocervical region. The hemodynamic changes in various spinal positions potentially have clinical relevance. OBJECTIVES: To investigate the effects of craniocervical positions and movements on hemodynamic parameters (blood flow velocity and/or volume) of cervical and craniocervical arteries. METHODS: A search of 4 databases (PubMed, Embase, CINAHL, and Index to Chiropractic Literature) and, subsequently, a hand search of reference lists were conducted. Full-text experimental and quasi-experimental studies on the influence of cervical positions on blood flow of the vertebral, internal carotid, and basilar arteries were eligible for this review. Two independent reviewers selected and extracted the data using the double-screening method. RESULTS: Of the 1453 identified studies, 31 were included and comprised 2254 participants. Most studies mentioned no significant hemodynamic changes during maximal rotation (n = 16). A significant decrease in hemodynamics was identified for the vertebral artery, with a hemodynamic decrease in the position of maximum rotation (n = 8) and combined movement of maximum extension and maximum rotation (n = 4). A similar pattern of decreased hemodynamics was also identified for the internal carotid and intracranial arteries. Three studies focused on high-velocity thrust positioning and movement. None of the studies reported hemodynamic changes. The synthesized data suggest that in the majority of people, most positions and movements of the craniocervical region do not affect blood flow. CONCLUSION: The findings of this systematic review suggest that craniocervical positioning may not alter blood flow as much as previously expected. LEVEL OF EVIDENCE: Therapy, level 2a. J Orthop Sports Phys Ther 2019;49(10):688-697. Epub 5 Jul 2019. doi:10.2519/jospt.2019.8578.

Objective Lower physical activity levels in older adults are associated with increased co-morbidities and disability. Physical therapists have a critical role in facilitating increases in physical activity. The communication they use may impact their effectiveness. This study investigates the additional value of therapist’s communication during physical therapy on older adults’ physical activity levels. Methods Systematic review and meta-analysis. Clinical trials were identified in PubMed, CINAHL, Embase, PsycINFO, PEDro, Cochrane, up to July 2016. Communication was classified with the Behavior Change Taxonomy(BCT). Effect sizes were pooled using Cochrane’s Review-Manager. Strength of the evidence was analyzed using GRADE’s criteria. Results Twelve studies were identified. Overall, communication techniques revealed an immediate and long-term effect(ES:0.19;0.24) on self-reported physical activity measures but not on performance-based, with moderate to high strength of evidence. Divided in BCT-categories, only ‘Generalisation of target behavior’, defined as communication aimed to help patients generalise an exercise from one situation to another at home), had a positive effect on self-reported activity(ES:0.34), with low strength of evidence. Conclusion Adding a communication technique to physical therapy is effective on self-reported physical activity measures but not on performance-based measures. Practice implications Add communication to exercise when treatment aims at perceived, but not performed, physical activity.

BackgroundTo evaluate the effect of (new) treatments or analyse prevalence and risk factors of contractures, rating scales are used based on joint range of motion. However, cut-off points for levels of severity vary between scales, and it seems unclear how cut-off points relate to function. The purpose of this study was to compare severity ratings of different rating scales for the shoulder and elbow and relate these with functional range of motion.MethodsOften used contracture severity rating scales in orthopedics, physiotherapy, and burns were included. Functional range of motion angles for the shoulder and elbow were derived from a recent synthesis published by our group. Shoulder flexion and elbow flexion range of motion data of patients three months after a burn injury were rated with each of the scales to illustrate the effects of differences in classifications. Secondly, the shoulder and elbow flexion range of motion angles were related to the required angles to perform over 50 different activities of daily living tasks.ResultsEighteen rating scales were included (shoulder: 6, elbow: 12). Large differences in the number of severity levels and the cut-off points between scales were determined. Rating the measured range of motions with the different scales showed substantial inconsistency in the number of joints without impairment (shoulder: 14-36%, elbow: 26-100%) or with severe impairment (shoulder: ConclusionThere is an urgent need for rating scales that express the severity of contractures in terms of loss of functionality. This study proposes a direction for a solution.

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. 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. The design was a prospective, single-blind, multicenter, superiority, cluster-randomized controlled trial. 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. 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.

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. 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. The design was a prospective, single-blind, multicenter, superiority, cluster-randomized controlled trial. 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. 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.

In this pilot study, we investigated the feasibility of a home-based, remotely guided exercise intervention for patients with gliomas. The six-month intervention included three home-based exercise sessions per week at 60%–85% of maximum heart rate. Participants wore heart rate monitors connected to an online platform to record activities that were monitored weekly by the physiotherapist.

To evaluate the construct validity and the inter-rater reliability of the Dutch Activity Measure for Post- Acute Care “6-clicks” Basic Mobility short form measuring the patient’s mobility in Dutch hospital care. First, the “6-clicks” was translated by using a forward-backward translation protocol. Next, 64 patients were assessed by the physiotherapist to determine the validity while being admitted to the Internal Medicine wards of a university medical center. Six hypotheses were tested regarding the construct “mobility” which showed that: Better “6-clicks” scores were related to less restrictive pre-admission living situations (p¼0.011), less restrictive discharge locations (p¼0.001), more independence in activities of daily living (p¼0.001) and less physiotherapy visits (p

In diverse richtlijnen wordt aangegeven dat psychosociale factoren van invloed kunnen zijn op het herstel van klachten. Worden hestelbelemmerende factoren niet meegenomen in de therapie, dan bestaat de kans op chroniciteit of recidivering van de klachten. Uit literatuur blijkt niet hoe een herstelbelemmerende copingstijl kan worden herkend en beïnvloed. Ook is onbekend hoe de psychosomatisch fysiotherapeut met dit gedrag omgaat in het behandeltraject. Voor de NFP en het Kenniscentrum Zorginnovatie van Hogeschool Rotterdam aanleiding om kwalitatief onderzoek te doen.

In diverse richtlijnen wordt aangegeven dat psychosociale factoren van invloed kunnen zijn op het herstel van klachten. Worden hestelbelemmerende factoren niet meegenomen in de therapie, dan bestaat de kans op chroniciteit of recidivering van de klachten. Uit literatuur blijkt niet hoe een herstelbelemmerende copingstijl kan worden herkend en beïnvloed. Ook is onbekend hoe de psychosomatisch fysiotherapeut met dit gedrag omgaat in het behandeltraject. Voor de NFP en het Kenniscentrum Zorginnovatie van Hogeschool Rotterdam aanleiding om kwalitatief onderzoek te doen.

BackgroundPhysical therapists' recommendations to patients to avoid daily physical activity can be influenced by the therapists' kinesiophobic beliefs. Little is known about the amount of influence of a physical therapist's kinesiophobic beliefs on a patient's actual lifting capacity during a lifting test.ObjectiveThe objective of this study was to determine the influence of physical therapists' kinesiophobic beliefs on lifting capacity in healthy people.DesignA blinded, cluster-randomized cross-sectional study was performed.MethodsThe participants (n=256; 105 male, 151 female) were physical therapist students who performed a lifting capacity test. Examiners (n=24) were selected from second-year physical therapist students. Participants in group A (n=124) were tested in the presence of an examiner with high scores on the Tampa Scale of Kinesiophobia for health care providers (TSK-HC), and those in group B (n=132) were tested in the presence of an examiner with low scores on the TSK-HC. Mixed-model analyses were performed on lifting capacity to test for possible (interacting) effects.ResultsMean lifting capacity was 32.1 kg (SD=13.6) in group A and 39.6 kg (SD=16.4) in group B. Mixed-model analyses revealed that after controlling for sex, body weight, self-efficacy, and the interaction between the examiners' and participants' kinesiophobic beliefs, the influence of examiners' kinesiophobic beliefs significantly reduced lifting capacity by 14.4 kg in participants with kinesiophobic beliefs and 8.0 kg in those without kinesiophobic beliefs.LimitationsGeneralizability to physical therapists and patients with pain should be studied.ConclusionsPhysical therapists' kinesiophobic beliefs negatively influence lifting capacity of healthy adults. During everyday clinical practice, physical therapists should be aware of the influence of their kinesiophobic beliefs on patients' functional ability.

BackgroundExercise capacity, muscle function, and physical activity levels remain reduced in recipients of lung transplantation. Factors associated with this deficiency in functional exercise capacity have not been studied longitudinally.ObjectiveThe study aims were to analyze the longitudinal change in 6-minute walking distance and to identify factors contributing to this change.DesignThis was a longitudinal historical cohort study.MethodsData from patients who received a lung transplantation between March 2003 and March 2013 were analyzed for the change in 6-minute walking distance and contributing factors at screening, discharge, and 6 and 12 months after transplantation. Linear mixed-model and logistic regression analyses were performed with data on characteristics of patients, diagnosis, waiting list time, length of hospital stay, rejection, lung function, and peripheral muscle strength.ResultsData from 108 recipients were included. Factors predicting 6-minute walking distance were measurement moment, diagnosis, sex, quadriceps muscle and grip strength, forced expiratory volume in 1 second (percentage of predicted), and length of hospital stay. After transplantation, 6-minute walking distance increased considerably. This initial increase was not continued between 6 and 12 months. At 12 months after lung transplantation, 58.3% of recipients did not reach the cutoff point of 82% of the predicted 6-minute walking distance. Logistic regression demonstrated that discharge values for forced expiratory volume in 1 second and quadriceps or grip strength were predictive for reaching this criterion.LimitationsStudy limitations included lack of knowledge on the course of disease during the waiting list period, type and frequency of physical therapy after transplantation, and number of missing data points.ConclusionsPeripheral muscle strength predicted 6-minute walking distance; this finding suggests that quadriceps strength training should be included in physical training to increase functional exercise capacity. Attention should be paid to further increasing 6-minute walking distance between 6 and 12 months after transplantation.

BACKGROUND: The predictive validity of the Low Back Pain Perception Scale is determined in two studies in general practice and showed sufficient discriminative ability, although the psychometric properties of the scale have never been established until now.OBJECTIVE: To determine the reliability and validity of the Low Back Pain Perception Scale in acute nonspecific low back pain patients.METHODS: The Low Back Pain Perception Scale has been authorized translated into Dutch by two bilingual content experts. A sample of 84 acute low back pain patients in physiotherapy primary care, mean age (SD) age 42 (12) years participated in this study. Internal reliability and a test-retest procedure within one-week interval were evaluated.RESULTS: The internal consistency Cronbach alpha = 0.38 (95% CI 0.09 to 0.56) and test - retest reliability within one week Intra Class Correlation coefficient = 0.50 (95% CI 0.31 to 0.64). Minimal Detectable Change was measured 1.95. The concurrent validity demonstrates Pearson's r = 0.35 (95% CI 0.14 to 0.53).CONCLUSIONS: The Low Back Pain Perception Scale demonstrates poor internal consistency and reliability and moderate concurrent validity. Extreme high or low scores may be clinical relevant therefore the scale can be used as a first screening instrument.

Background: Current evidence shows that manual therapy elicits analgesic effect in different populations (healthy, pain inflicted and patients with musculoskeletal pain) when carried out at the spinal column, although the clinical significance of these effects remains unclear. Also the analgesic effects of manual therapy on peripheral joints have not been systematically reviewed. Methods: A systematic review was carried out following the PRISMA-guidelines. Manual therapy was defined as any manual induced articular motion with the aim of inducing analgesic effects. Outcome measure was pain threshold. Results: A total of 13 randomized trials were included in the review. In 10 studies a significant effect was found. Pressure pain thresholds increased following spinal or peripheral manual techniques. In three studies both a local and widespread analgesic effect was found. No significant effect was found on thermal pain threshold. Discussion: Moderate evidence indicated that manual therapy increased local pressure pain thresholds in musculoskeletal pain, immediately following the intervention. No consistent result was found on remote pressure pain threshold. No significant changes occured on thermal pain threshold values. The clinical relevance of these effects remains contradictory and therefore unclear. (C) 2014 Elsevier Ltd. All rights reserved.