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Objective: Colorectal cancer survivors (CRCS) often experience high levels of distress. The objective of this randomized controlled trial was to evaluate the effect of blended cognitive behavior therapy (bCBT) on distress severity among distressed CRCS. Methods: CRCS (targeted N = 160) with high distress (Distress Thermometer ≥5) between 6 months and 5 years post cancer treatment were randomly allocated (1:1 ratio) to receive bCBT, (14 weeks including five face‐to‐face, and three telephone sessions and access to interactive website), or care as usual (CAU). Participants completed questionnaires at baseline (T0), four (T1) and 7 months later (T2). Intervention participants completed bCBT between T0 and T1. The primary outcome analyzed in the intention‐to‐treat population was distress severity (Brief Symptom Inventory; BSI‐18) immediately post‐intervention (T1). Results: 84 participants were randomized to bCBT (n = 41) or CAU (n = 43). In intention‐to‐treat analysis, the intervention significantly reduced distress immediately post‐intervention (−3.86 points, 95% CI −7.00 to −0.73) and at 7 months post‐randomization (−3.88 points, 95% CI −6.95 to −0.80) for intervention compared to CAU. Among secondary outcomes, at both time points, depression symptoms, anxiety symptoms, cancer worry, and cancer‐specific distress were significantly lower in the intervention arm. Self‐efficacy scores were significantly higher. Overall treatment satisfaction was high (7.4/10, N = 36) and 94% of participants would recommend the intervention to other colorectal cancer patients. Conclusions: The blended COloRectal canceR distrEss reduCTion intervention seems an efficacious psychological intervention to reduce distress severity in distressed CRCS. Yet uncertainty remains about effectiveness because fewer participants than targeted were included in this trial. Trial Registration: Netherlands Trial Register NTR6025. [ABSTRACT FROM AUTHOR]

Dropout from a rehabilitation programme often occurs in patients with chronic nonspecific low back pain of non-native origin. However, the exact dropout rate is not known. The objective of this study was to determine the difference in dropout rate between native and non-native patients with chronic nonspecific low back pain participating in a rehabilitation programme in The Netherlands. A retrospective study (n = 529) of patient files was performed in two rehabilitation centres and two rehabilitation departments of general hospitals in The Netherlands. Patient files were checked for diagnosis, status of origin, sex, age and outcome, that is, reason for finishing treatment. The difference in dropout rate between patients of Dutch and non-Dutch origin was tested by [chi][superscript 2] tests and logistic regression-analysis, controlling for age, sex, type of rehabilitation institute and phase of the rehabilitation programme. Dropout occurred among one fifth (18.7%) of the total patient population. Dropout among patients of non-Dutch origin was twice as high as among native Dutch patients (P less than 0.001). In regression analyses dropout was related to status of non-Dutch origin, treatment in a rehabilitation centre and the diagnostic phase of a rehabilitation programme. In conclusion, patients of non-Dutch origin drop out considerably more frequently than native Dutch patients. Dropout is higher in the diagnostic phase than in the treatment phase and in rehabilitation centres than in hospitals. Future research should clarify the reasons for the high dropout rate in patients of non-native origin.

Background: GPs can play a central role in the care of patients with persistent somatic symptoms (PSS). To date, little is known about these patients' experiences relating to their coordination of care. Aim: To explore the experiences of patients with PSS relating to coordination of care — in particular by their GP — during their illness trajectory. Design and setting: This qualitative study was carried out from January to April 2019 in the Netherlands as part of a multicentre prospective cohort study on the course of PSS (PROSPECTS). Method: Thematic content analysis of 15 interviews. Results: Three themes were identified: care fragmentation during the diagnostic trajectory; transition from the search for a cure to coping; and reframing to coping: GPs' role in facilitating supportive care. Patients experienced a lack of collaboration from healthcare workers during the diagnostic trajectory. Guidance by their GP in a process of shared decision making was positively valued by patients. Moving the focus from searching for a cure to coping with symptoms was described as a 'personal endeavour', made even more challenging by the ongoing uncertainty experienced by patients. When reframing to coping, the extent to which patients felt aligned with their GP played an important role in whether their supportive care request was met. Conclusion: Patients experienced difficulties when navigating the diagnostic trajectory and shifting to coping. The findings of this study underline the importance of collaboration between GPs and other healthcare professionals during the diagnostic trajectory. The authors recommend that GPs provide proactive guidance and are sensitive to patients who shift to coping by providing them with supportive care in a process of shared decision making. [ABSTRACT FROM AUTHOR]

Objectives: To assess whether (i) high-intensity resistance training (RT) leads to increased muscle strength compared to low-intensity RT in patients with knee osteoarthritis (OA); and (ii) RT with vitamin D supplementation leads to increased muscle strength compared to placebo in a subgroup with vitamin D deficiency. Design: Randomized controlled trial Setting: Outpatient rehabilitation centre Subjects: Patients with knee OA Interventions: 12 weeks of RT at high-intensity RT (70–80% of 1-repetition maximum (1-RM)) or low-intensity RT (40–50% of 1-RM) and 24 weeks of vitamin D (1200 International units vitamin D3 per day) or placebo supplementation. Main measures: Primary outcome measure was isokinetic muscle strength. Other outcome measure for muscle strength was the estimated 1-RM. Secondary outcome measures were knee pain and physical functioning. Results: 177 participants with a mean age of 67.6 ± 5.8 years were included, of whom 50 had vitamin D deficiency. Isokinetic muscle strength (in Newton metre per kilogram bodyweight) at start, end and 24 weeks after the RT was 0.98 ± 0.40, 1.11 ± 0.40, 1.09 ± 0.42 in the high-intensity group and 1.02 ± 0.41, 1.15 ± 0.42, 1.12 ± 0.40 in the low-intensity group, respectively. No differences were found between the groups, except for the estimated 1-RM in favour of the high-intensity group. In the subgroup with vitamin D deficiency, no difference on isokinetic muscle strength was found between the vitamin D and placebo group. Conclusions: High-intensity RT did not result in greater improvements in isokinetic muscle strength, pain and physical functioning compared to low-intensity RT in knee OA, but was well tolerated. Therefore these results suggest that either intensity of resistance training could be utilised in exercise programmes for patients with knee osteoarthritis. No synergistic effect of vitamin D supplementation and RT was found, but this finding was based on underpowered data. [ABSTRACT FROM AUTHOR]

Background: Psychological distress is highly prevalent among patients with metastatic colorectal cancer. Aims: To perform an economic evaluation of a combined screening and treatment program targeting psychological distress in patients with metastatic colorectal cancer in comparison with usual care. Design: Societal costs were collected alongside a cluster randomized controlled trial for 48 weeks. A total of 349 participants were included. Setting: Participants were recruited from oncology departments at 16 participating hospitals in the Netherlands. Methods: Outcome measures were the Hospital Anxiety and Depression Scale and quality-adjusted life-years. Missing data were imputed using multiple imputation. Uncertainty was estimated using bootstrapping. Cost-effectiveness planes and cost-effectiveness acceptability curves were estimated to show uncertainty surrounding the cost-effectiveness estimates. Sensitivity analyses were performed to check robustness of results. Results: Between treatment arms, no significant differences were found in Hospital Anxiety and Depression Scale score (mean difference: –0.058; 95% confidence interval: –0.13 to 0.011), quality-adjusted life-years (mean difference: 0.042; 95% confidence interval: –0.015 to 0.099), and societal costs (mean difference: –1152; 95% confidence interval: –5058 to 2214). Cost-effectiveness acceptability curves showed that the probability of cost-effectiveness was 0.64 and 0.74 at willingness-to-pay values of €0 and €10,000 per point improvement on the Hospital Anxiety and Depression Scale, respectively. The probability that the intervention was cost-effective compared to usual care for quality-adjusted life-years was 0.64 and 0.79 at willingness-to-pay values of €0 and €20,000 per quality-adjusted life-year, respectively. Conclusion: The intervention is dominant over usual care, primarily due to lower costs in the intervention group. However, there were no statistically significant differences in clinical effects and the uptake of the intervention was quite low. Therefore, widespread implementation cannot be recommended. [ABSTRACT FROM AUTHOR]

Background: The aim of this study was to explore self-perceived care needs and determinants of identified needs in older adults with joint pain and comorbidity.Methods: This is a cross-sectional study using baseline data from a cohort study of older adults in the Netherlands (≥65 years) with joint pain and comorbidity (n = 407). We used the Camberwell Assessment of Need for the Elderly (CANE) to assess self-perceived care needs. Regression analyses were conducted to examine the associations between needs and sociodemographic factors (age, gender, partner status and educational level), physical factors (pain intensity, comorbidity, frailty and physical functioning) and psychosocial factors (anxiety, depression and social support).Results: Older adults with joint pain and comorbidity reported on average 4.0 care needs out of 13 CANE items, of which 0.3 were unmet. High levels of environmental and physical needs were reported, such as needs with regard to physical illness (91%), household (61%) and mobility/falls (53%). However, most of these needs were met. Only few people reported psychosocial needs, but a large proportion of these needs was unmet, especially regarding company (66.7%) and daytime activities (37%). Psychosocial needs were more often present in frail participants (OR 2.40, 95% CI 1.25-4.61), and those with less perceived social support (OR 1.05, 95% CI 1.01-1.08) and more depressive symptoms (OR 1.17, 95% CI 1.07-1.26).Discussion/Conclusions: Unmet needs are mainly present in the psychosocial domain. Specific attention targeted at these unmet needs may improve psychosocial well-being of older adults with joint pain and comorbidity. [ABSTRACT FROM AUTHOR]

Aims: To assess the prevalence, 3-year course, and associated factors of temporomandibular joint (TMJ) pain in patients with newly diagnosed rheumatoid arthritis (RA). Methods: A total of 264 patients with newly diagnosed RA were included. Patients were assessed after 3 months, 6 months, 9 months, 1 year, 1.5 years, 2 years, and 3 years. TMJ pain was scored by manual palpation, and the prevalence of TMJ pain was calculated at baseline and at all seven follow-up intervals during 3 years. Factors assessed for a potential association with TMJ pain at baseline included: demographic factors (gender and age), disease-related factors (symptom duration, rheumatoid factor [RF], anti-cyclic citrullinated protein [anti-CCP], C-reactive protein [CRP], and Disease Activity Score 28 [DAS28]), and functional factors (Health Assessment Questionnaire [HAQ] and European Quality of Life 5 Dimensions Questionnaire [EQ5D]–anxiety/depression). A stepwise logistic regression model was used to determine factors associated with TMJ pain in patients with RA. Results: The prevalence of TMJ pain in patients with RA was 10.6% at baseline, which decreased to 3.6% in the first year after inclusion and remained stable thereafter. Disease activity as determined by the DAS28 was significantly associated with TMJ pain (odds ratio [OR] = 1.51; 95% confidence interval [95% CI] = 1.12–2.05; P = .009) at baseline. A second logistic regression analysis was performed with the following variables of the DAS28: erythrocyte sedimentation rate (ESR), tender joint count, swollen joint count, and global health. Tender joint count (OR = 1.06; 95% CI = 1.01–1.12; P = .03) and global health (OR = 1.02; 95% CI = 1.00–1.03; P = .03) were significantly associated with TMJ pain at baseline. The remaining factors included in the analysis were not significantly associated with TMJ pain at baseline. Conclusion: The prevalence of TMJ pain in patients with newly diagnosed RA is approximately 10% and decreases during follow-up, especially in the first year. Disease activity is a risk factor for TMJ pain in patients with newly diagnosed RA. [ABSTRACT FROM AUTHOR]

Purpose: In an equitable healthcare system, healthcare utilization should be predominantly explained by patient-perceived need and clinical need factors. This study aims to analyze whether predisposing, enabling, and need factors are associated with the utilization of supportive care (i.e., dietary care, oncological nursing care, physical therapy, psychological care, or participation in a rehabilitation program consisting of an exercise component and a psycho-educational component) among survivors of colorectal cancer in the Netherlands.Methods: Cross-sectional data of 3957 survivors of colorectal cancer (1-11 years after diagnosis) were used. Clinical data from the Eindhoven Cancer Registry were linked to questionnaire data from the PROFILES registry. Regression analyses were used to examine which predisposing, enabling, and need factors were associated with self-reported utilization of supportive care.Results: Utilization of supportive care was primarily associated with younger age, patient-perceived need (i.e., lower physical health, anxious mood, depressive mood, and fatigue), and clinical need (i.e., tumor stage, radiotherapy, chemotherapy, comorbidity, having a stoma and lower BMI) factors.Conclusions: In the Netherlands, utilization of supportive care by survivors of colorectal cancer is primarily associated with younger age, patient-perceived need, and clinical need factors. Apart from the association with younger age, the utilization of supportive care services seems to be quite equitable. Further research is needed to determine whether there is indeed inequity in the provision of supportive care to older survivors, or whether older survivors are less in need of supportive care. [ABSTRACT FROM AUTHOR]

Objectives: Dysregulated biological stress systems and adverse life events, independently and in interaction, have been hypothesised to initiate chronic pain. We examine whether (1) function of biological stress systems, (2) adverse life events, and (3) their combination predict the onset of chronic multisite musculoskeletal pain.Methods: Subjects (n=2039) of the Netherlands Study of Depression and Anxiety, free from chronic multisite musculoskeletal pain at baseline, were identified using the Chronic Pain Grade Questionnaire and followed up for the onset of chronic multisite musculoskeletal pain over 6 years. Baseline assessment of biological stress systems comprised function of the hypothalamic-pituitary-adrenal axis (1-h cortisol awakening response, evening levels, postdexamethasone levels), the immune system (basal and lipopolysaccharide-stimulated inflammation) and the autonomic nervous system (heart rate, pre-ejection period, SD of the normal-to-normal interval, respiratory sinus arrhythmia). The number of recent adverse life events was assessed at baseline using the List of Threatening Events Questionnaire.Results: Hypothalamic-pituitary-adrenal axis, immune system and autonomic nervous system functioning was not associated with onset of chronic multisite musculoskeletal pain, either by itself or in interaction with adverse life events. Adverse life events did predict onset of chronic multisite musculoskeletal pain (HR per event=1.14, 95% CI 1.04 to 1.24, p=0.005).Conclusions: This longitudinal study could not confirm that dysregulated biological stress systems increase the risk of developing chronic multisite musculoskeletal pain. Adverse life events were a risk factor for the onset of chronic multisite musculoskeletal pain, suggesting that psychosocial factors play a role in triggering the development of this condition. [ABSTRACT FROM AUTHOR]

Objective: Severe pain in patients with knee osteoarthritis (OA) hampers the ability to exercise. A protocol for the standardized optimization of analgesics in combination with exercise therapy was developed. The purpose of this protocol was to reduce pain, thereby allowing the patient to participate in exercise therapy. The objective of the present study was to evaluate the feasibility and outcome of the protocol.Methods: Forty-nine patients with knee OA and severe knee pain (numerical rating scale for pain ≥7) were included. Analgesics were prescribed following an incremental protocol. After 6 weeks, a 12-week exercise therapy program was added. Information about analgesic use and exercise therapy content was recorded. Knee pain and activity limitations were assessed at baseline, after 6 weeks, and after 18 weeks.Results: Statistically significant improvements in pain and activity limitations were found in intent-to-treat analysis after 6 weeks of analgesic use and after the intervention was completed. Mean improvements from baseline were 30% (P < 0.001) for pain and 17% (P < 0.001) for activity limitations after the intervention was completed. Seventy-eight percent of the patients were able to exercise according to the protocol. In these patients, exercise therapy following 6 weeks of analgesic use resulted in a further improvement of activity limitations of 10% (P = 0.004).Conclusion: The combined intervention of standardized analgesic prescription and exercise therapy allows most patients with knee OA and severe pain to participate in exercise therapy, leading to reduction of pain and activity limitations. These promising results need to be confirmed in a randomized controlled trial. [ABSTRACT FROM AUTHOR]

Background: Substantial variation exists in physical functioning (PF) among patients with comparable pain severity, which may be partly explained by underlying psychological processes, like cognitive appraisal of pain and coping with pain. It remains unclear to what extent such determinants contribute to changes in PF over time, especially in older populations. Therefore, we examined longitudinal associations of cognitive appraisals and coping strategies with PF, in older adults with joint pain and comorbidity.Methods: A prospective cohort study among 407 older adults with joint pain and comorbidity provided data over 18 months, with 6 month time-intervals. We measured PF (RAND-36), five cognitive appraisals (consequences, concerns, emotional representations, self-efficacy, catastrophizing), four coping strategies (ignoring pain, positive self-statement, increasing activity levels, activity avoidance) and three time-dependent covariates; pain intensity, anxiety and depressive symptoms. Longitudinal associations were analyzed with Generalized Estimated Equations (GEE), by testing auto-regressive models, adjusted for covariates.Results: More negative thoughts about consequences of pain (β = -0.54, 95% CI = -1.02; -0.06), more catastrophizing (β = -0.67, 95% CI = -1.26; -0.07) and more activity avoidance (β = -0.32, 95% CI = -0.57; -0.08) were significantly associated with subsequent deterioration in PF, whereas higher perceived self-efficacy (β = 0.22, 95% CI = 0.12; 0.31) was associated with subsequent improvement in PF. Neither concerns, emotional representations, ignoring pain, positive self-statement nor increasing activity levels were longitudinally related to PF.Conclusions: More negative thoughts about consequences of pain, more catastrophizing and more activity avoidance contributed to deteriorated PF, whereas higher perceived self-efficacy contributed to improved PF. This knowledge may contribute to future management of functional limitations in older adults with joint pain and comorbidity. [ABSTRACT FROM AUTHOR]

Background: A multidisciplinary, guideline-based Stepped-Care-Strategy (SCS), has recently been developed to improve the management of hip and knee osteoarthritis (OA). To date, it is unknown to what extent current Dutch OA care is consistent with the SCS, both with respect to the content of care as well as the sequence of care. Furthermore, there is a lack of clarity regarding the role of different health care providers in the performance of OA care according to the SCS. Therefore, the main purpose of this study is to describe the content of primary care in patients with hip/knee OA, including the compliance to the SCS and taking into account the introduction of patient self-referral to physical therapy. Methods: Data were used from NIVEL Primary Care Database. In total, 12.118 patients with hip/knee OA who visited their GP or physical therapist were selected. Descriptive statistics were used to compare the content of care in GP-referred and self-referred patients to physical therapy. Results: Content of care performed by GPs mostly concerned consultations, followed by NSAID prescriptions and referrals to secondary care. Both prescriptions of acetaminophen and referrals to physical therapy respectively dietary therapy were rarely mentioned. Nevertheless, still 65% of the patients in physical therapy practice were referred by their GP. Compared to GP-referred patients, self-referred patients more often presented recurrent complaints and were treated less often by activity-related exercise therapy. Education was rarely registered as singular intervention, neither in GP-referred nor in self-referred patients. Conclusion: In accordance with the SCS, less advanced interventions are more often applied than more advanced interventions. To optimize the adherence to the SCS, GPs could reconsider the frequent use of NSAIDs instead of analgesics and the low referral rate to allied health care. Self-referral to physical therapy partially distorts both the low referral rate in general practice and the low application rate of education as singular intervention in physical therapy practice. Further research is recommended to evaluate the effects of task-shifting in OA care, taking into account the content of the SCS. [ABSTRACT FROM AUTHOR]

Purpose: To explore the associations between (improvement in) fatigue and (improvement in) clinical and cognitive factors in patients with chronic widespread pain (CWP), participating in multidisciplinary rehabilitation treatment. Methods: Data were used from baseline, 6 and 18 months of follow-up during a prospective cohort study of 120 CWP patients who completed multidisciplinary rehabilitation treatment. Cross-sectional and longitudinal relationships were analyzed between fatigue, clinical (i.e. pain, interference of pain and depression) and pain related cognitive factors (i.e. negative emotional cognitions, active cognitive coping, and control and chronicity beliefs). Results: Higher levels of pain, interference of pain, depression, negative emotional cognitions, and negative control and chronicity beliefs were associated with a higher level of fatigue. Improvement in depression was related to improvement in fatigue. Conclusions: In CWP patients, worse clinical status, and dysfunctional pain-related cognitions are associated with a higher level of fatigue. Our results suggest that improvement in depression might be a mechanism of improvement in fatigue. Furthermore, improvement in fatigue seems to be independent of improvement in pain related cognitions. Targeting fatigue in multidisciplinary pain treatment may need specific strategies. [ABSTRACT FROM AUTHOR]

Objective. Knee OA has been conceptualized as a multicompartmental disease, as a compartmental disease or as a combination of these two disease processes. The aim of this study was to determine the associations between four radiographic features (joint space narrowing, osteophyte formation, sclerosis and cysts) across and within the three knee compartments (medial tibiofemoral, lateral tibiofemoral and patellofemoral compartment) in knee OA.Methods. Data from the Amsterdam OA Cohort were used. In 298 patients diagnosed with knee OA, radiographic features were examined in three knee joint compartments. Radiographic features were scored according to standardized scoring methods. Factor analysis was used to examine associations between the four radiographic features across and within compartments.Results. A bifactor model showed a general multicompartmental factor: 10 of 12 radiographic features across the entire joint were associated with the general factor. The bifactor model also showed three compartmental factors—one for each compartment: joint space narrowing, sclerosis and to a lesser extent osteophyte formation were associated with these compartmental factors.Conclusion. These findings suggest a multicompartmental disease process in the knee, characterized by associations among features across the entire joint, as well as compartmental disease processes in each knee compartment, characterized by associations among features within specific compartments. Longitudinal studies are needed to explore the possibility of the development from a compartmental disease to a multicompartmental disease and the impact of contributing factors on the development. [ABSTRACT FROM AUTHOR]

Objective. A prospective study was conducted in order to establish whether AS patients, who are defined as non-responders after 3 months of anti-TNF therapy, show improvement on performance-based tests of physical functioning.Methods. At baseline and 3 months after the start of anti-TNF therapy, AS patients completed seven performance-based tests of physical functioning, questionnaires on self-reported physical functioning (BASFI) and disease activity (BASDAI), and a pain and a global patient assessment. The concordance between &geq;20% intra-individual improvement on the performance-based test of physical functioning and (i) response to anti-TNF therapy [Assessment of SpondyloArthritis International Society 20% (ASAS20) response] and (ii) &geq;20% intra-individual improvement on self-reported physical functioning (BASFI) was assessed.Results. One hundred AS patients were included, of which 82 patients completed all tests at both time points. After 3 months of anti-TNF therapy, 27 (32.9%) patients were categorized as non-responders according to the ASAS20 response criteria. Improvement in performance-based physical functioning was seen in 13 of the 27 non-responders (48.1%) (i.e. n = 13/82 = 15.9% of the total group). Furthermore, 30 (36.6%) patients showed no improvement on self-reported physical functioning (BASFI). However, 17 of the 30 (56.7%) patients did improve on the performance-based tests of physical functioning (i.e. n = 17/82 = 20.7% of the total group).Conclusion. After 3 months of anti-TNF therapy, performance-based tests of physical functioning showed improvement in 48.1% of the ASAS20 non-responders. With these performance-based tests, new information on outcome after anti-TNF therapy can be generated. Using performance-based tests alongside the BASFI could have additional value in the evaluation of outcomes for patients receiving anti-TNF therapy. [ABSTRACT FROM AUTHOR]

STUDY DESIGN: Prospective longitudinal study. OBJECTIVE: To explore the working mechanism of manual therapy, we investigated whether 3 cervical spine variables were mediators of the effect of manual therapy on headache frequency. BACKGROUND: Manual therapy has been shown to reduce headache frequency in participants with chronic tension-type headache (CTTH). To what extent specific elements of treatment contribute to the effectiveness of manual therapy in CTTH is unknown. METHODS: One hundred eighty-two participants with CTTH participated in a prospective longitudinal study: 142 underwent manual therapy and 40 participants received usual care by their general practitioner. Regression analysis was performed according to the steps described by Baron and Kenny, and the proportion of mediated effect was estimated for 3 potential mediators: (1) cervical range of motion, (2) neck flexor endurance, and (3) forward head posture. Outcome was defined as a 50% or greater reduction in headache days. RESULTS: Neck flexor endurance mediated 24.5% of the effect of manual therapy. Cervical range of motion and forward head posture showed no mediated effect. CONCLUSION: Increased neck flexor endurance appears to be a working mechanism of manual therapy. This finding supports isometric training of neck flexors in participants with CTTH. Trial registered with Netherlands Trial Register (TR 1074). [ABSTRACT FROM AUTHOR]

Objective. To examine the association of serum CRP and ESR with muscle strength in patients with knee OA.Methods. Cross-sectional data from 285 patients with knee OA from the Amsterdam Osteoarthritis (AMS-OA) cohort were analysed. CRP (mg/l) and ESR (mm/l) were measured in serum from patients’ blood samples and the values were dichotomized for the analyses. Strength of quadriceps and hamstring muscles was assessed using an isokinetic dynamometer. Univariable and multivariable linear regression analyses were used to assess the association of CRP and ESR with muscle strength, adjusting for relevant confounders.Results. Elevated levels of serum CRP (β = −0.10; P = 0.04) and ESR (β = −0.12; P = 0.02) were associated with lower muscle strength after adjustment for age, sex, comorbidities and NSAID use. The associations were no longer significant when BMI was incorporated in the adjusted model.Conclusion. Inflammation might influence muscle strength in patients with knee OA. Moreover, the link between inflammation and obesity might explain the effect that BMI has in the associations between inflammatory markers (i.e. CRP and ESR) and muscle strength. [ABSTRACT FROM PUBLISHER]

Objective. To describe the relationship between comorbidity (absolute number as well as the presence of specific comorbidities) and pain, physical functioning and mental health status of participants with early symptomatic OA of the hip or knee.Methods. In the Netherlands, a prospective 10-year follow-up study was initiated by the Dutch Arthritis Association in participants with early symptomatic OA of the hip or knee: CHECK (Cohort Hip and Cohort Knee), which consists of 1002 individuals. At baseline, linear regression analysis was used to determine the influence of comorbidity on the outcome variables: Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain, WOMAC physical functioning, Medical Outcomes Study Short Form 36 (SF-36) Physical Component Summary and Mental Component Summary.Results. Of 979 subjects, 67% reported one or more comorbidities. After controlling for age, gender, social status and severity of radiographic OA (Kellgren and Lawrence score), back disorders have the largest effect on WOMAC pain and physical functioning, and one of the largest effects on physical status of SF-36, besides obesity. Mental status was negatively influenced by the additional presence of duodenal ulcer, thyroid disease, and migraine or chronic headache.Conclusion. In early stage of OA, the presence of additional problems in the musculoskeletal system and of obesity have a negative effect on pain and physical health status. Also mental status is affected in early symptomatic OA by the presence of specific comorbidities. Comorbidity should be assessed and treated to improve the burden of illness in patients with early symptomatic OA. [ABSTRACT FROM PUBLISHER]

Background: To improve the management of hip or knee osteoarthritis (OA), a multidisciplinary guideline-based stepped-care strategy (SCS) with recommendations regarding the appropriate non-surgical treatment modalities and optimal sequence for care has been developed. Implementation of this SCS in the general practice may be hampered by the negative attitude of general practitioners (GPs) towards the strategy. In order to develop a tailored implementation plan, we assessed the GPs' views regarding specific recommendations in the SCS and their working procedures with regard to OA. Methods: A survey was conducted among a random sample of Dutch GPs. Questions included the GP's demographical characteristics and the practice setting as well as how the management of OA was organized and whether the GPs supported the SCS recommendations. In particular, we assessed GP's views regarding the effectiveness of 14 recommended and non-recommended treatment modalities. Furthermore, we calculated their agreement with 7 statements based on the SCS recommendations regarding the sequence for care. With a linear regression model, we identified factors that seemed to influence the GPs' agreement with the SCS recommendations. Results: Four hundred fifty-six GPs (37%) aged 30-65 years, of whom 278 males (61%), responded. Seven of the 11 recommended modalities (i.e. oral Non-Steroidal Anti-Inflammatory Drugs, physical therapy, glucocorticoid intra-articular injections, education, lifestyle advice, acetaminophen, and tramadol) were considered effective by the majority of the GPs (varying between 95-60%). The mean agreement score, based on a 5-point scale, with the recommendations regarding the sequence for care was 2.8 (SD = 0.5). Ten percent of the variance in GPs' agreement could be explained by the GPs' attitudes regarding the effectiveness of the recommended and non-recommended non-surgical treatment modalities and the type of practice. Conclusion: In general, GPs support the recommendations in the SCS. Therefore, we expect that their attitudes will not impede a successful implementation in general practice. Our results provide several starting points on which to focus implementation activities for specific SCS recommendations; those related to the prescription of pain medication and the use of X-rays. We could not identify factors that contribute substantially to GPs' attitudes regarding the SCS recommendations regarding the sequence for care. [ABSTRACT FROM AUTHOR]

The objective of this study was to evaluate whether self-reported knee instability is associated with activity limitations in patients with knee osteoarthritis (OA), in addition to knee pain and muscle strength. A cohort of 248 patients diagnosed with knee OA was examined. Self-reported knee instability was defined as the perception of any episode of buckling, shifting, or giving way of the knee in the past 3 months. Knee pain was assessed using a numeric rating scale, and knee extensor and flexor strength were measured using an isokinetic dynamometer. Activity limitations were measured by using the Western Ontario and McMasters Universities Osteoarthritis Index physical function questionnaire, the timed Get Up and Go, and the timed stair climbing and three questionnaires evaluating walking, climbing stairs, and rising from a chair. Other potential determinants of activity limitations were also collected, including joint proprioception, joint laxity, age, sex, body mass index (BMI), disease duration, and radiographic disease severity. Regression analyses evaluated the effect of adding self-reported knee instability to knee pain and muscle strength, when examining associations with the activity limitations measures. Self-reported knee instability was common (65 %) in this cohort of patients with knee OA. Analyses revealed that self-reported knee instability is significantly associated with activity limitations, even after controlling for knee pain and muscle strength. Joint proprioception, joint laxity, age, sex, BMI, duration of complaints, and radiographic severity did not confound the associations. In conclusion, self-reported knee instability is associated with activity limitations in patients with knee OA, in addition to knee pain and muscle strength. Clinically, self-reported knee instability should be assessed in addition to knee pain and muscle strength. [ABSTRACT FROM AUTHOR]

Aim. To explore the treatment experiences in patients of Moroccan and Turkish origin and their rehabilitation therapists regarding an adapted outpatient cardiac rehabilitation programme. Background. Non-native patients who participated in a cardiac rehabilitation programme at a Dutch rehabilitation centre had more difficulties to achieve the treatment aims than native Dutch patients. Therefore, an adapted programme for non-native patients, lacking proficiency in Dutch, has been instigated. The programme contains six adapted treatment modules and additional strategies: adapted education regarding (1) the heart and the vascular system and (2) the use of healthy food, with use the of (audio) visual educational materials, (3) adapted physical exercise module with explicit involvement of the patients' relatives, (4) standard use of professional interpreters, (5) increase in the number and length of consultations and (6) individual treatment instead of a group programme. Design. Qualitative study. Method. Semi-structured, face-to-face interviews were conducted with eight patients of Moroccan and Turkish origin and five native Dutch rehabilitation therapists. By comparison, three native Dutch patients were interviewed regarding the regular programme. Results. The results indicate that the patients' disease symptoms reduced and that patients adopted lifestyle changes. Therapists experienced that the number and length of the consultations, the structural use of interpreters and (audio) visual educational materials contributed to the achievement of the treatment aims. Conclusion. An adapted cardiac rehabilitation programme with separate modules and additional strategies for non-native patients appears to lead to satisfied patients who adopted lifestyle changes. Relevance to clinical practice. The findings of this study are important as the study highlights the practical actions that may be taken by physicians and healthworkers to adjust rehabilitation treatment to the needs of patients of non-native origin. [ABSTRACT FROM AUTHOR]

Background: Many assume that outcomes from physical therapy research in one country can be generalized to other countries. However, no well designed studies comparing outcomes among countries have been conducted. In this exploratory study, our goal was to compare patient demographics and treatment processes in outpatient physical therapy practice in the United States, Israel and the Netherlands. Methods: Cross-sectional data from three different clinical databases were examined. Data were selected for patients aged 18 years and older and started an episode of outpatient therapy between January 1st 2005 and December 31st 2005. Results are based on data from approximately 63,000 patients from the United States, 100,000 from Israel and 12,000 from the Netherlands. Results: Age, gender and the body part treated were similar in the three countries. Differences existed in episode duration of the health problem, with more patients with chronic complaints treated in the United States and Israel compared to the Netherlands. In the United States and Israel, physical agents and mechanical modalities were applied more often than in the Netherlands. The mean number of visits per treatment episode, adjusted for age, gender, and episode duration, varied from 8 in Israel to 11 in the United States and the Netherlands. Conclusion: The current study showed that clinical databases can be used for comparing patient demographic characteristics and for identifying similarities and differences among countries in physical therapy practice. However, terminology used to describe treatment processes and classify patients was different among databases. More standardisation is required to enable more detailed comparisons. Nevertheless the differences found in number of treatment visits per episode imply that one has to be careful to generalize outcomes from physical therapy research from one country to another. [ABSTRACT FROM AUTHOR]

Background: Clinical guidelines are considered important instruments to improve quality in health care. Since 1998 the Royal Dutch Society for Physical Therapy (KNGF) produced evidence-based clinical guidelines, based on a standardized program. New developments in the field of guideline research raised the need to evaluate and update the KNGF guideline program. Purpose of this study is to compare different guideline development programs and review the KNGF guideline program for physical therapy in the Netherlands, in order to update the program. Method: Six international guideline development programs were selected, and the 23 criteria of the AGREE Instrument were used to evaluate the guideline programs. Information about the programs was retrieved from published handbooks of the organizations. Also, the Dutch program for guideline development in physical therapy was evaluated using the AGREE criteria. Further comparison the six guideline programs was carried out using the following elements of the guideline development processes: Structure and organization; Preparation and initiation; Development; Validation; Dissemination and implementation; Evaluation and update. Results: Compliance with the AGREE criteria of the guideline programs was high. Four programs addressed 22 AGREE criteria, and two programs addressed 20 AGREE criteria. The previous Dutch program for guideline development in physical therapy lacked in compliance with the AGREE criteria, meeting only 13 criteria. Further comparison showed that all guideline programs perform systematic literature searches to identify the available evidence. Recommendations are formulated and graded, based on evidence and other relevant factors. It is not clear how decisions in the development process are made. In particular, the process of translating evidence into practice recommendations can be improved. Conclusion: As a result of international developments and consensus, the described processes for developing clinical practice guidelines have much in common. The AGREE criteria are common basis for the development of guidelines, although it is not clear how final decisions are made. Detailed comparison of the different guideline programs was used for updating the Dutch program. As a result the updated KNGF program complied with 22 AGREE criteria. International discussion is continuing and will be used for further improvement of the program. [ABSTRACT FROM AUTHOR]

Background and Purpose. One-time physical therapist consultation, prior to possible referral for physical therapy intervention, may enhance the quality of patient care, particularly if the referring physician is uncertain as to whether intervention by a physical therapist will be beneficial. The purpose of this study was to describe the use of consultation by a group of primary care physicians (PCPs) who could refer patients for a one-time consultation. Subjects and Methods. A 7-month observational study was conducted in the Netherlands with 59 pairs of randomly selected PCPs and physical therapists practicing in primary health care. Data were collected for the PCPs, the physical therapist, and the patients. Self administered questionnaires (completed at the start and at the completion of the study), consultation request and report forms, and treatment referral records from health insurance agencies were used to obtain data. National reference data on patients referred by PCPs for intervention by a physical therapist were used to compare the data of patients referred by PCPs for a one-time consultation. The number and nature of consultation requests were determined as well as patient characteristics. The PCPs' satisfaction with the outcome and process of a one-time consultation and its impact on PCPs' management decisions also were described. Results. The number of referrals for a one-time consultation was 302 (X=5.9 per PCP, SD=5.4, range=0-20), resulting in a mean referral rate of 4.7 per 1,000 patients (SD=4.6). Characteristics of patients referred for a one-time consultation differed from national reference data of patients referred by their PCP for intervention by a physical therapist. Discussion and Conclusion. The results show that PCPs used the opportunity for a one-time physical therapist consultation and were satisfied with the outcome and process of consultation. The findings... [ABSTRACT FROM AUTHOR]

Background: Foot problems in people with rheumatoid arthritis (RA) are highly prevalent and have a substantial impact on quality of life. Healthcare professionals from various professions can be involved in the management of these foot problems. There is currently no consensus on optimal management. Therefore, the aim of the present study was to develop multidisciplinary recommendations for the management of foot problems in people with RA in the Netherlands. Methods: The recommendations were based on research evidence and consensus among experts, following published strategies for the development of practice recommendations. The expert group was composed of 2 patients and 22 experienced professionals (rheumatologists, rehabilitation physicians, orthopaedic surgeons, specialized nurses, podiatrists, orthopaedic shoe technicians, pedicurists, and researchers) in the Netherlands. For each developed recommendation i) the level of evidence was determined, and ii) the level of agreement (among the expert group) was set by an anonymous voting procedure using a numeric rating scale. The mean and range of the level of agreement for each recommendation was calculated. A recommendation was approved when ≥70% of the expert group voted an NRS-agreement ≥7. Results: In total, 41 recommendations were developed. Two recommendations concerned a framework for diagnosis and treatment. Thirty-nine recommendations on foot care were developed: seven on diagnosis (including check-ups of feet and shoes and diagnostic imaging), 27 on treatment (including corticosteroid injections, foot surgery, therapeutic shoes, foot orthoses, exercise therapy, toe-orthoses and toenail-braces, treatment of toenails and skin), four on communication, and one on organisation of RA-related footcare. All recommendations were approved by the expert group. The percentage score of NRS-agreement ≥7 ranged from 80 to 100%. Conclusions: These are the first published multidisciplinary recommendations specific to the management of foot problems in people with RA. Multidisciplinary recommendations can provide guidance in timely referrals and access to adequate footcare. More research is needed to strengthen the evidence on diagnosis and treatment of RA-related foot problems. These national recommendations may be a first step towards developing international multidisciplinary recommendations for the management of foot problems in RA. [ABSTRACT FROM AUTHOR]

Objective: Pain interference and pain behavior are highly relevant outcomes in patients with rheumatoid arthritis (RA). The Patient-Reported Outcomes Measurement Information System (PROMIS) is a universally applicable set of item banks measuring patient-reported health, and if applied as computerized adaptive tests (CATs), more efficiently and precisely than current instruments. The objective was to study the psychometric properties of the Dutch-Flemish PROMIS pain interference (PROMIS-PI) and the PROMIS pain behavior (PROMIS-PB) item banks in patients with RA., Methods: A total of 2,029 patients with RA completed the full PROMIS-PI (version 1.1, 40 items), and 1,554 patients completed the full PROMIS-PB (version 1.1, 39 items). The following psychometric properties were studied: unidimensionality, local dependence, monotonicity and graded response model (GRM) fit, cross-cultural validity (differential item functioning [DIF] for language [Dutch versus Flemish]), other forms of measurement invariance, construct validity, reliability, and floor and ceiling effects., Results: The PROMIS-PI and PROMIS-PB banks were sufficiently unidimensional (Omega-hierarchical [Omega-H] 0.99, 0.95, and explained common variance 0.95, 0.78, respectively), had negligible local dependence (0.3-1.4% of item pairs), good monotonicity (H 0.75, 0.46), and a good GRM model fit (no misfitting items). Furthermore, both item banks showed good cross-cultural validity (no DIF for language), measurement invariance (no DIF for age, sex, administration mode, and disease activity), good construct validity (all hypotheses met), high reliability (>0.90 in the range of patients with RA), and an absence of floor and ceiling effects (0% minimum or maximum score, respectively)., Conclusion: Both PROMIS-PI and PROMIS-PB banks showed good psychometric properties in patients with RA and can be used as CATs in research and clinical practice., (© 2019, American College of Rheumatology.)

Objectives: To explore patients' experiences with fluctuations in persistent physical symptoms (PPS) and to understand which factors-from their viewpoint-play a role in these fluctuations., Design: Qualitative study using semistructured interviews and thematic content analysis., Setting: This qualitative study is part of a multicentre prospective cohort study on the course of PPS. Patients were recruited in general practices and specialised treatment facilities for PPS throughout the Netherlands., Participants: Interviews were conducted with a sample of fifteen patients with PPS to explore their experiences with fluctuations in symptom severity., Results: We identified three themes in the analysis: (1) patterns in symptom fluctuations (2) perceived causes of symptom exacerbations and (3) Patients' strategies in gaining control over symptom exacerbations. Daily and weekly fluctuations in symptoms were an important element in patients' experiences. In particular anticipating on the worsening of symptoms impacted their daily routines and posed various challenges. Symptom exacerbations were attributed to overstepping physical limits and/or the impact of negative emotions. Resigning to physical limits, adjusting ones daily planning, weighing personal needs and learning to say 'no' were described as different strategies in gaining control over symptom exacerbations., Conclusions: Fluctuations in the severity of symptoms-and in particular daily and weekly symptom exacerbations-are an important element of the symptom experience in patients with PPS and poses various challenges. Patients attributed symptom exacerbation to overstepping physical limits and/or negative emotions. Patients described different strategies in gaining control over symptom exacerbations., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY. Published by BMJ.)

Background: Foot problems are highly prevalent in patients with rheumatoid arthritis. Treatment of foot problems related to rheumatoid arthritis often consists of custom made foot orthoses. One of the assumed working mechanisms of foot orthoses is redistribution of plantar pressure by creating a larger weight bearing area. Overall, the reported treatment effect of foot orthoses on foot pain in rheumatoid arthritis is small to medium. Therefore, we developed a foot orthoses optimization protocol for evaluation and adaptation of foot orthoses by using the feedback of in-shoe plantar pressure measurements. The objectives of the present study were: 1) to evaluate the 3-months outcomes of foot orthoses developed according to the protocol on pain, physical functioning and forefoot plantar pressure in patients with foot problems related to rheumatoid arthritis, and 2) to determine the relationship between change in forefoot plantar pressure and change in pain and physical functioning., Methods: Forty-five patients with foot problems related to rheumatoid arthritis were included and received foot orthoses developed according to the protocol. Outcome measures were assessed at baseline and after three months of wearing foot orthoses in 38 patients. Change scores and effect sizes (ES) were calculated for pain, physical functioning and plantar pressure. In a subgroup of patients with combined forefoot pain and high plantar pressure, the relationship between change in plantar pressure and change in pain and physical functioning was analyzed., Results: In the total group of 38 patients, statistically significant changes in pain (ES 0.69), physical functioning (ES 0.82) and forefoot plantar pressure (ES 0.35) were found. In the subgroup (n = 23) no statistically significant relationships were found between change in plantar pressure and change in pain or physical functioning., Conclusion: Foot orthoses developed according to a protocol for improving the plantar pressure redistribution properties lead to medium to large improvements in pain and physical functioning. The hypothesis that more pressure reduction would lead to better clinical outcomes could not be proven.

We used the Dutch-Flemish version of the USA PROMIS adult V1.0 item bank for Anxiety as input for developing a computerized adaptive test (CAT) to measure the entire latent anxiety continuum. First, psychometric analysis of a combined clinical and general population sample ( N = 2,010) showed that the 29-item bank has psychometric properties that are required for a CAT administration. Second, a post hoc CAT simulation showed efficient and highly precise measurement, with an average number of 8.64 items for the clinical sample, and 9.48 items for the general population sample. Furthermore, the accuracy of our CAT version was highly similar to that of the full item bank administration, both in final score estimates and in distinguishing clinical subjects from persons without a mental health disorder. We discuss the future directions and limitations of CAT development with the Dutch-Flemish version of the PROMIS Anxiety item bank.

Background: This study evaluated the effectiveness of a screening and stepped care program (the TES program) in reducing psychological distress compared with care as usual (CAU) in patients with metastatic colorectal cancer starting with first-line systemic palliative treatment., Patients and Methods: In this cluster randomized trial, 16 hospitals were assigned to the TES program or CAU. Patients in the TES arm were screened for psychological distress with the Hospital Anxiety and Depression Scale and the Distress Thermometer/Problem List (at baseline and 10 and 18 weeks). Stepped care was offered to patients with distress or expressed needs, and it consisted of watchful waiting, guided self-help, face-to-face problem-solving therapy, or referral to specialized mental healthcare. The primary outcome was change in psychological distress over time, and secondary outcomes were quality of life, satisfaction with care, and recognition and referral of distressed patients by clinicians. Linear mixed models and effect sizes were used to evaluate differences., Results: A total of 349 patients were randomized; 184 received the TES program and 165 received CAU. In the TES arm, 60.3% of the patients screened positive for psychological distress, 26.1% of which entered the stepped care program (14.7% used only watchful waiting and 11.4% used at least one of the other treatment steps). The observed low use of the TES program led us to pursue a futility analysis, which showed a small conditional power and therefore resulted in halted recruitment for this study. No difference was seen in change in psychological distress over time between the 2 groups (effect size, -0.16; 95% CI, -0.35 to 0.03; P>.05). The TES group reported higher satisfaction with the received treatment and better cognitive quality of life (all P<.05)., Conclusions: As a result of the low use of stepped care, a combined screening and treatment program targeting psychological distress in patients with metastatic colorectal cancer did not improve psychological distress. Our results suggest that enhanced evaluation of psychosocial concerns may improve aspects of patient well-being.

Background: Patients with advanced disease experience high levels of psychological distress, yet there is low uptake of psychosocial services offered to patients who screened positive for distress. In this study we aimed to identify predictors for use of psychosocial services in patients with metastatic colorectal cancer (mCRC) receiving first line chemotherapy enrolled in a prospective cluster randomized trial (CRT)., Methods: Patients completed measures on psychological distress, physical distress, and quality of life at baseline. Demographics, clinical characteristics at baseline and clinical events during treatment (e.g. severe adverse events, clinical benefit) were extracted from patient records. Patients reported psychosocial service utilization in- and outside the hospital after 10, 24 and 48 weeks of treatment. Multivariable logistic regression models were used to identify predictors for the use of psychosocial services., Results: Out of 349 patients, seventy patients (20.0%) used psychosocial support services during the follow-up period. Use of psychosocial services was associated with younger age, a higher educational level, presence of more pain (at baseline), and the expressed need to talk to a professional (at baseline). In addition, patients without progressive disease within the first ten weeks of treatment were more likely to use psychosocial services ., Conclusions: One in five patients with mCRC receiving first line palliative treatment used psychosocial services during this prospective longitudinal CRT. Sociodemographic factors (age, education), clinical factors (pain and no progressive disease) and the expressed need to talk to a professional predicted use of psychosocial services. Identification of these predictors may contribute to the understanding of factors that determine the need for psychosocial services., Trial Registration: Netherlands Trial Register NTR4034 .

Information on the association of self-reported knee instability with clinical outcomes after Total Knee Arthroplasty (TKA) and 1 year follow-up is scarce. The aims were to determine (i) the course and prevalence of self-reported knee instability before and 1 year after TKA and (ii) the associations of preoperative, postoperative, and retained self-reported knee instability with pain, activity limitations, and quality of life (QoL) in patients with knee osteoarthritis. Patients undergoing primary TKA, selected from the Longitudinal Leiden Orthopaedics and Outcomes of OsteoArthritis Study, had their knee instability measured using a questionnaire. The Knee injury and Osteoarthritis Outcome Score pain, activity limitations, and QoL subscales were administered before and 1 year after surgery. Multivariable regression analyses were performed to examine associations between knee instability, pain, activity limitations, and QoL, adjusted for covariates (age, gender, comorbidities, and radiographic severity). Of the 908 included patients, 649 (71%) and 187 (21%) reported knee instability before and following TKA, respectively. Of the patients with preoperative knee instability, this perception was retained in 165 (25%) cases. Knee instability was preoperatively associated with pain (B -9.6; 95%CI: -12.4 to -6.7), activity limitations (B -7.5; 95%CI: -10.2 to -4.8), and QoL (B -4.7; 95%CI: -7.0 to -2.4) and postoperatively with pain (B -15.0; 95%CI: -18.5 to -11.6), activity limitations (B -15.1; 95%CI: -18.4 to -11.8), and QoL (B -18.7; 95%CI: -22.3 to -15.3). Retained knee instability was associated with postoperative pain (B -15.1; 95%CI: -18.9 to -11.2), activity limitations (B -14.1; 95%CI: -17.8 to -10.4), and QoL (B -18.0; 95%CI: -21.7 to -14.3). In conclusion, in clinical care, self-reported knee instability is retained postoperatively in 25% of the patients. Retained knee instability is associated with more pain, activity limitations, and poorer QoL postoperatively. © 2018 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 36:2671-2678, 2018., (© 2018 Orthopaedic Research Society. Published by Wiley Periodicals, Inc.)

The Dutch-Flemish PROMIS Group translated the adult PROMIS Pain Interference item bank into Dutch-Flemish. The aims of the current study were to calibrate the parameters of these items using an item response theory (IRT) model, to evaluate the cross-cultural validity of the Dutch-Flemish translations compared to the original English items, and to evaluate their reliability and construct validity. The 40 items in the bank were completed by 1085 Dutch chronic pain patients. Before calibrating the items, IRT model assumptions were evaluated using confirmatory factor analysis (CFA). Items were calibrated using the graded response model (GRM), an IRT model appropriate for items with more than two response options. To evaluate cross-cultural validity, differential item functioning (DIF) for language (Dutch vs. English) was examined. Reliability was evaluated based on standard errors and Cronbach's alpha. To evaluate construct validity correlations with scores on legacy instruments (e.g., the Disabilities of the Arm, Shoulder and Hand Questionnaire) were calculated. Unidimensionality of the Dutch-Flemish PROMIS Pain Interference item bank was supported by CFA tests of model fit (CFI = 0.986, TLI = 0.986). Furthermore, the data fit the GRM and showed good coverage across the pain interference continuum (threshold-parameters range: -3.04 to 3.44). The Dutch-Flemish PROMIS Pain Interference item bank has good cross-cultural validity (only two out of 40 items showing DIF), good reliability (Cronbach's alpha = 0.98), and good construct validity (Pearson correlations between 0.62 and 0.75). A computer adaptive test (CAT) and Dutch-Flemish PROMIS short forms of the Dutch-Flemish PROMIS Pain Interference item bank can now be developed.

Background: A stepped care strategy (SCS) to improve adequate healthcare use in patients with osteoarthritis was developed and implemented in a primary care region in the Netherlands., Aim: To assess the association between care that is in line with the SCS recommendations and health outcomes., Design and Setting: Data were used from a 2-year observational study of 313 patients who had consulted their GP because of osteoarthritis., Method: Care was considered 'SCS-consistent' if all advised modalities of the previous steps of the SCS were offered before more advanced modalities of subsequent steps. Pain and physical function were measured with the Western Ontario and McMaster Universities Osteoarthritis Index (range 0-100); active pain coping with the Pain Coping Inventory (range 10-40); and self-efficacy with the Dutch General Self-Efficacy Scale (range 12-48). Crude and adjusted associations between SCS-consistent care and outcomes were estimated with generalised estimating equations., Results: No statistically significant differences were found in changes over a 2-year period in pain and physical function between patients who received SCS-inconsistent care (n = 163) and patients who received SCS-consistent care (n = 117). This was also the case after adjusting for possible confounders, that is, -4.3 (95% confidence interval [CI] = -10.3 to 1.7) and -1.9 (95% CI = -7.0 to 3.1), respectively. Furthermore, no differences were found in changes over time between groups in self-efficacy and pain coping., Conclusion: The results raised several important issues that need to be considered regarding the value of the SCS, such as the reasons that GPs provide SCS-inconsistent care, the long-term effects of the SCS, and the effects on costs and side effects., (© British Journal of General Practice 2014.)

Background: Exercise therapy in patients with hip and/or knee osteoarthritis is effective in reducing pain, increasing physical activity and physical functioning, but costly and a burden for the health care budget. A web-based intervention is cheap in comparison to face-to-face exercise therapy and has the advantage of supporting in home exercises because of the 24/7 accessibility. However, the lack of face-to-face contact with a professional is a disadvantage of web-based interventions and is probably one of the reasons for low adherence rates. In order to combine the best of two worlds, we have developed the intervention e-Exercise. In this blended intervention face-to-face contacts with a physical therapist are partially replaced by a web-based exercise intervention. The aim of this study is to investigate the short- (3 months) and long-term (12 months) (cost)-effectiveness of e-Exercise compared to usual care physical therapy. Our hypothesis is that e-Exercise is more effective and cost-effective in increasing physical functioning and physical activity compared to usual care., Methods/design: This paper presents the protocol of a prospective, single-blinded, multicenter cluster randomized controlled trial. In total, 200 patients with OA of the hip and/or knee will be randomly allocated into either e-Exercise or usual care (physical therapy). E-Exercise is a 12-week intervention, consisting of maximum five face-to-face physical therapy contacts supplemented with a web-based program. The web-based program contains assignments to gradually increase patients' physical activity, strength and stability exercises and information about OA related topics. Primary outcomes are physical activity and physical functioning. Secondary outcomes are health related quality of life, self-perceived effect, pain, tiredness and self-efficacy. All measurements will be performed at baseline, 3 and 12 months after inclusion. Retrospective cost questionnaires will be sent at 3, 6, 9 and 12 months and used for the cost-effectiveness and cost-utility analysis., Discussion: This study is the first randomized controlled trial in the (cost)-effectiveness of a blended exercise intervention for patients with osteoarthritis of the hip and/or knee. The findings will help to improve the treatment of patients with osteoarthritis., Trial Registration: NTR4224.

Background: Studies on hypothalamic-pituitary-adrenal axis (HPA-axis) function amongst patients with chronic pain show equivocal results and well-controlled cohort studies are rare in this field. The goal of our study was to examine whether HPA-axis dysfunction is associated with the presence and the severity of chronic multi-site musculoskeletal pain., Methods: Data are from the Netherlands Study of Depression and Anxiety including 1125 subjects with and without lifetime depressive and anxiety disorders. The Chronic Pain Grade questionnaire was used to determine the presence and severity of chronic multi-site musculoskeletal pain. Subjects were categorized into a chronic multi-site musculoskeletal pain group (n = 471) and a control group (n = 654). Salivary cortisol samples were collected to assess HPA-axis function (awakening level, 1-h awakening response, evening level, diurnal slope and post-dexamethasone level)., Results: In comparison with the control group, subjects with chronic multi-site musculoskeletal pain showed significantly lower cortisol level at awakening, lower evening level and a blunted diurnal slope. Lower cortisol level at awakening and a blunted diurnal slope appeared to be restricted to those without depressive and/or anxiety disorders, who also showed a lower 1-h awakening response., Conclusions: Our results suggest hypocortisolemia in chronic multi-site musculoskeletal pain. However, if chronic pain is accompanied by a depressive or anxiety disorder, typically related to hypercortisolemia, the association between cortisol levels and chronic multi-site musculoskeletal pain appears to be partly masked. Future studies should take psychopathology into account when examining HPA-axis function in chronic pain.

Introduction: The aim of this study was to examine the associations of elevated serum C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) with change in muscle strength in patients with established knee osteoarthritis (OA), at 2 years., Methods: Data from 186 patients with knee OA were gathered at baseline and at 2-year follow-up. CRP (in milligrams per liter) and ESR (in millimeters per hour) were measured in serum from patients' blood. Strength of quadriceps and hamstrings muscles was assessed by using an isokinetic dynamometer. The association of inflammatory markers with change in knee muscle strength was analyzed by using uni- and multi-variate linear regression models., Results: Patients with elevated CRP values at both baseline and 2-year follow-up exhibited a lower increase in knee muscle strength for a period of 2 years (β = -0.22; P = 0.01) compared with the group with non-elevated levels at both times of assessment. The association persisted after adjustment for relevant confounders. Elevated ESR values at both times of assessment were not significantly associated with change in knee muscle strength (β = -0.05; P = 0.49)., Conclusions: Our results indicate that elevated CRP values are related to a lower gain in muscle strength over time in patients with established knee OA. Although the mechanism to explain this relationship is not fully elucidated, these results suggest inflammation as a relevant factor influencing muscle strength in this group of patients.

Background: To enhance guideline-based non-surgical management of hip or knee osteoarthritis (OA), a multidisciplinary, stepped-care strategy has been implemented in primary care in a region of the Netherlands. To facilitate this implementation, the self-management booklet "Care for Osteoarthritis" was developed and introduced. The aim of the booklet was to educate patients about OA, to enhance the patient's active role in the treatment course, and to improve the communication with health care providers. To successfully introduce the booklet on a large scale we assessed barriers and facilitators for patients to using this booklet., Methods: Seventeen primary care patients with hip or knee OA who received the self-management booklet participated in this qualitative study using semi-structured interviews. Purposive sampling was used to ensure diversity of the patients' view about the booklet. The interviews were transcribed verbatim and analysed using a thematic analysis approach., Results: Three core themes with patient perceived barriers and facilitators to use the booklet emerged from the interviews: 1) the role of health care providers, 2) the patient's perceptions about OA and its manageability, and 3) the patient's perceptions about the usefulness of the booklet and patient's information needs. Regarding the first theme, a barrier was the lack of encouragement from health care providers to use the booklet in the treatment course of OA. Moreover, patients had doubts concerning the health care providers' endorsement of non-surgical treatment for OA. Barriers from the second theme were: thinking that OA is not treatable or that being pro-active during the treatment course is not important. In contrast, being convinced about the importance of an active participation in the treatment course was a facilitator. Third, patients' perceptions about the usefulness of the booklet and patients' information needs were both identified as barriers as well as facilitators for booklet use., Conclusions: This study contributes to the understanding of patient perceived barriers and facilitators to use a self-management booklet in the treatment course of OA. The results offer practical starting points to tailor the implementation activities of the booklet nationwide and to introduce comparable educational tools in OA primary care or in other chronic diseases.

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

Background: Body-mass index (BMI) and depressed mood are both positively associated with pain and activity limitations in knee osteoarthritis (OA), and are interrelated. The aims of the present study were: 1) to assess whether BMI and depressed mood are independently associated with knee pain and activity limitations; and 2) to compare the relative contributions of BMI and depressed mood to knee pain and activity limitations., Methods: A cross-sectional study in 294 patients with clinical knee OA. Regression analyses were performed with knee pain or activity limitations (self-reported and performance-based) as dependent variables, and BMI and depressed mood as independent variables. All analyses were adjusted for age, gender, marital status, education level, radiographic OA and comorbidity. Dominance analyses were performed to examine the relative contributions of BMI and depressed mood to knee pain and activity limitations., Results: BMI and depressed mood were positively and independently associated with knee pain and activity limitations. BMI and depressed mood explained small parts (3.0% and 2.3%, respectively) of variance in knee pain. BMI explained a substantial part of variance in both self-reported (9.8%) and performance-based (20.4%) activity limitations, while depressed mood explained a small part of variance (3.1% in self-reported and 2.6% in performance-based activity limitations)., Conclusions: In patients with knee OA both BMI and depressed mood seem to be independently associated with knee pain and activity limitations. The contribution of BMI to activity limitations is most substantial, thereby offering a relevant target for interventions.

Purpose: To assess the efficacy of client-centred occupational therapy (OT) according to a client-centred process framework, as compared to usual care OT, in patients with multiple sclerosis (MS)., Method: A multicentre cluster randomised controlled trial with the institution (i.e. hospital or rehabilitation centre) as the unit of randomisation was performed. A total of 269 outpatients with MS, 13 hospitals and rehabilitation centres and 29 occupational therapists participated. Primary outcomes included measures of disability, participation and autonomy. Secondary outcomes included fatigue, generic health-related quality of life, quality and evaluation of therapy, therapy compliance and therapy frequency. Measurements were taken at baseline, four months and at eight months follow-up., Results: Primary outcome measures did not show significant differences between the two interventions. Secondary outcomes revealed significant differences in favour of the usual care OT on fatigue (physical scale and total scale) and health-related quality of life (bodily pain and vitality) at four months. After eight months only significant differences on mental health were found. Process outcomes (i.e. the information scale of therapy quality and the client-centredness of the organisation) were in favour of the client-centred intervention., Conclusion: Because the client-centred intervention resulted in no effects on the primary outcomes and small but negative effects on the secondary functional outcomes, we should seriously reconsider the application of client-centred practice., Implications for Rehabilitation: An increasing number of interventions claim to incorporate client-centred practice. Client-centred practice is associated with improved satisfaction but the effects on functional health-related outcomes have not been fully evaluated. The findings of this study show that the process outcomes of therapy were in favour of the client-centred intervention, but no effects were found on the primary outcomes and negative effects on the secondary functional health outcomes. It is suggested that the implementation of client-centred practice should be adjusted in order to achieve optimal health outcomes.

Objective: To describe foot-related health care use over time in a cohort of rheumatoid arthritis (RA) patients in an outpatient secondary care center for rheumatology and rehabilitation in The Netherlands., Methods: A total of 1,087 patients with recent-onset RA from 1995 to September 2010 were included in the study. All foot-related visits to the podiatrist, rehabilitation physician, orthopedic surgeon, and the multidisciplinary foot-care clinic were registered and described. Logistic regression techniques for longitudinal data were used to analyze the course of foot-related health care use., Results: A total of 32.9% of patients visited a podiatrist in secondary care during the course of their disease. For most patients, a visit to the podiatrist took place during the first year after diagnosis. This was followed by a significant decrease in visits in the ensuing years. Nine percent of patients visited the rehabilitation physician with foot symptoms, with peak prevalences between year 10 and 11 and during year 14 of followup. The orthopedic surgeon was visited by 5.3% of patients with foot symptoms, with a significant increase in visits over time. The multidisciplinary foot-care clinic was visited by 7.5% of patients. This was significantly associated with visits to the rehabilitation physician., Conclusion: In an outpatient secondary care center in The Netherlands, RA patients with foot symptoms visited the podiatrist in an early stage of the disease. When foot symptoms worsened, patients visited the rehabilitation physician, who subsequently referred patients to the multidisciplinary foot-care clinic for therapeutic footwear. The orthopedic surgeon was the final step in the management of foot symptoms., (Copyright © 2013 by the American College of Rheumatology.)

Objective: To determine the association of postural control with muscle strength, proprioception, self-reported knee instability and activity limitations in patients with knee osteoarthritis., Methods: A total of 284 patients with knee osteoarthritis from the Amsterdam Osteoarthritis cohort were included. Postural control was assessed using the One-Leg Stand Test (OLST), in which the patients were asked to stand on one leg for 30 s. Muscle strength (isokinetic dynamometer), proprioception (joint motion detection threshold) and self-reported knee instability (episodes of buckling, shifting or giving way) were also assessed. Activity limitations were assessed using the Get Up and Go (GUG) test, the walking up-down stairs test, and Western Ontario and McMaster University Osteoarthritis Index - Physical Function subscale. Regression analyses were used to assess the associations., Results: Muscle weakness (p = 0.02) and proprioceptive inaccuracy (p < 0.001) were associated with decreased postural control. Decreased postural control was associated with less time performing the GUG test (p < 0.001) and the walking up-down stairs test (p < 0.001). These associations were found after adjustment for relevant confounders., Conclusion: In patients with knee osteoarthritis, decreased postural control is associated with muscle weakness, proprioceptive inaccuracy and performance-based activity limitations. These results highlight the importance of including assessment and training of postural control in this group of patients.

The objective of this study was to evaluate whether self-reported knee instability is associated with activity limitations in patients with knee osteoarthritis (OA), in addition to knee pain and muscle strength. A cohort of 248 patients diagnosed with knee OA was examined. Self-reported knee instability was defined as the perception of any episode of buckling, shifting, or giving way of the knee in the past 3 months. Knee pain was assessed using a numeric rating scale, and knee extensor and flexor strength were measured using an isokinetic dynamometer. Activity limitations were measured by using the Western Ontario and McMasters Universities Osteoarthritis Index physical function questionnaire, the timed Get Up and Go, and the timed stair climbing and three questionnaires evaluating walking, climbing stairs, and rising from a chair. Other potential determinants of activity limitations were also collected, including joint proprioception, joint laxity, age, sex, body mass index (BMI), disease duration, and radiographic disease severity. Regression analyses evaluated the effect of adding self-reported knee instability to knee pain and muscle strength, when examining associations with the activity limitations measures. Self-reported knee instability was common (65 %) in this cohort of patients with knee OA. Analyses revealed that self-reported knee instability is significantly associated with activity limitations, even after controlling for knee pain and muscle strength. Joint proprioception, joint laxity, age, sex, BMI, duration of complaints, and radiographic severity did not confound the associations. In conclusion, self-reported knee instability is associated with activity limitations in patients with knee OA, in addition to knee pain and muscle strength. Clinically, self-reported knee instability should be assessed in addition to knee pain and muscle strength.

Objective: To determine whether muscle strength, proprioceptive accuracy, and laxity are associated with self-reported knee instability in a large cohort of knee osteoarthritis (OA) patients, and to investigate whether muscle strength may compensate for impairment in proprioceptive accuracy or laxity, in order to maintain knee stability., Methods: Data from 283 knee OA patients from the Amsterdam Osteoarthritis cohort were used. Univariable and multivariable logistic regression analyses were performed to assess the association between muscle strength, proprioceptive accuracy (motion sense), frontal plane varus-valgus laxity, and self-reported knee instability. Additionally, effect modification between muscle strength and proprioceptive accuracy and between muscle strength and laxity was determined., Results: Self-reported knee instability was present in 67% of the knee OA patients and mainly occurred during walking. Lower muscle strength was significantly associated with the presence of self-reported knee instability, even after adjusting for relevant confounding. Impaired proprioceptive accuracy and high laxity were not associated with self-reported knee instability. No effect modification between muscle strength and proprioceptive accuracy or laxity was found., Conclusion: Lower muscle strength is strongly associated with self-reported knee instability in knee OA patients, while impairments in proprioceptive accuracy and laxity are not. A compensatory role of muscle strength for impaired proprioceptive accuracy or high laxity, in order to stabilize the knee, could not be demonstrated., (Copyright © 2012 by the American College of Rheumatology.)

Inadequacies in health care practices have been reported despite existing guidelines to manage hip or knee osteoarthritis. To facilitate guideline implementation and improve utilization of non-surgical treatment options a care strategy should be developed. This study describes the development of an evidence-based, multidisciplinary, patient-centered, stepped care strategy. A national, multidisciplinary, steering group developed the strategy in three phases: (1) consensus among steering group members (first draft); (2) written consultation of 23 representatives of patient organizations and professional associations involved in osteoarthritis care (second draft); (3) consensus of the final draft after discussion in two rounds during a conference with representatives from the different disciplines. The final stepped care strategy presents, in three tiers, the optimal order for non-surgical treatment modalities. It recommends that more advanced options should only be considered if options listed in previous steps failed to produce satisfactory results. Hence, the first step treatment options can be offered to all patients but may also be provided through self care (education, life style advice, and acetaminophen). The second step (exercise therapy, dietary therapy, and non-steroidal anti-inflammatory drugs) and third step treatment options (multidisciplinary care, intra-articular injections, and transcutaneous electrical nerve stimulation) can be considered for people with persisting complaints. Trough a consensus procedure, we succeeded to develop a multidisciplinary, patient-centered, stepped care strategy based on national guidelines. This strategy provides a framework for health care providers and patients with hip or knee osteoarthritis to discuss the optimal timing of the various treatment options.

Purpose: (i) To determine whether adaptations for non-native patients have been implemented in pain rehabilitation programmes; (ii) to determine whether characteristics of the rehabilitation institute are related to having adaptations for non-native patients in place., Subjects: Rehabilitation institutes and rehabilitation departments of general hospitals in The Netherlands who offer a pain rehabilitation programme., Method: A questionnaire was handed over in person or by e-mail to the rehabilitation physicians of the participating institutes. Twenty-seven (90%) questionnaires were returned. The questionnaire concerned programme adaptations and institute characteristics. The data were analysed by χ(2) tests or Fischer's exact tests and logistic regression analysis., Results: Twelve institutes (44.4%) reported having adaptations in place for non-native patients in their pain rehabilitation programme. The most common adaptations were as follows: increased number of consultations (25.9% of the institutes); longer consultations (25.9%) and education for employees regarding cultural competency (11.1%). Institutes which treated a high percentage (≥11%) of non-native patients had implemented significantly more frequently adaptations to their rehabilitation programme (p = 0.04). The number of adaptations was neither associated with the proportion of non-native citizens in the local population nor with the number of the institutes' employees., Conclusion: Less than half of the institutes had implemented one or more programme adaptations for non-native patients. Institutes which had made adaptations to their rehabilitation programme treated more non-native patients.

Objective: To explore which factors led to drop-out in patients of Turkish and Moroccan origin with chronic non-specific low back pain who participated in a rehabilitation programme., Subjects: Patients of Turkish or Moroccan origin with chronic non-specific low back pain (n = 23) from 2 rehabilitation centres and 4 rehabilitation departments of general hospitals in the Netherlands., Methods: In-depth semi-structured interviews were conducted with patients of Turkish and Moroccan origin (n = 23), rehabilitation physicians (n = 8) and rehabilitation therapists (n = 2). Interviews were transcribed or summarized and subsequently coded and analysed according to themes., Results: Most patients dropped out due to expectations of a specific medical diagnosis and pain relief as the main aims of rehabilitation treatment. Other reasons for drop-out detected in the interviews were: lack of acknowledgement of the patient's complaints, lack of trust in the rehabilitation physician, contradicting views to those of the physician from the patients' country of origin with regard to the cause and treatment of pain, and communication problems., Conclusion: The major reason for drop-out was patients having different expectations, from those of their health providers, of the aim of treatment, as a result of a different view of the origin and treatment of low back pain.

In the Netherlands the current, conservative management of osteoarthritis of the hip and knee is heterogeneous and suboptimal. Existing guidelines only provide indications for certain interventions, but they do not provide recommendations about the sequence of these treatments. A step-by-step treatment strategy has now been developed in addition to the guidelines. Its aim is to optimize and clarify the conservative policy for osteoarthritis. In addition, communication between patients and professionals and between professionals themselves must be encouraged. According to the treatment strategy, relatively advanced interventions are considered only after simpler interventions have had insufficient results. A care booklet has also been developed that contains information for patients about osteoarthritis, treatment options, healthcare professionals and the treatment strategy.

Dropout from a rehabilitation programme often occurs in patients with chronic nonspecific low back pain of non-native origin. However, the exact dropout rate is not known. The objective of this study was to determine the difference in dropout rate between native and non-native patients with chronic nonspecific low back pain participating in a rehabilitation programme in The Netherlands. A retrospective study (n = 529) of patient files was performed in two rehabilitation centres and two rehabilitation departments of general hospitals in The Netherlands. Patient files were checked for diagnosis, status of origin, sex, age and outcome, that is, reason for finishing treatment. The difference in dropout rate between patients of Dutch and non-Dutch origin was tested by chi tests and logistic regression-analysis, controlling for age, sex, type of rehabilitation institute and phase of the rehabilitation programme. Dropout occurred among one fifth (18.7%) of the total patient population. Dropout among patients of non-Dutch origin was twice as high as among native Dutch patients (P < 0.001). In regression analyses dropout was related to status of non-Dutch origin, treatment in a rehabilitation centre and the diagnostic phase of a rehabilitation programme. In conclusion, patients of non-Dutch origin drop out considerably more frequently than native Dutch patients. Dropout is higher in the diagnostic phase than in the treatment phase and in rehabilitation centres than in hospitals. Future research should clarify the reasons for the high dropout rate in patients of non-native origin.