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Samenvatting Inleiding De helft van de volwassen Nederlanders heeft matig tot ernstig overgewicht. De gecombineerde leefstijlinterventie begeleidt mensen met overgewicht naar een gezonde leefstijl. Naast fysieke contactmomenten kunnen digitale coachingsmiddelen ingezet worden om cliënten op afstand te begeleiden. In de praktijk blijkt dat digitale toepassingen nog niet ten volle worden benut. Om het gebruik te stimuleren is inzicht nodig in de ervaringen en ondersteuningsbehoeften van leefstijlcoaches ten aanzien van de inzet van digitale technologie. Methode Met één vragenlijst en twee focusgroepgesprekken zijn data verzameld over het gebruik, de wensen en ondersteuningsbehoeften rond het inzetten van digitale coachingsmiddelen bij leefstijlcoaches. De vragenlijsten zijn descriptief geanalyseerd en de focusgroepgesprekken zijn thematisch geanalyseerd. Resultaten Uit de vragenlijstresultaten (N = 79) en de focusgroepgesprekken (N = 10) bleek dat leefstijlcoaches vooral ervaring hebben opgedaan met videobellen, applicaties en online informatie. Ze gaven aan dat digitale coaching de zelfredzaamheid van hun cliënten ondersteunt. Online groepsbegeleiding wordt als minder effectief ervaren dan fysieke groepssessies, omdat er weinig interactie tussen cliënten plaatsvindt. Ook ervaren leefstijlcoaches praktische barrières bij het gebruik. Ze hebben behoefte aan uitwisseling van ervaringen met collega’s, scholing en instructies over de manier waarop digitale coachingsmiddelen ingezet kunnen worden. Conclusie Leefstijlcoaches achten digitale coachingsmiddelen van toegevoegde waarde bij de individuele begeleiding van hun cliënten. Het wegnemen van praktische barrières en het faciliteren van uitwisseling en scholing kunnen een ruimere inzet van digitale coachingsmiddelen stimuleren.

Contains fulltext : 248982.pdf (Publisher’s version ) (Closed access) Introduction: Integrating web-based or mobile components and face-to-face components within a treatment process is called blended care. As part of the participatory development of a blended physiotherapeutic intervention for patients with low back pain (e-Exercise LBP), a proof of concept study was carried out and showed promising results.Objective: To investigate the feasibility of the e-Exercise LBP prototype for patients and physiotherapists to improve the intervention.Methods: A mixed methods study was executed, embedded in the development phase of e-Exercise LBP. 21 physiotherapists treated 41 patients with e-Exercise LBP. Quantitative data consisted of: patients' satisfaction on a five-point Likert Scale; patients' and physiotherapists' experienced usability of the web-based application (System Usability Scale) and; patients' experiences with e-Exercise LBP (closed-ended questions and statements related to the elements and goals of e-Exercise LBP). Semi-structured interviews about experiences with e-Exercise LBP were conducted with seven patients and seven physiotherapists. Qualitative data were analyzed by a phenomenological approach. Quantitative data were analyzed with descriptive statistics.Results: Patients were satisfied with e-Exercise LBP (mean: 4.0; SD:0.8; range: extreme dissatisfaction (1)-extreme satisfaction (5)). Usability of the web-based application was acceptable (patients: mean: 73.2 (SD:16.3); physiotherapists: mean: 63.3 (SD:12.0); range: 0-100). Interviews revealed that physiotherapists' training is essential to successfully integrate the web-based application and face-to-face sessions within physiotherapy treatment. Also, patients addressed the need of reminder messages to support long-term (exercise) adherence.Conclusion: e-Exercise LBP appeared to be feasible. However, various prerequisites and points of improvement were mentioned to improve physiotherapists' training and the prototype.

Background Combined lifestyle interventions (CLI) aim to help clients with weight-related health risks to change their physical activity levels and dietary behaviors. These long-term (2 year) interventions are mostly delivered through face-to-face sessions with limited use of eHealth technologies. To integrate eHealth into existing CLIs, it is important to determine how behavior change techniques (BCTs) are being used by health professionals in the online and offline treatment of overweight clients. Therefore, we conducted semi-structured interviews with providers and developers of online and offline CLIs. Methods Due to the COVID-19 restrictions all semi-structured interviews were organized online. We recruited professionals who had experience with the (1) provision of the traditional ‘offline’ CLIs, (2) provision of online CLIs and (3) the development of (online) CLIs. The interview guide contained topics about the use and requirements of online and offline BCTs in practice. The data were analyzed through an inductive thematic approach. Findings Thirty-eight lifestyle professionals were interviewed. Professionals who work online use diary apps, smartwatches or smartphone-based accelerometers to support clients in changing their dietary and physical activity behavior. These tools help professionals in the provision of specific BCTs, including monitoring, feedback and shaping knowledge. Monitoring is seen as a starting point for feedback. Professionals use online modules to enhance knowledge about health consequences of unhealthy behavior. Coaches who work predominantly offline use goal setting and action planning techniques. Although online contact can be a quick and easy way to interact, physical meetings are seen as the best way to enhance social support. Conclusion These Findings suggest that it may be beneficial to use monitoring devices to provide just-in-time feedback based on the client’s actual performance. Based on the Findings we are now developing an online platform with instructions for lifestyle coaches how to integrate online BCTs into practice.

Introduction: E-Exercise is an effective 12-week blended intervention consisting of around five face-to-face physiotherapy sessions and a web-based application for patients with hip/knee osteoarthritis. In order to facilitate effective implementation of e-Exercise, this study aims to identify physiotherapists' experiences and determinants related to the usage of e-Exercise. Methods: An explanatory sequential mixed methods design embedded in a randomized controlled trial comparing e-Exercise with usual physiotherapy in patients with hip/knee osteoarthritis. Usage of e-Exercise was based on recruitment rates of 123 physiotherapists allocated to e-Exercise and objective web-based application usage data. Experiences and determinants related to e-Exercise usage were investigated with a questionnaire and clarified with semi-structured interviews. Results: Of the 123 physiotherapists allocated to e-Exercise, 54 recruited more than one eligible patient, of whom 10 physiotherapists continued using e-Exercise after the study period. Physiotherapists had mixed experiences with e-Exercise. Determinants related to intervention usage were appropriateness, added value, time, workload, professional autonomy, environmental factors, and financial consequences. Physiotherapists recommended to improve the ability to tailor e-Exercise to the individual needs of the patient patients' individual needs. Discussion: Determinants related to the usage of e-Exercise provided valuable information for the implementation of e-Exercise on broader scale. Most importantly, the flexibility of e-Exercise needs to be improved. Next, there is a need for education on how to integrate an online program within physiotherapy.

Background Physical activity (PA) is important for children with a chronic disease. Serious games may be useful to promote PA levels among these children. Objective The primary purpose of this systematic review was to evaluate the effectiveness of serious games on PA levels in children with a chronic disease. Methods PubMed, EMBASE, PsycINFO, ERIC, Cochrane Library, and CINAHL were systematically searched for articles published from January 1990 to May 2018. Both randomized controlled trials and controlled clinical trials were included to examine the effects of serious games on PA levels in children with a chronic disease. Two investigators independently assessed the intervention, methods, and methodological quality in all articles using the Cochrane risk of bias tool. Both qualitative and quantitative analyses were performed. Results This systematic review included 9 randomized controlled trials (886 participants). In 2 of the studies, significant between-group differences in PA levels in favor of the intervention group were reported. The meta-analysis on PA levels showed a nonsignificant effect on moderate to vigorous PA (measured in minutes per day) between the intervention and control groups (standardized mean difference 0.30, 95% CI –0.15 to 0.75, P=.19). The analysis of body composition resulted in significantly greater reductions in BMI in the intervention group (standardized mean difference –0.24, 95% CI –0.45 to 0.04, P=.02). Conclusions This review does not support the hypothesis that serious games improve PA levels in children with a chronic disease. The meta-analysis on body composition showed positive intervention effects with significantly greater reductions in BMI in favor of the intervention group. A high percentage of nonuse was identified in the study of serious games, and little attention was paid to behavior change theories and specific theoretical approaches to enhance PA in serious games. Small sample sizes, large variability between intervention designs, and limited details about the interventions were the main limitations. Future research should determine which strategies enhance the effectiveness of serious games, possibly by incorporating behavior change techniques.

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

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

BACKGROUND Physical activity (PA) is important for children with a chronic disease. Serious games may be useful to promote PA levels among these children. OBJECTIVE The primary purpose of this systematic review was to evaluate the effectiveness of serious games on PA levels in children with a chronic disease. METHODS PubMed, EMBASE, PsycINFO, ERIC, Cochrane Library, and CINAHL were systematically searched for articles published from January 1990 to May 2018. Both randomized controlled trials and controlled clinical trials were included to examine the effects of serious games on PA levels in children with a chronic disease. Two investigators independently assessed the intervention, methods, and methodological quality in all articles using the Cochrane risk of bias tool. Both qualitative and quantitative analyses were performed. RESULTS This systematic review included 9 randomized controlled trials (886 participants). In 2 of the studies, significant between-group differences in PA levels in favor of the intervention group were reported. The meta-analysis on PA levels showed a nonsignificant effect on moderate to vigorous PA (measured in minutes per day) between the intervention and control groups (standardized mean difference 0.30, 95% CI –0.15 to 0.75, P=.19). The analysis of body composition resulted in significantly greater reductions in BMI in the intervention group (standardized mean difference –0.24, 95% CI –0.45 to 0.04, P=.02). CONCLUSIONS This review does not support the hypothesis that serious games improve PA levels in children with a chronic disease. The meta-analysis on body composition showed positive intervention effects with significantly greater reductions in BMI in favor of the intervention group. A high percentage of nonuse was identified in the study of serious games, and little attention was paid to behavior change theories and specific theoretical approaches to enhance PA in serious games. Small sample sizes, large variability between intervention designs, and limited details about the interventions were the main limitations. Future research should determine which strategies enhance the effectiveness of serious games, possibly by incorporating behavior change techniques.

OBJECTIVE:To develop a blended physiotherapeutic intervention for patients with non-specific low back pain (e-Exercise LBP) and evaluate its proof of concept.DESIGN:Focus groups with patients, physiotherapists, and eHealth and LBP experts were conducted to investigate values according to the development of e-Exercise LBP. Proof of concept was evaluated in a multicentre study.SETTING:Dutch primary care physiotherapy practices (n=21 therapists).PARTICIPANTS:Adults with non-specific LBP (n=41).INTERVENTION:e-Exercise LBP was developed based on clinical LBP guidelines and the focus groups, using the Center for eHealth Research Roadmap. Face-to-face physiotherapy sessions were integrated with a web application consisting of 12 information lessons, video-supported exercises and a physical activity module with the option to gradually increase individuals' level of physical activity. The intervention could be tailored to patients' risk of persistent disabling LBP, according to the STarT Back Screening Tool.MAIN OUTCOME MEASURES:Functional disability, pain, physical activity, sedentary behaviour and fear-avoidance beliefs, measured at baseline and 12 weeks.RESULTS:After 12 weeks, improvements were found in functional disability [Quebec Back Pain Disability Scale: mean difference (MD) -12.2/100; 95% confidence interval (CI) 8.3 to 16.1], pain (Numeric Pain Rating Scale: MD -2.8/10; 95% CI 2.1 to 3.6), subjective physical activity (Short Questionnaire to Assess Health Enhancing Physical Activity: MD 11.5minutes/day; 95% CI -47.8 to 24.8) and objective sedentary behaviour (ActiGraph: MD -23.0minutes/day; 95% CI -8.9 to 55.0). Small improvements were found in objective physical activity and fear-avoidance beliefs. The option to gradually increase physical activity was activated for six patients (15%). On average, patients received seven face-to-face sessions alongside the web application.CONCLUSIONS:The results of this study provide the first indication of the effectiveness of e-Exercise LBP, particularly for disability and pain among patients with LBP. Future studies will focus on end-user experiences and (cost-) effectiveness.KEYWORDS:Low back pain; Physiotherapy; Telemedicine; e-Health

Background Physiotherapy, consisting of education, graded activity and exercises, is effective in improving levels of physical functioning and pain in patients with osteoarthritis (OA) of hip and/or knee. Blended physiotherapy, in which physiotherapy sessions and an online application are integrated, might support patients in taking an active role in the management of their condition and may reduce disease related costs. Recently, the blended physiotherapy intervention e-Exercise was developed.Bossen 2016 E-Exercise is an integration of five face-to-face physiotherapy sessions with an online application consisting of information-, exercise-, and a graded activity module. Objectives To evaluate the cost-effectiveness of e-Exercise compared to usual physiotherapy in patients with OA of hip and/or knee, from the societal as well as the healthcare perspective. Methods This economic evaluation was conducted alongside a 12 month cluster randomised controlled trial, in which 108 patients received e-Exercise and 99 patients received usual physiotherapy. Clinical outcome measures were quality-adjusted life years (QALYs) according to the EuroQol (EQ-5D-3L), physical functioning (HOOS/KOOS) and physical activity (Actigraph Accelerometer). Costs were measured using self-reported questionnaires. Missing data were multiply imputed and bootstrapping was used to estimate statistical uncertainty. Results Total societal costs and total healthcare costs did not significantly differ between groups. Intervention costs (ΔC €−202; 95% CI:−286 tot −120) and medication costs (ΔC €−151; 95%:−340 tot −52) were significantly lower in e-Exercise compared to usual physiotherapy. No significant differences in effectiveness were found between groups (QALYS (0–1): B=0.01; 95% CI: −0.03 till 0.04; HOOS/KOOS (0–100): B=1.49; 95% CI: −4.70 till 0.69; Accelerometer (min/dag): B=−3.46; 95% CI: −11.66 till 4.73). For physical functioning and physical activity, the maximum probability of e-Exercise being cost-effective compared to usual physiotherapy was moderate ( Conclusions E-Exercise itself was significantly cheaper compared to usual physiotherapy in patients with hip and/or knee OA, but not cost-effective from the societal- as well as healthcare perspective. The decision between both interventions can be based on the preferences of the patient and the physiotherapist. Reference [1] Bossen D, Kloek C, Snippe HW, Dekker J, de Bakker D, Veenhof C. A Blended Intervention for Patients With Knee and Hip Osteoarthritis in the Physical Therapy Practice: Development and a Pilot Study. JMIR research protocols2016;5(1):e32. Disclosure of Interest None declared

Introduction We developed a guideline for occupational health professionals (OHPs) to optimise guidance and assessment of people with a chronic disease. Since adherence to such guidelines is generally low, a training can be used to increase OHPs compliance. Because limited evidence is available on the development of a guideline training, this study provides insight on how such a training can be developed. Methods A qualitative approach of four steps was used. First, focus groups were held to explore OHPs training needs. OHPs prioritised guideline evidence based on implementation needs, and required knowledge and skills to use the evidence in practice. Second, based on the training needs, learning objectives were formulated by the researchers. Third, experts in the field of education were interviewed to explore relevant teaching methods. Finally, researchers integrated all results in a final training approach to optimise OHPs guidance and assessment. Results OHPs reported various training needs, after which 17 learning objectives were formulated, such as identification of factors and effective interventions that influence work participation, and stimulating the own role of people with a chronic disease. To provide these learning goals in practice, experts reported various teaching methods, including the provision of homework, case study, role play, discussion of best practices, debate, and interview with stakeholders. The training needs and teaching methods were integrated in a six hour training day. Discussion This study shows that OHPs indicated several training needs to use the guideline in practice. These training needs can be provided through the use of various teaching methods, which are mostly closely related to OHPs daily practice. Providing an overview of the proces of development of may support researchers and developers of occupational guidelines in the development of other guideline trainings.

Introduction A large amount of people with a chronic disease experience difficulties in participation in work, mostly irrespective of diagnosis. How can OHPs be facilitated in supporting people with chronic disease in work participation? Methods First, evidence was gathered through two systematic reviews, examining factors and interventions influencing work participation. A questionnaire and five focus groups meetings were used to explore perspectives of people with a chronic disease regarding value of work, solutions to participate in work and need of support. Second, for OHPs to use the evidence in practice, a training was developed through input of focus meetings with OHPs and interviews with education experts. The training was evaluated on feasibility using a questionnaire. Results Health-related, environmental and personal factors such as age, social support and motivation were reported to influence participation in work irrespective of diagnosis. Effective interventions that increase work participation irrespective of diagnosis, focused on changes in work tasks, work environment, work organisation and work conditions. People with a chronic disease reported to value work. They had several solutions to retain or return to work, e.g.: energy management, changes in work tasks or environment. They needed support from colleagues, OHPs or patient federations to find or implement these solutions. OHPs reported several training needs to use the evidence in practice, which can be learned through the use of teaching methods as a case study, debate, role play or interview with stakeholders. Evaluation of the feasibility of the training will follow. Discussion Various factors and interventions, the role of people with a chronic disease, and perceived value of work influence work participation irrespective of diagnosis. A training is developed to facilitate OHPs in the use of the evidence to optimise their support to people with a chronic disease.

Steeds meer mensen krijgen tijdens hun werkzame leven te maken met een chronische ziekte. Een belangrijke ontwikkeling in de zorg inclusief de zorg voor werkbehoud en terugkeer naar werk is de centrale rol van de chronisch zieke werkende met regie over zijn/haar gezondheid met hulp van naasten en zorgprofessionals. Zorgprofessionals bieden vooral expertise en ondersteuning. Hierdoor verandert de rol van bedrijfsartsen en verzekeringsartsen. Dit vormt de rode draad in een nieuw onderzoeksprogramma. Een proeftuinproject vormt een integraal onderdeel. Hiermee ligt de focus vanaf het begin op de context van chronisch zieke werkenden en het benutten van ervaringsdeskundigheid uit de praktijk.

IntroductionKnee and hip osteoarthritis (OA) is a leading cause of disability worldwide. Therapeutic exercise is a recommended core treatment for people with knee and hip OA, however, the observed effect sizes for reducing pain and improving physical function are small to moderate. This may be due to insufficient targeting of exercise to subgroups of people who are most likely to respond and/or suboptimal content of exercise programmes. This study aims to identify: (1) subgroups of people with knee and hip OA that do/do not respond to therapeutic exercise and to different types of exercise and (2) mediators of the effect of therapeutic exercise for reducing pain and improving physical function. This will enable optimal targeting and refining the content of future exercise interventions.Methodsand analysisSystematic review and individual participant data meta-analyses. A previous comprehensive systematic review will be updated to identify randomised controlled trials that compare the effects of therapeutic exercise for people with knee and hip OA on pain and physical function to a non-exercise control. Lead authors of eligible trials will be invited to share individual participant data. Trial-level and participant-level characteristics (for baseline variables and outcomes) of included studies will be summarised. Meta-analyses will use a two-stage approach, where effect estimates are obtained for each trial and then synthesised using a random effects model (to account for heterogeneity). All analyses will be on an intention-to-treat principle and all summary meta-analysis estimates will be reported as standardised mean differences with 95% CI.Ethics and disseminationResearch ethical or governance approval is exempt as no new data are being collected and no identifiable participant information will be shared. Findings will be disseminated via national and international conferences, publication in peer-reviewed journals and summaries posted on websites accessed by the public and clinicians.PROSPERO registration numberCRD42017054049.

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

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

Background: Despite well documented health benefits, adults with a chronic condition do not meet the recommended physical activity (PA) guidelines. Therefore, secondary prevention programs focusing on PA are needed. The internet has become a popular medium for the delivery of PA interventions. In particular, web-based programs have shown promise in PA behaviour change. Objective: This systematic review summarizes the evidence about the effectiveness of web-based PA interventions in adults with chronic disease. Methods: A literature search of several electronically databases was performed. Articles that evaluated a web-based PA intervention and used a controlled design were included. Moreover, studies were eligible for inclusion if they used a non- or minimal-treatment control group and if PA outcomes measures were applied. Two reviewers independently assessed methodological quality and extracted data from the included studies. Results were analysed using a best-evidence synthesis based on methodological quality. Results: Seven articles were included. Five out of seven studies were graded as high methodological quality and two were classified as low quality. The majority of the study population had a sedentary lifestyle and all patients were diagnosed with a chronic disease, such as multiple sclerosis, diabetes mellitus 2 or heart failure. Three out of seven interventions were superior to the non or minimal treatment. Although web-based programs showed better results than non-or minimal treatment, results did not attain statistical significance. Conclusions: Although a trend toward positive effects was identified in favor of the intervention groups, our best evidence synthesis revealed that there is conflicting evidence on the effectiveness of web-based PA interventions in patients with a chronic disease. The inconsistent results may have been attributable to a lack of power, since the number of patients was small and the percentage dropout was notably high. (aut. ref.)

Recent heeft het Coronel Instituut de richtlijn ‘Chronisch Ziek en Werk’ ontwikkeld. Aanleiding van deze richtlijn is dat werk(zoek)enden met een chronische ziekte vaak tegen dezelfde moeilijkheden aanlopen en dezelfde oplossingen hebben in het behouden van of terugkeren naar werk. De methode van ontwikkeling volgde de stappen van de evidence-based richtlijnontwikkeling. De richtlijn geeft een overzicht van de belangrijkste factoren die werkparticipatie kunnen belemmeren en bevorderen. Het vroegtijdig inzetten van de interventies kan deze belemmeringen (gedeeltelijk) wegnemen en arbeidsparticipatie bevorderen. Belangrijk uitgangspunt is dat de werk(zoek)ende zelf, indien mogelijk, de touwtjes in handen heeft. Veel aanbevelingen uit de richtlijn richten zich op het bevorderen van zelfregie.

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

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

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

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

Background It is estimated worldwide that approximately 9.6% of men and 18% of women aged over 60 years have osteoarthritis. It is known that exercise therapy for patients with hip and/or knee osteoarthritis is an effective therapy to reduce pain, increase physical activity and improve physical functioning. However, the therapy is costly and adherence to home exercises appeared to be disappointing. In a blended intervention face-to-face exercise therapy can be partly substituted by an online intervention in order to generate a cheaper intervention. The online part of such an intervention has the potential to support home exercises because of its 24/7 accessibility. Research into the development of blended interventions is limited. Objectives The objective of this study is to describe the iterative development process and final version of ‘E-Exercise: a blended exercise intervention for patients with hip and/or knee osteoarthritis’ Methods E-Exercise development followed four steps: 1) conceptualization (critique of literature and theory); 2) formative research (focus groups with physical therapists and interviews with patients); 3) pilot testing (pilot, n=8 patients); and, 4) qualitative evaluation of the intervention with physical therapists (n=7) and patients (n=6). During the developmental process of E-Exercise a project group of relevant stakeholders focused on the development of a business model on implementation of E-Exercise. Results A final version of the E-Exercise intervention has been developed. E-Exercise is a 12-week intervention, consisting of maximum five face-to-face physical therapy contacts (in week 1, 2, 6 and 12) supplemented with a web-based program. The web-based program contains three different sections. In the “activity” section, the patient selects a central activity, for example walking or cycling. Each week, new assignments are generated to gradually increase patients9 load ability for these specific activity. The “exercise” section contains strength and stability exercises and the “information” section includes OA related topics. Key findings identified throughout the development process of the E-Exercise program were: the need for more insight in the web-based part of the intervention (by physical therapists), and the positive evaluation of E-Exercise of both physical therapists and patients. Considering the business model on E-Exercise an overview have been made on the wishes and the contributions of the different stakeholders concerning this intervention. Conclusions The final version of E-Exercise feasible to use in physical therapy practice for patients with osteoarthritis of hip or knee. E-Exercise is being evaluated in a community-based randomised controlled efficacy trial. During this evaluation a final business model will be developed. Acknowledgements This study is financed bij ZonMW, the Dutch Rheumatoid Arthritis Foundation and the Royal Dutch Society for Physical Therapy Disclosure of Interest None declared

BackgroundPatients 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. ObjectiveThe 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. MethodsThe 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. ResultsOf 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. ConclusionsJoin2move resulted in changes in the desired direction for several primary and secondary outcomes. Given the benefits and its self-help format, Join2move could be a component in the effort to enhance PA in sedentary patients with knee and/or hip OA. Trial RegistrationThe Netherlands National Trial Register: NTR2483; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=2483 (Archived by WebCite at http://www.webcitation.org/67NqS6Beq).

Background: A large proportion of patients with osteoarthritis (OA) do not meet the recommended levels of physical activity (PA). Although inactivity may enhance in short-term pain reduction, prolonged inactivity may augment functional decline. Therefore, we developed a web-based intervention that provides a highly individualized behaviourally based physical activity program for patients with hip and/or knee OA. Objective: The aim of this study is to describe the systematic development process, a pilot study and the usability of a 9-week web-based intervention on PA behaviour change in individuals with hip and/or knee OA. Methods: An iterative design approach was used to develop, test and enhance various prototypes. End-users (i.e. patients with knee and/hip OA) were involved continuously throughout the development process. The intervention incorporates core principles of the behaviour graded activity theory. A pilot study prototype was tested through a non-randomized pilot study among 20 patients with hip and/or knee OA. PA levels, pain scores and physical function were measured through online questionnaires (week 0, 6 and 12). Subsequently, two usability methods (heuristic evaluation and a thinking aloud approach) were applied to determine the usability of the intervention. Results: After several iterations of testing and revising, we developed the final version, entitled as Artrose In Beweging (AIB). The program includes an introduction module (module 1) and 8 text based week assignments (module 2). OA patients, between 50 and 80 years of age, participated in the pilot study and received the intervention. After 12 weeks, there was a non-significant increase in PA (1697 to 2044 minutes per week). After six weeks, pain scores increased from 5.3 to 6.6 (p=0.04). After 12 weeks, however, this significant increase disappeared. Considering physical function, a non-significant small increase was observed. Although participants were enthusiastic about the web-based intervention, users perceived difficulties to login and completing the entire introduction module. Furthermore, users rated the rigid character of the intervention, i.e. the inability edit and undo executed actions, as annoying. Based on 16 the interviews after the pilot study, we adjusted the functions into a more flexible format. Conclusion: This paper outlines the preliminary effectiveness, development and usability of a web-based PA intervention. The results suggest that the intervention is feasible in promotion of PA among patients with hip and/or knee OA. The intervention was easy to use and the satisfaction with the program was high. Preliminary results from the pilot study revealed that PA scores increased, although differences were not statistical significant. Pain scores increased significantly after six week and decreased to baseline values after twelve weeks. Findings require validation in other studies. Therefore, the intervention will be further tested in a one year randomized controlled trial. (aut. ref.)

BackgroundExercise 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/DesignThis 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.DiscussionThis 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.Keywords: Osteoarthritis, Physical activity, Blended care e-Health