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To evaluate compliance with the precaution to sleep in a supine position following total hip arthroplasty (THA) and its impact on the other precautions. Single-center, parallel-group, stratified, randomized trial. Patients were allocated to a Restricted Group or an Unrestricted Group. This study focuses on compliance with the precaution to sleep in a supine position, compliance with the remaining set of precautions and the burden of restricted sleeping. Measurements were made using a self-administered diary and questionnaires. Trial registration number: NCT02107248. During the first 2 weeks, 81% of the patients in the restricted group were compliant with sleeping in a supine position. Patients in the Unrestricted Group significantly kept sleeping fewer days per week in a supine position than patients in the Restricted Group (p = 0.000). No significant differences between the two groups were found regarding compliance with the remaining set of precautions. The burden of the sleeping restriction is significantly lowered in the Unrestricted Group (p = 0.000) Compliance with restricting patients to sleep in a supine position is high. Removing this precaution has a significant decrease in burden for patients without affecting compliance with the remaining set of precautions. ClinicalTrials.gov NCT02107248 – Sleeping precautions cause a high rate of burden to patients, whereas movement precautions do not. By removing sleeping precautions, the burden is significantly reduced without affecting the remaining set of precautions. Compliance with movement precautions is high compared to other more functional precautions. [ABSTRACT FROM AUTHOR]

Background: High-level evidence for short–term outcomes of contemporary anterior cruciate ligament (ACL) suture repair (ACLSR) in comparison with those of ACL reconstruction (ACLR) is scarce. High-level evidence for mid- and long–term results is lacking, whereas outcomes of ACLSR in several historical studies were shown to deteriorate at midterm follow–up after initial good short–term outcomes. Hypothesis: Contemporary ACLSR is noninferior to ACLR in the treatment of acute ACL rupture in terms of patient self–reported outcomes at 5 years postoperatively. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: A total of 48 patients were enrolled in the study and, after stratification and randomization, underwent either dynamic augmented (DA) ACLSR or anatomic single–bundle ACLR. The primary outcome measure was the International Knee Documentation Committee 2000 (IKDC) subjective score (IKDCs). Furthermore, the Knee injury and Osteoarthritis Outcome Score (KOOS), Tegner Activity Scale score (TAS), visual analog scale score for satisfaction (VASs), IKDC physical examination score (IKDCpe), limb symmetry index for quadriceps (LSIq) and hamstrings (LSIh) strength and jump test battery (LSIj), Kellgren-Lawrence grade of osteoarthritis (OA), and rate of adverse events were recorded. Analyses were based on an intention–to–treat principle. Results: The lower limit of the 2–sided 95% CI for the median IKDCs of the DA ACLSR group (n = 23; 75.9) was lower than the prespecified noninferiority margin (n = 21; 86.6). Therefore, the null hypothesis was rejected. However, the upper limit of the 2–sided 95% CI of the DA ACLSR group (100.0) was higher than the median IKDCs of the ACLR group (96.6), rendering the result for noninferiority inconclusive. No statistical difference was found between groups for median IKDCs (repair, 90.2; reconstruction, 96.6). Furthermore, no statistically significant differences were found for any of the secondary outcome measures for the DA ACLSR compared with the ACLR group: KOOS Symptoms, 92.9 versus 96.4; KOOS Pain, 100 versus 97.2; KOOS Activities of Daily Living, 100 versus 100; KOOS Sport and Recreation, 85.0 versus 100; TAS score, 7.0 versus 6.5; VASs, 9.2 versus 8.7; IKDCpe, 81.8% versus 100%; LSIq, ≥91.6 versus ≥88.2; LSIh, ≥95.1 versus ≥90.7; LSIj, ≥94.2 versus ≥97.6; OA grade 0, 90.9% versus 77.8%; clinical ACL failure rate, 20.8% versus 27.2%; and repeat surgery rate, 37.5% versus 20.0%, respectively. Conclusion: It remains inconclusive whether the effectiveness of DA ACLSR is noninferior to that of ACLR in terms of subjective patient–reported outcomes as measured using the IKDCs. Although DA ACLSR may be a viable treatment option for patients with acute ACL rupture, caution must be exercised when considering this treatment for young, active patients, corresponding to the present study population. [ABSTRACT FROM AUTHOR]

Background: Needle aspiration of calcific deposits (NACD) is a frequently used treatment for rotator cuff calcific tendinitis (RCCT). However, a substantial number of patients experience recurrent or persisting shoulder symptoms after NACD. Purpose: To compare the effects of adjuvant application of platelet-rich plasma (PRP) after NACD (NACP+PRP) with those of conventional NACD with corticosteroids (NACD+corticosteroids) on pain, shoulder function, and quality of life (QoL). Study Design: Randomized controlled trial; Level of evidence, 1. Methods: In a single-center, double-blinded, randomized controlled trial, 80 adults with symptomatic RCCT were randomly allocated to receive NACD+corticosteroids or NACD+PRP. Pain, shoulder function, and QoL were assessed at baseline; 6 weeks; and 3, 6, 12, and 24 months after treatment using a numeric rating scale for pain (NRS); the Constant-Murley score (CMS); the Disabilities of the Arm, Shoulder and Hand questionnaire (DASH); the Oxford Shoulder Score (OSS); and the EuroQol 5-dimension scale (EQ-5D). Additionally, resorption of calcific deposits and the integrity of rotator cuff tendons were assessed by using standard radiographs and ultrasound examination, respectively. The results were analyzed using noninferiority analysis for NRS scores and a mixed model for repeated measures. Results: Eighty patients were included (48 female; mean age, 49 ± 6 years; 41 patients in the NACD+PRP group). Both groups showed improvement of clinical scores at the 2-year follow-up (P <.001 for all clinical scores). NACD+PRP was found to be noninferior to NACD+corticosteroids with regard to the mean decrease of NRS scores (4.34 vs 3.56; P =.003). Mixed-model analysis showed a significant difference in favor of NACD+PRP (CMS, P <.001; DASH, P =.002; OSS, P =.010; EQ-5D, P <.001). However, clinically relevant differences in favor of NACD+PRP were only seen at the 6-month follow-up for NRS and CMS scores, whereas at the 6-week follow-up a clinically relevant difference in favor of NACD+corticosteroids was found for all clinical scores except for the NRS. Full resorption of calcific deposits was present in 84% of the NACD+PRP group compared with 66% in the NACD+corticosteroids group (P =.081). In the NACD+PRP group, 10 (24%) patients required a second NACD procedure compared with 19 (49%) patients in the NACD+corticosteroids group (P =.036). Six complications, of which 5 were frozen shoulders, occurred in the NACD+PRP group compared with 1 complication in the NACD+corticosteroids group (P =.11). Conclusion: NACD+PRP resulted in worse clinical scores at the 6-week follow-up but better clinical scores at the 6-month follow-up compared with NACD+corticosteroids. At the 1- and 2-year follow-ups, the results were comparable between groups. Furthermore, PRP seemed to reduce the need for additional treatments but was associated with more complications. In conclusion, NACD+corticosteroids had a favorable early effect on pain and function combined with low comorbidity. Thus, it remains the treatment of choice for patients with RCCT. Registration: NCT02173743 (ClinicalTrials.gov identifier). [ABSTRACT FROM AUTHOR]

Background: Anterior cruciate ligament suture repair (ACLSR) was abandoned late last century in favor of anterior cruciate ligament (ACL) reconstruction (ACLR) because of overall disappointing results. However, in recent years there has been renewed and increasing interest in ACLSR for treatment of ACL ruptures. Several contemporary ACLSR techniques are being used, but any difference in effectiveness is unclear. Hypothesis: Contemporary nonaugmented (NA), static augmented (SA), and dynamic augmented (DA) ACLSR leads to (1) comparable outcomes overall and (2) comparable outcomes between proximal third, middle third, and combined ACL rupture locations (a) within and (b) between ACLSR technique categories. Study Design: Systematic review. Methods: An electronic search was performed in the MEDLINE and Embase databases for the period between January 1, 2010, and August 7, 2019. All articles describing clinical and patient-reported outcomes for ACLSR were identified and included, and outcomes for NA, SA, and DA ACLSR categories were compared. Results: A total of 31 articles and 2422 patients were included. The majority of articles (65%) and patients (89%) reported outcomes of DA ACLSR. Overall, there was high heterogeneity in study characteristics and level as well as quality of evidence (19 level 4; 7 level 3; 3 level 2; and 2 level 1). Most studies indicated excellent patient-reported outcomes. Overall, the variability in (and the maximum of) the reported failure rate was high within all ACLSR categories. The variability in (and the maximum of) the reported rate of all other complications was highest for DA ACLSR. Regarding ACL rupture location, the failure rate was highest in proximal ACL ruptures within the SA and DA ACLSR categories; rates of all other reported complications were highest in combined ACL ruptures within the DA ACLSR category. However, no studies in the NA category and only 1 study in the SA ACLSR category evaluated combined ACL ruptures. The majority of studies comparing ACLSR and ACLR found no differences in outcomes. Conclusion: The amount of high-quality evidence for contemporary ACLSR is poor. This makes it difficult to interpret differences among ACLSR categories and among ACL rupture locations and, though promising, to establish the role of ACLSR in the treatment of ACL ruptures. More high-quality large randomized clinical trials with longer follow-up comparing ACLSR and ACLR are needed. [ABSTRACT FROM AUTHOR]

Background: Contemporary anterior cruciate ligament (ACL) suture repair techniques have been subject to renewed interest in recent years. Although several clinical studies have yielded good short-term results, high-quality evidence is lacking in regard to the effectiveness of this treatment compared with ACL reconstruction. Hypothesis: Dynamic augmented ACL suture repair is at least as effective as anatomic single-bundle ACL reconstruction for the treatment of acute ACL rupture in terms of patient self-reported outcomes at 2 years postoperatively. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: After stratification and randomization, 48 patients underwent either dynamic augmented ACL suture repair or ACL reconstruction with a single-bundle, all-inside, semitendinosus technique. The International Knee Documentation Committee (IKDC) subjective score at 2 years postoperatively was the primary outcome measure. Patient-reported outcomes (IKDC subjective score, Knee injury and Osteoarthritis Outcome Score, Tegner score, visual analog scale for satisfaction), clinical outcomes (IKDC physical examination score, leg symmetry index for the quadriceps, hamstrings strength, and jump test battery), and radiological outcomes as well as adverse events including reruptures were recorded. Analyses were based on an intention-to-treat principle. Results: The lower limit for the median IKDC subjective score of the repair group (86.2) fell within the prespecified noninferiority margin, confirming noninferiority of dynamic augmented ACL suture repair compared with ACL reconstruction. No statistical difference was found between groups for median IKDC subjective score (repair, 95.4; reconstruction, 94.3). Overall, 2 reruptures (8.7%) occurred in the dynamic ACL suture repair group and 4 reruptures (19.0%) in the ACL reconstruction group; further, 5 repeat surgeries—other than for revision ACL surgery—took place in 4 patients from the dynamic ACL suture repair group (20.8%) and in 3 patients from the ACL reconstruction group (14.3%). Conclusion: Dynamic augmented ACL suture repair is not inferior to ACL reconstruction in terms of subjective patient-reported outcomes as measured with the IKDC subjective score 2 years postoperatively. However, for reasons other than revision ACL surgery due to rerupture, a higher number of related adverse events leading to repeat surgery were seen in the dynamic augmented ACL suture repair group within 2 years postoperatively. Clinical Relevance: Dynamic augmented ACL suture repair might be a viable treatment option for patients with an acute ACL rupture. Registration: NCT02310854 (ClinicalTrials.gov identifier). [ABSTRACT FROM AUTHOR]

Background: Platelet-rich plasma (PRP) has proven to be a very safe therapeutic option in the treatment of tendon, muscle, bone, and cartilage injuries. Currently, several commercial separation systems are available for the preparation of PRP. The concentrations of blood components in PRP among these separation systems vary substantially. Purpose: To systematically review and evaluate the differences between the concentrations of blood components in PRP produced by various PRP separation systems. Study Design: Systematic review. Methods: MEDLINE/PubMed, the Cochrane Central Register of Controlled Trials (CENTRAL), and EMBASE were searched for studies that compared the concentrations of blood components and growth factors in PRP between various separation systems and studies that reported on the concentrations of blood components and growth factors of single separation systems. The primary outcomes were platelet count, leukocyte count, and concentration of growth factors (eg, platelet-derived growth factor–AB [PDGF-AB], transforming growth factor–β1 [TGF-β1], and vascular endothelial growth factor [VEGF]). Furthermore, the preparation protocols and prices of the systems were compared. Results: There were 1079 studies found, of which 19 studies were selected for inclusion in this review. The concentrations of platelets and leukocytes in PRP differed largely between, and to a lesser extent within, the studied PRP separation systems. Additionally, large differences both between and within the studied PRP separation systems were found for all the growth factors. Furthermore, preparation protocols and prices varied widely between systems. Conclusion: There is a large heterogeneity between PRP separation systems regarding concentrations of platelets, leukocytes, and growth factors in PRP. The choice for the most appropriate type of PRP should be based on the specific clinical field of application. As the ideal concentrations of blood components and growth factors for the specific fields of application are yet to be determined for most of the fields, future research should focus on which type of PRP is most suitable for the specific field. [ABSTRACT FROM AUTHOR]

A 49-year-old man with a 15-year-old nonunion of a midshaft clavicle fracture suffered from progressive tingling in his entire arm and fingers for two years, due to irritation of the brachial plexus in the costoclavicular space, especially upon elevation of the arm. After open reduction and internal plate fixation, all symptoms were resolved and complete consolidation of the fracture was achieved at one-year follow-up. This case demonstrates two things: brachial plexus compression can occur even many years after a nonunion of a clavicle fracture and union can be still achieved, even in a longstanding nonunion. [ABSTRACT FROM AUTHOR]

This case report describes a successful two-stage treatment in a 75-year-old male with a displaced neck of femur fracture, also suffering from an active chronic osteomyelitis of the ipsilateral calcaneus. In our case, a below-knee amputation was performed first, followed by total hip arthroplasty two weeks later. At 15-month follow-up, full recovery of the prefracture level of activities of daily living without significant impairment was obtained. Only a few cases of total hip arthroplasty in amputees have been published, but the indication for surgery was mainly traumatic or advanced osteoarthritis. Treating patients with this type of comorbidities is challenging; therapeutic dilemmas can be major. The management in cases like these requires a thorough evaluation and a clear surgical and medical treatment plan, preferably conducted by a multidisciplinary orthogeriatric team. [ABSTRACT FROM AUTHOR]

Management of patients with amyotrophic lateral sclerosis (ALS) mainly consists of (psycho) social support and advice on activities of daily living. We evaluated the effects of tele-treatment in addition to the conventional method of care in four patients with ALS. A Web application was built with information about ALS and a link to the tele-treatment environment. The latter contained a chat room and a link to start personal computer (PC)-based videoconferencing with a rehabilitation physician. The effect on quality of care was evaluated by questionnaires and interviews. The interviews showed that patients were satisfied with tele-treatment and experienced a pleasant contact during teleconsultations. The rehabilitation physician experienced acceptance of tele-treatment by the patients and a decrease in the time needed for travelling. Tele-treatment was especially suitable for discussing the practical issues about ALS. On the other hand, psychosocial and emotional issues still needed to be discussed during traditional face-to-face contact. Therefore tele-treatment should only be given in addition to face-to-face contact, rather than as a replacement for it. [ABSTRACT FROM AUTHOR]

This report describes the Awareness project which attempts to make a step forward new kind of e‐health services by realizing remote monitoring of health functions and by demonstrating the feasibility of free health treatment concepts; meaning monitoring and treatment independent of time and place utilizing a mobile service infrastructure. [ABSTRACT FROM AUTHOR]

This report describes the possibilities of information and communication technology in healthcare. Attention is paid of how ICT can support the communication between health care professionals mutually as well as the communication between professionals and patients. Besides this some barriers that hampers implementation in everyday healthcare practice are described. [ABSTRACT FROM AUTHOR]

Introduction: Although NACD has proven to be an effective minimal invasive treatment for calcific tendinitis of the rotator cuff, little is known about the factors associated with treatment failure or the need for multiple procedures.Methods: Patients with symptomatic calcific tendinitis who were treated by NACD were evaluated in a retrospective cohort study. Demographic details, medical history, sonographic and radiographic findings were collected from patient files. Failure of NACD was defined as the persistence of symptoms after a follow-up of at least six months. NACD procedures performed within six months after a previous NACD procedure were considered repeated procedures. Multivariate logistic regression analysis was used to determine factors associated with treatment failure and multiple procedures.Results: 431 patients (277 female; mean age 51.4±9.9 years) were included. Smoking (adjusted odds ratio (AOR): 1.7, 95% CI 1.0-2.7, p=0.04) was significantly associated with failure of NACD. Patients with Gärtner and Heyer (GH) type I calcific deposits were more likely to need multiple NACD procedures (AOR: 3.4, 95% CI 1.6-7.5, p<0.01) compared to patients with type III calcific deposits. Partial thickness rotator cuff tears were of no influence on the outcome of NACD or the number of treatments necessary.Conclusion: Smoking almost doubled the chance of failure of NACD and the presence of GH type I calcific deposits significantly increased the chance of multiple procedures. Partial thickness rotator cuff tears did not seem to affect the outcome of NACD. Based on the findings in this study, the importance of quitting smoking should be emphasized prior to NACD and partial thickness rotator cuff tears should not be a reason to withhold patients NACD. [ABSTRACT FROM AUTHOR]

Background: Total hip arthroplasty (THA) is a very common procedure in orthopedic surgery. In the Netherlands, 25,642 primary THAs were performed in 2013. Postoperative hip dislocation is one of the major complications and has been reported in 0.5 to 10.6 % of patients after primary THA. Several reports regarding the use of an anterolateral surgical approach have shown that a non-restriction or reduced restriction protocol does not increase the dislocation rate. For the posterolateral surgical approach it has been suggested that patient restrictions might be unnecessary but the amount of available literature is scarce. As such, randomized controlled trials aimed at investigating restrictions following THA using a posterior approach are strongly recommended. The aim of this prospective randomized controlled trial is to investigate the non-inferiority hypothesis concerning the early dislocation rate after THA in patients with and without the use of a reduced restriction protocol.Methods/design: After providing informed consent a group of 456 patients with symptomatic coxarthrosis will be randomized to receive a THA either with care as usual, i.e. receiving postoperative restrictions including the advice to sleep in a supine position for the first 8 weeks postoperatively, or reduced restrictions with no recommendations regarding the position during sleeping. Primary outcome measure will be the percentage of early dislocations within the first 8 weeks after THA. Secondary outcome measures will be patient satisfaction, time to functional recovery, quality of sleep and patient's self-reported compliance with postoperative instructions.Discussion: To our knowledge this will be the first randomized controlled trial that compares a reduced restriction protocol with a restricted protocol following THA using a posterolateral surgical approach. Our hypothesis is that a reduced restriction protocol following THA with use of a posterolateral surgical approach has no influence on the early dislocation rate compared to a restricted protocol. Instead, embracing a reduced restriction protocol might even contribute to a higher quality of sleep, thereby facilitating a faster uptake and return to daily functions in patients after THA.Trial Registration: ClinicalTrials.gov NCT02107248 , registration date 3 April 2014. [ABSTRACT FROM AUTHOR]

Background: Although needle aspiration of calcific deposits (NACD) has proven to be an effective treatment for calcific tendinitis of the rotator cuff (CTRC) in patients who are resistant to conservative treatment, little is known about the effectiveness of NACD in terms of complete relief of symptoms and the effectiveness of repeated NACD procedures. Furthermore, analyses of complications of the procedure in large series are scarce.Methods: 431 consecutive patients with symptomatic CTRC treated by NACD were included in this retrospective cohort study. Short-term effects were assessed at two weeks post-treatment by using an 11-point numeric rating scale (NRS). The six months outcome was determined on a dichotomous symptom scale (symptom free or persistence of symptoms). NACD procedures performed within six months of a previous NACD procedure were considered repeated procedures. All complications that occurred within six months of the NACD procedure were registered.Results: At two weeks post-treatment, a significant improvement of pain scores was noted (mean reduction of NRS: 4.4 points; p<0.001). 74% of patients had complete relief of symptoms at six months post-treatment. 143 (33.2%) patients required multiple treatments. These repeated procedures were equally effective as the primary procedure. Complications of the NACD procedure were seen in 31 (7.2%) patients: 21 patients (4.9%) developed a subacromial bursitis, seven patients (1.6%) a frozen shoulder and three patients (0.7%) developed a septic bursitis.Conclusion: Needle aspiration of calcific deposits (NACD) is an effective treatment for calcific tendinitis of the rotator cuff in the majority of patients. Approximately one third of the patients will require multiple treatments, which were equally effective as the primary procedure. Based on this, patients should not be withheld a second or even a third treatment in case of persistent symptoms. Furthermore, NACD has a low complication rate, the risk of infection should, however, always be accounted for.Level Of Evidence: Retrospective study, level IV. [ABSTRACT FROM AUTHOR]

User acceptance of myoelectric forearm prostheses is currently low. Awkward control, lack of feedback, and difficult training are cited as primary reasons. Recently, researchers have focused on exploiting the new possibilities offered by advancements in prosthetic technology. Alternatively, researchers could focus on prosthesis acceptance by developing functional requirements based on activities users are likely to perform. In this article, we describe the process of determining such requirements and then the application of these requirements to evaluating the state of the art in myoelectric forearm prosthesis research. As part of a needs assessment, a workshop was organized involving clinicians (representing end users), academics, and engineers. The resulting needs included an increased number of functions, lower reaction and execution times, and intuitiveness of both control and feedback systems. Reviewing the state of the art of research in the main prosthetic subsystems (electromyographic [EMG] sensing, control, and feedback) showed that modern research prototypes only partly fulfill the requirements. We found that focus should be on validating EMG-sensing results with patients, improving simultaneous control of wrist movements and grasps, deriving optimal parameters for force and position feedback, and taking into account the psychophysical aspects of feedback, such as intensity perception and spatial acuity. [ABSTRACT FROM AUTHOR]

Introduction: Over recent years, the popularity of videogames has gone beyond youth and gamers and is slowly entering the field of professional healthcare. Exergames are an attractive alternative to physical therapy. The primary aim of this pilot study was to explore the user experience (usability, satisfaction, level of motivation, and game experience) of the patient with the "PlayMancer" exergame. The secondary aim was to explore the progression of the performed motor skills (walking velocity, overhead reach ability, and cervical range of motion) and the clinical changes (to physical condition, disability, and pain intensity) in a group of patients with chronic musculoskeletal pain using an exergame for 4 weeks., Materials and Methods: In the European PlayMancer project, an exergame for physical rehabilitation of chronic pain patients was developed. This exergame is controlled by relevant motions of the patient's body captured by a motion suit and several infrared cameras. In three different integrated minigames, the patient can train the following motor skills: Walking velocity, overhead reaching, and neck mobility., Results: Ten patients participated in this study and completed the 4 weeks of gaming. Patients rated the usability of the exergames as good (score of 78.5 [standard deviation 9.7; range, 60.0-97.5]) on the System Usability Scale, and the game motivated all patients to perform their exercises. Patients enjoyed playing and were pleased with both the game environment and the game play. Overall, the patients made a progression in the examined motor skills during the minigames over the 4 weeks of gaming., Conclusions: The "PlayMancer" exergame is a potential tool for achieving physical rehabilitation because it motivates patients to perform their exercises and as a result increases their motor skills and physical condition.

We investigated the potential prognostic factors for clinically relevant improvements in pain intensity and pain-related disability after myofeedback-based teletreatment. Sixty-five female computer users, 56 female patients with whiplash-associated disorders and 18 female patients with non-specific neck and shoulder pain participated in the study. They received myofeedback-based teletreatment or usual treatment. Questionnaires concerning prognostic factors, pain and disability were completed before the start of the intervention (baseline) and at follow-ups at the end of the intervention, and after 3 and 6 months. Logistic regression analyses were performed in order to investigate prognostic factors for clinically relevant improvement. In the intervention group, improvement in pain intensity was predicted by baseline pain intensity. Baseline pain intensity and disability, and fear-avoidance and endurance related pain coping responses were prognostic factors for outcome in pain-related disability in this group. There were few differences between the intervention groups; fear-avoidance coping responses influenced the outcome after teletreatment only. Myofeedback-based teletreatment appears to be an useful telemedicine intervention, especially for participants with moderate to high levels of pain and disability, high perceived help/hopelessness, and those who tend to deal with their pain by avoiding social and physical activities.

We investigated the effectiveness and efficiency of a four-week myofeedback-based teletreatment service in subjects with non-specific neck and shoulder pain. Subjects were recruited in Belgium, Germany and the Netherlands and randomly allocated to the intervention or conventional care. Subjects in the intervention group received four weeks of myofeedback training. Pain intensity and disability were evaluated by questionnaires at baseline, immediately after four weeks of treatment and at follow-up 3 months later. To investigate efficiency, the time-investment of both therapists and patients were assessed. Seventy-one subjects were included in the study (36 in the intervention group and 35 in the conventional care group). Myofeedback-based teletreatment was at least as effective clinically as conventional care. Pain intensity and disability decreased after 4 weeks of treatment in both groups and part of the effect remained at 3 months' follow-up. The teletreatment also increased efficiency for therapists by almost 20% and patients experienced the benefits of less travel time and travel costs by remote consultation. Myofeedback-based teletreatment has the potential to ensure more efficient treatment for patients with non-specific neck and shoulder pain.

Lack of user acceptance of telemedicine services is an important barrier to deployment and stresses the need for involving users, i.e. medical professionals. However, the involvement of users in the service development process of telemedicine services is difficult because of (a) the knowledge gap between the expertise of medical and technical experts; (b) the language gap, i.e. the use of different terminologies between the medical and the technical professions; and (c) the methodological gap in applying requirement methods to multidisciplinary scientific matters. We have developed a guideline in which the medical and technical domains meet. The guideline can be used to develop a scenario from which requirements can be elicited. In a retrospective analysis of a myofeedback-based teletreatment service, the technically-oriented People-Activities-Context-Technology (PACT) framework and medically-oriented principles of evidence-based medicine were incorporated into a guideline. The guideline was developed to construct the content of a scenario which describes the new teletreatment service. This allows the different stakeholders to come together and develop the service. Our approach provides an arena for different stakeholders to take part in the early stages of the design process. This should increase the chance of user acceptance and thus adoption of the service being developed.

We evaluated the clinical effects of a myofeedback-based teletreatment service in terms of pain, pain-related disability and work ability. We also investigated the time investment/savings of this treatment with respect to conventional care. Sixty-five women with neck and shoulder pain at work participated in the study. Thirty-three took part in the teletreatment and 32 participated in a control group which continued with conventional care. Questionnaires were completed before the start of the intervention (baseline) and at initial follow-up (T0) and 3 months (T3) after the intervention ended. A general linear model analysis for repeated measurements showed an improvement in terms of pain and work ability for both groups taken together, with no differences between them. Non-parametric tests showed an intervention effect in pain-related disability for both groups together and no differences between them when tested at baseline, T0 and T3. The time saved in relation to conventional care was mainly from reduced travel time, which was 41 min per teleconsultation. The teletreatment service allowed employees to take part in muscle relaxation training while performing their regular work. The clinical evaluation showed that the treatment was on par with conventional care, but without the effort and time loss associated with regular visits to the clinic. We conclude that the myofeedback-based teletreatment service has potential for addressing neck and shoulder symptoms at the workplace.

We designed a business model for deploying a myofeedback-based teletreatment service. An iterative and combined qualitative and quantitative action design approach was used for developing the business model and the related value network. Insights from surveys, desk research, expert interviews, workshops and quantitative modelling were combined to produce the first business model and then to refine it in three design cycles. The business model engineering strategy provided important insights which led to an improved, more viable and feasible business model and related value network design. Based on this experience, we conclude that the process of early stage business model engineering reduces risk and produces substantial savings in costs and resources related to service deployment.

We investigated the ease of use and usefulness as a measure of patient satisfaction, compliance, clinical benefit and its mutual relationships concerning a teletreatment application for chronic pain. Fifty-two subjects with neck and shoulder pain received and completed a four-week myofeedback-based teletreatment intervention. Prior to the onset of the intervention (at baseline) and immediately after the intervention they were asked to fill in questionnaires to measure discrepancies (gap scores) between expectations and experiences with the ease of use and usefulness of the treatment, as well as pain intensity and pain disability. In addition, the actual use of the system (i.e. the volume of muscle activity data available on the server) was logged. The subjects reported a significantly higher score on ease of use after the intervention compared to baseline, suggesting that the equipment was easier to use than they expected. Compliance was associated with clinical benefit. There was no significant relation between patient satisfaction and compliance. Patient satisfaction is a key indicator of how well the telemedicine treatment met expectations and compliance is important because of its association with clinical outcomes.