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In order to prevent physical decline it is necessary that patients remain physically active as much as possible during hospitalization. In this thesis, two intervention projects aiming to increase physical activity in hospitalized patients have been investigated. In part 1, an intervention for family participation in physiotherapy-related tasks in patients admitted to the Intensive Care Unit has been developed. The developed intervention contains three components: 1) brochure including a menu of activities divided into simple activities to calm the patient (e.g. reading a book) and physiotherapy-related tasks such as passive movements, active limb exercises, and functional exercises; 2) poster in patient room demonstrating what family wants/can do; and 3) instruction moment with physiotherapist. Subsequently, its feasibility was investigated in a pilot study. The findings of this study demonstrate that family participation in physiotherapy-related tasks in patients admitted to the Intensive Care Unit is feasible. Part 2 focused on the implementation and evaluation of Hospital in Motion, a multidisciplinary implementation project aiming to improve movement behavior of hospitalized patients. During one year, an action plan, consisting of multidimensional 'exercise interventions', was implemented in four different wards. Results show that the percentage of time spent in bed (during the day) decreased. In addition, experienced factors of influence on the implementation of Hospital in Motion were investigated. Findings demonstrate that interventions must be multidimensional and tailored to the target group in order to bring about effective and sustainable changes. Subsequently, these interventions must be implemented and evaluated step-by-step for each individual intervention.

Medically unexplained physical symptoms (MUPS) are an important health problem in primary care, with a spectrum from mild to chronic. The burden of chronic MUPS is substantial for patients, health care professionals, and society. Therefore, early identification of patients with moderate MUPS is needed in order to prevent chronicity. We developed a screening method (PRESUME) and determined its prognostic accuracy for identification of moderate MUPS. The PRESUME screening method consists of three subsequent steps based on consultation frequency, exclusion of medical/psychiatric diagnosis and identification of MUPS. Overall, the PRESUME screening method demonstrated moderate prognostic accuracy for sustained MUPS related symptoms after 1 year and low to moderate accuracy after 5 years. On average 55.5% of the moderate MUPS patients, still had MUPS related symptoms or developed chronic MUPS in 5 year follow-up. The PRESUME screening method can support timely pattern recognition by the GP. In the next step, we developed a proactive blended and integrated mental health and physical therapy intervention (PARASOL) based on a literature search and focus groups with experts (general practitioners, physical therapists, psychologists, and mental health nurses). The PARASOL intervention is a 12-week blended primary care intervention consisting of 4 face-to-face consultations with the mental health nurse and 5 physical therapy sessions, supplemented with a web-based program consisting of graded activity, exercises and information modules. We investigated the effectiveness of the PARASOL intervention on subjective symptom impact, as registered with the adequate relief question, and quality of life in patients with moderate MUPS compared with usual care in a cluster randomized clinical trial. All measurements were performed at baseline, 3, and 12 months after baseline. In total 160 participants were included. Compared to usual care (n=80), patients in the PARASOL intervention (n=80) had more adequate short-term relief (31.2% in intervention group vs. 13.7% in control group). On quality of life and secondary outcomes no significant between group differences on short- and long-term were found. Within the intervention group, almost half of the outcome measures had significantly improved on short- and long-term, compared to none in the usual care group. Not achieving the preset sample size might be an important reason why we were not able to demonstrate the effectiveness of the PARASOL intervention. Through semi-structured interviews more in-depth insights were gained into patients’ perspectives on usability of the PARASOL intervention. Patients appreciated the personal and holistic approach, recognizable information, the intervention as an incentive, and the inter-professional collaboration. Usability could be improved on the accessibility and tech support of the web-based program, the possibility to ask questions online, and tailoring the intervention to individual’ needs. Overall, patients were generally positive about the PARASOL intervention.

Physical inactivity increases the risk for chronic diseases and mortality, and is a problem faced by countries worldwide. Strategies to promote physical activity among inactive target groups are therefore necessary. In this regard, a settings-based approach towards physical activity promotion has been encouraged. The organized sports setting, in particular sports clubs, is seen as a promising setting to increase physical activity among inactive groups within a population. The main focus of this thesis was to understand if and how the organized sports setting can successfully contribute to increasing physical activity levels among inactive people. Fourteen Dutch sporting programs aimed at increasing sport participation in inactive population groups, were studied during the three-year funded implementation period and six and half years thereafter. These programs were developed by ten National Sports Federations (NSFs) as part of the National Action Plan for Sport and Exercise (NAPSE) and implemented by sports clubs in the Netherlands (period 2008-2011). The research in this thesis focused on the effectiveness of two programs within the NAPSE and characteristics of insufficiently active participants who benefited the most from these programs in terms of increasing health-enhancing physical activity. Furthermore, factors influencing the implementation and long-term sustainability of all NAPSE programs were examined. The results showed that sporting programs that are few weeks in duration may be used to increase physical activity levels of inactive people in the sports clubs setting. Moreover, programs were more effective in increasing physical activity when participants received familial support with regard to their sport participation. Therefore, strategies that promote familial support, such as including family members as sporting buddies or involving them in other club activities (e.g. social activities, volunteering), could enhance the effectiveness of the programs. In general, it was difficult to attract large numbers of inactive people to the sporting programs. Therefore, NSFs and sports clubs should collaborate more with organizations or people in the community that are connected to the inactive target group, to recruit more inactive people. Furthermore, the implementation and long-term sustainability of these programs is influenced by many factors. For successful implementation and long-term sustainability of programs, it is, for example, important to involve the inactive target group and sports clubs in program design. Also, NSFs should support sports clubs in implementing these programs. Based on the research results, recommendations are provided for policy makers, NSFs and sports clubs to enhance the impact of sporting programs aimed at inactive people in the future.

Globally, stroke affects 16 million individuals every year. Patients who survive a stroke are at high risk for recurrent stroke and other cardiovascular events. In the next decades, the prevalence of stroke is expected to increase worldwide, highlighting the need for effective disease management and secondary prevention strategies. A lack of moderate to vigorous physical activity (MVPA) and high amounts of sedentary behavior (SB) are independent risk factors for all-cause mortality, cardiovascular diseases and functional decline. Although the independent health risks of these single behaviors are highlighted in research, these behaviors are not self-contained but cluster in patterns (e.g., high MVPA/high LPA/low SB or low MVPA/low LPA/high SB). There is a growing interest in the optimal distribution of daily activities, more specifically, the interplay between SB and PA levels in people with stroke. Movement behavior patterns reflect the total habitual behavior during waking hours. The results are based on the RISE (Reducing sedentary behavior, Identification of people at risk, in people with Stroke, Effectiveness in daily living) cohort study with 200 participants involved. The period shortly after stroke seems to be crucial to change movement behavior. Most recovery of function occurs within the first week after stroke, when most people still receive professional care and motivational preparedness to achieve the desired behavior change is potentially high. However, in this thesis no changes in movement behavior were objectified. Overall, it seems that people with stroke are highly sedentary compared to healthy peers. Three movement behavior patterns were identified: Sedentary exercisers (22.6%) were sedentary; however, sedentary time was often interrupted, and overall, these participants were sufficiently active. Sedentary movers’ (45.6%) sedentary behavior was comparable to sedentary exercisers’ sedentary behavior. However, this group was inactive. The time sedentary exercisers spent in MVPA, sedentary movers spent in light physical activity. Sedentary prolongers (31.6%) were highly sedentary, accumulated their sedentary time in long prolonged bouts and were physically inactive. Low-levels of self-efficacy seems to be an important associating factor with sedentary prolongers. Physical functioning at baseline and in the course of the first year after stroke differ between movement behavior patterns. Physical functioning remained relatively stable during the first year after stroke in sedentary exercisers. Physical functioning improved during the first six months after discharge in sedentary movers and sedentary prolongers and deteriorated in the following six months. Sedentary prolongers deteriorated significant more compared to sedentary movers. It seems that physical functioning outcomes at baseline are decisive for the course of physical functioning within the first year. In summary, three distinctive movement behavior patterns are identified in people with stroke returning to their home-setting. These patterns seem to require a tailored approach, in which different target behavior and content of intervention seem to be needed. An unfavorable movement behavior pattern, with less physical activity and high sedentary behavior, is associated with a functional decline in the long-term. Secondary prevention using a behavioral approach to change movement behavior seems to be indicated in people with stroke who have an unfavorable movement behavior pattern.

e-Exercise zorgt voor vergelijkbare vooruitgang bij artrose met minder bezoeken aan de fysiotherapeut Patiënten met artrose aan de heup, knie of beiden die e-Exercise volgen gaan ongeveer evenveel vooruit als patiënten die reguliere fysiotherapie volgen, terwijl ze veel minder vaak bij de fysiotherapeut komen. Dit blijkt uit onderzoek van Nivel en Hogeschool Utrecht-onderzoeker Corelien Kloek, die hierop 4 april promoveert aan Tilburg University. Binnen e-Exercise worden reguliere fysiotherapiebehandelingen gecombineerd met een web-applicatie waarmee de patiënt thuis toegang heeft tot beweegopdrachten, oefeningen en informatie. Herinneringsmailtjes, video’s, monitoring door de fysiotherapeut en gepersonaliseerde feedback stimuleren de patiënt om met de opdrachten aan de slag te gaan. Lagere kosten Uit het onderzoek van Kloek blijkt dat patiënten met e-Exercise in vergelijkbare mate vooruitgaan in fysiek functioneren, pijn, vermoeidheid, zelf-effectiviteit en kwaliteit van leven, als mensen die reguliere fysiotherapiesessies volgen. De kosten van de interventie e-Exercise vielen significant lager uit dan die van reguliere fysiotherapie. Dit komt doordat het behandelgemiddelde bij e-Exercise op 5 sessies lag en bij reguliere fysiotherapie op 12. e-Exercise bleek voor de maatschappij echter niet significant kosteneffectiever dan reguliere fysiotherapie. Stimulans om aan de slag te gaan Patiënten die meededen aan het onderzoek hebben gemiddeld 10 van de 12 online modules gevolgd en gaven aan dat e-Exercise stimuleerde om thuis actief met de informatie en opdrachten aan de slag te gaan. Het gebruik van e-Exercise door fysiotherapeuten na afloop van het onderzoek viel tegen en behoeft nog aandacht. Zo gaven fysiotherapeuten aan behoefte te hebben aan een platform dat inzetbaar is voor meerdere doelgroepen, maar ook aan businessmodellen die aansluiten bij deze nieuwe manier van werken. Beschikbaar vanaf april 2018 Sinds het begin van het project is er in een werkgroep nagedacht over de implementatie van e-Exercise. Als resultaat hiervan worden er momenteel gesprekken gevoerd met zorgverzekeraars, wordt e-Exercise vanuit de Hogeschool Utrecht, het UMC Utrecht en Fontys Paramedische Hogeschool uitgebreid naar andere doelgroepen en wordt er scholing gegeven over e-Exercise. Vanaf april 2018 komt e-Exercise beschikbaar in de HWO-Afsprakenapp, een bestaande applicatie waarmee fysiotherapeuten hun patiënt kunnen herinneren aan opdrachten, oefeningen en afspraken. Artrose toenemend probleem Artrose is een chronische aandoening die zich kenmerkt door pijn en stijfheid in de gewrichten. Fysiotherapie, bestaande uit voorlichting, oefeningen en beweegopdrachten, is effectief in het verbeteren van het dagelijks functioneren en het verminderen van pijn bij mensen met artrose aan de heup en/of knie. Gezien het toenemende aantal mensen met artrose, is er behoefte aan interventies die die enerzijds stimuleren dat mensen in hun eigen omgeving actief met hun aandoening aan de slag gaan, en anderzijds ook nog eens goedkoper zijn. Onderzoek Binnen het e-Exercise project is door onderzoekers van het onderzoeksinstituut Nivel en Tilburg University (Tranzo) onderzocht of de integratie van een web-applicatie binnen reguliere fysiotherapie, ook wel blended care, een potentiële oplossing is. Tijdens het e-Exercise project is in samenwerking met patiënten, fysiotherapeuten en experts de interventie e-Exercise ontwikkeld. Na een pilot-fase is e-Exercise in 143 praktijken onderzocht op (kosten-)effectiviteit in vergelijking met reguliere face-to-face therapie. De 208 patiënten die mee hebben gedaan zijn door de onderzoekers 12 maanden gevolgd. Dit onderzoek is gefinancierd vanuit ZonMw Onderzoeksprogramma Sport, het Reumafonds en het Koninklijk Genootschap voor Fysiotherapie. Hoe werkt e-Exercise? https://www.youtube.com/watch?v=4l9GoQWWy58

Van de hele bevolking maakt 60 tot 90 procent ooit een episode van lagerugklachten door (KNGF, 2005). Het is dan ook niet verwonderlijk dat lagerugklachten de meest voorkomende klachten zijn waarmee patienten zich aanmelden in de kinesitherapeutische/fysiotherapeutische praktijk (Landelijk Informatiesysteem Paramedische Zorg (LiPZ), 2012). Aspecifieke lagerugklachten is een veel voorkomende verwijsdiagnose (31,8% van de verwijzingen naar de kinesitherapeut/fysiotherapeut) (KNGF, 2005). Men spreekt van aspecifieke lagerugklachten als er geen aantoonbare structurele oorzaak is voor de klachten. Ongeveer 35 procent van de patienten die zich met lagerugklachten bij de huisarts melden, heeft na twaalf weken nog steeds klachten en tot drie kwart van de lagerugklachten kan binnen een jaar recidiveren (KNGF, 2005).

Jaarboek Fysiotherapie Kinesitherapie 2014

Jaarboek Fysiotherapie/Kinesitherapie 2012 (Yearbook Physiotherapy) P. Calders, JJXR Geraerts, J Nijs, C. Veenhof, EEH van Wegen, CP van Wilgen (eds) Houten, The Netherlands: Bohn Stafleu van Loghum 2012 (350p).