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Background Free movement of the limbs is a prerequisite of mobility and autonomy in old age. Joint contractures, i.e. restrictions in full range of motion of any joint due to deformity, disuse or pain, are common problems of frail older people, particularly in nursing home residents.
Contractures are among the most unexplored and underreported syndromes in clinical and homecare settings. Epidemiological studies indicate a wide range of prevalence of joint contractures in older individuals between 20% and 80%. This variation is due to different definitions of contracture and varying diagnostic criteria or data collection methods, different research settings, sample size and study participants? characteristics.
The aetiology of joint contractures is multifaceted. In older people contractures may be caused by a variety of health conditions and situations, but immobility due to an acute injury or disease seems to be the major risk factor. Upper limb joint contractures may result in loss of ability to dress or eat independently while lower limb contractures may lead to instability and inability to walk independently and higher risk of bed confinement.
Joint contractures further increase the risk of other adverse patient outcomes like pain, pressure ulcers and risk of falls. Thus, joint contractures are a major cause for excess disability in older people with a significant impact on overall quality of life and functioning. Preventive and rehabilitation interventions targeting joint contractures may decrease morbidity, increase functioning and quality of life, and, ultimately, prevent long-term disability. In the United States of America, presence of joint contractures is an established indicator of quality of care in nursing facilities.
In Germany, joint contracture risk assessment and prevention have recently been defined as a quality indicator of nursing home care that should be regularly monitored by experts from the statutory health insurance system. Nursing homes are obliged to report whether they regularly assess the risk of joint contracture and administer relevant preventive measures. In clinical settings, joint contractures are assessed by measuring the range of motion.
However, from a patient- and nursing-oriented perspective the relevance of a systematic registration of contractures in care-dependent older people is unclear unless their impact on functioning is understood. Contracture assessment is only an intermediate step in the evaluation of patient-relevant outcomes such as quality of life, functioning, and the ability to participate in everyday life and social participation. Arguably, a clinical definition of joint contracture is difficult because the contracture?s severity is determined by the consequences on activities of daily living, quality of life and social participation. In addition, there is no consensus on aspects most relevant to the affected individuals.
A variety of functional measures is currently used for the assessment and evaluation of geriatric patients. To date, there is no consensus on common concepts for the choice of outcome measures specifically for evaluating the impact of interventions targeted on joint
Background Vertigo and dizziness are among the most common health problems in medical practice [1, 2, 3, 4, 5]. Vertigo and dizziness include both consequences of disease as well as definable disease entities such as benign paroxysmal positional vertigo, Meniere?s disease, or vestibular migraine.
Irrespective of the various causes and underlying health conditions, vertigo and dizziness have significant impact on functioning and overall quality of life of the affected individuals To give some examples, the most common peripheral-vestibular disorder benign paroxysmal positioning vertigo - which is also the most frequent type of vestibular disorder - causes brief rotatory vertigo attacks, mainly triggered by rapid head movements, e.g. when turning around in the bed or lacing shoes.
Central-peripheral disorders, which may be caused by brain ischemia, multiple sclerosis, or other permanent or transient brain lesions, can make vertigo attacks lasting from minutes to even weeks [6]. In addition, vertigo and dizziness are a considerable burden to economy and health care [4, 7, 8]. Precondition of effective management and treatment of potentially disabling conditions like vertigo is - besides careful diagnosis of the underlying condition -the assessment of outcomes which are relevant to the patient.
This is not only important to monitor treatment effects but also to set goals and to plan therapy [6]. As summarized by Morris et al. [9] outcome measures in vertigo vary by the entities they are addressing, such as subjective experience of disability or signs and symptoms. Most of them reflect either the patients? or health professionals? experience.
As an example, the frequently used Dizziness Handicap Inventory [10] addresses the patients? experience of the consequences of vertigo on daily living. Most outcome measures are developed and validated on the basis of empirical findings or professional experience [11].
However, none of them refer to a common theoretical framework. A theoretical framework is fundamental for defining an Outcome measurement and helps to ensure that the whole potential spectrum of issues is reflected [12]. In addition to the lack of theoretical foundation there is still no agreement on standards used to measure outcomes in patients with vertigo.
This is illustrated by a recently published Cochrane Review in the field of vestibular rehabilitation which noted 15 different outcome measures of patients? complaints in 21 studies [13]. To address both these issues, the Integrated Center for Research and Treatment of Vertigo, Balance and Ocular Motor Disorders ( IFB LMU ) at the Ludwig-Maximilians-Universität in Munich set up a project that aims to develop an international standard for the description of functioning and disability in patients with vertigo and dizziness based on the International Classification of Functioning, Disability and Health (ICF).
With the ICF, which is part of the family of international classifications of the World Health Organisation (WHO), there is a common theoretical framework for describing and measuring health and disability.
The ICF models the individuals' functioning and health as a complex interaction between a health condition.
Objective: To identify candidate categories for brief International Classification of Functioning, Disability and Health (ICF) Core Sets for the reporting and measurement of functioning in patients in the acute hospital.
Design: Prospective multi-centre cohort study.
Patients: Patients receiving rehabilitation interventions for musculoskeletal, neurological or cardiopulmonary injury or disease in acute hospitals.
Methods: Functioning and contextual factors were coded using the ICF. The criterion for selecting candidate categories for the brief ICF Core Sets was based on their ability to discriminate between patients with high or low functioning status. Discrimination was assessed using multivariable regression models, the independent variables being all of the ICF categories of the respective comprehensive ICF Core Set. Analogue ratings of overall functioning as reported by patients and health professionals were used as dependent variables.
Results: A total of 391 patients were included in the study (91 neurological, 109 cardiopulmonary, 191 musculoskeletal), mean age 63.4 years, 50.1% female. Selection yielded 33 categories for neurological, 31 for cardiopulmonary, and 30 for musculoskeletal.
Conclusion: The present selection of categories can be considered an initial proposal, serving to identify the ICF categories most relevant for the practical assessment and monitoring of functioning in patients with acute neurological, cardiopulmonary, and musculoskeletal conditions.
Objective: To identify candidate categories for International Classification of Functioning, Disability and Health (ICF) Core Sets for the reporting and measurement of functioning in patients in early post-acute rehabilitation facilities.
Design: Prospective multi-centre cohort study.
Patients: Patients receiving rehabilitation interventions for musculoskeletal, neurological or cardiopulmonary injury or disease in early post-acute rehabilitation facilities.
Methods: Functioning was coded using the ICF. The criterion for selecting candidate categories for the ICF Core Sets was based on their ability to discriminate between patients with high or low functioning status. Discrimination was assessed using multivariable regression models, the independent variables being all of the ICF categories of the respective comprehensive ICF Core Set. Analogue ratings of overall functioning as reported by patients and health professionals were used as dependent variables.
Results: A total of 165 patients were included in the study (67 neurological, 37 cardiopulmonary, 61 musculoskeletal), mean age 67.5 years, 46.1% female. Selection yielded 38 categories for neurological, 32 for cardiopulmonary, and 31 for musculoskeletal.
Conclusion: The present selection of categories can be considered an initial proposal, serving to identify the issues most relevant for the assessment and monitoring of functioning in patients undergoing early post-acute rehabilitation for neurological, cardiopulmonary, and musculoskeletal conditions.
Objective: To identify candidate categories for International Classification of Functioning, Disability and Health (ICF) Core Sets for the reporting and clinical measurement of functioning in older patients in early post-acute rehabilitation facilities.
Design: Prospective multi-centre cohort study. Patients: Older patients receiving rehabilitation interventions in early post-acute rehabilitation facilities.
Methods: Functioning was coded using the ICF. The criterion for selecting candidate categories for the brief ICF Core Sets was based on their ability to discriminate between patients with high or low functioning status. Discrimination was assessed using multivariable regression models, the independent variables being all of the ICF categories of the respective comprehensive ICF Core Set. Analogue ratings of overall functioning as reported by patients and health professionals were used as dependent variables.
Results: A total of 209 patients were included in the study, mean age 80.4 years, 67.0% female. Selection yielded a total of 29 categories for the functioning part and 9 categories for the contextual part of the ICF.
Conclusion: The present selection of categories can be considered an initial proposal, serving to identify the issues most relevant for the clinical assessment and monitoring of functioning in older patients undergoing early post-acute rehabilitation.
Objective: To identify goals of patients with rehabilitation needs in the acute hospital setting using the International Classification of Functioning, Disability and Health (ICF), to examine association of goal achievement with improvement in overall functioning, and to examine whether ICF Core Sets for the acute hospital cover patients goals.
Design: Multi-centre cohort study.
Patients: A total of 397 patients (50% female, mean age 63 years) from 5 hospitals in Austria, Switzerland and Germany. Methods: A semi-structured questionnaire was used to assess patient goals and goal achievement. Overall functioning from the patients' and health professionals' perspective was assessed on a numerical rating scale. Improvement in functioning was calculated using a residualized gain score. Association between goal achievement and improvement in overall functioning was assessed with logistic regression.
Results: A total of 397 patients reported achievement of at least 1 goal. Eighty-eight percent of the goals were translated into categories of the ICF. Logistic regression analyses revealed significant association between goal achievement and overall functioning.
Conclusion: The ICF might be useful to identify and structure patient's goals in acute hospital care. The association between goal achievement and improved functioning underlines that it is essential to involve the patient in the process of planning rehabilitation interventions in acute hospitals.
In this contribution a method for the prediction of the radiated sound out of the velocity field of a vibrating ceiling is presented. The numerical method was validated via measurements on a real structure using a pp-probe. It is based on Integral Transform techniques and can be applied in the postprocessing of a FEM simulation
(harmonic analysis) [1]. The method was verified by measurements on the real structure and can be used for parametrical studies.
Rounding off the Parts 1 and 2 of this publication nomograms, based on dimensionless parameters, can be developed to predict the sound radiation of light weight slabs. Hereby different sets of geometry as well as different configurations of ceilings can be studied in order to describe the acoustical and dynamical behaviour of wooden ceilings.
In order to set up guidelines for the design of light-weighted ceilings for timber constructions to be used by engineers in practice, investigations based on both measurements and numerical models have been carried out [1, 2, 3].
The setup and the calibration of the numerical model of the structure are outlined briefly.
A semi-analytical approach for the prediction of radiated sound is presented, which is based on Integral Transform Methods. The method can be applied in the post processing of a Finite Element computation.
Thus as a first step the structure, consisting of a timber slab, a floating floor and a suspended ceiling, is built up in a Finite Element model, where the material properties of wood and the characteristics of the system are considered.
The model is parameterized in order to enable computations with varying geometry and material parameters and calibrated with the help of measurements using model updating techniques.
The velocity pattern resulting out of the FEM computation is transformed from the spatial into the wavenumber domain and from the time into the frequency domain using Fourier Transform Methods. Applying this velocity pattern as a boundary condition to the Helmholtz Equation, which results out of the Fourier Transform of the wave equation, the wavenumbers, which fulfil the radiation condition, can be selected and the pressure field in the adjacent acoustic fluid can be computed.
Due to the properties of the Fourier-Transform the radiated sound power can be calculated efficiently in the transformed domain out of pressure and velocity.
In a second part of the contribution the model for the air cushion in the suspended ceiling is discussed, where a FSI-model for the acoustic fluid and the structure is compared against engineering approaches using simplifications concerning mass distribution and transfer impedances between the individual nodes at the interface
Numerical models for the prediction of vibroacoustical characteristics of light-weighted ceilings
(2013)
In order to set up guidelines for the design of light-weighted ceilings for timber constructions to be used by engineers in practice, investigations based on both measurements and numerical models have been carried out within the cooperative research project “VibWood”.
In this contribution the setup and the calibration of the numerical model of the structure as well as the prediction of radiated sound are discussed, where a special focus is set on a dimensionless description in order to deduce information for a wide range of system’s specifications.
The structure, consisting of a timber slab, a floating floor and a suspended ceiling, is built up in a Finite Element model, where the material properties of wood and the characteristics of the system (e.g.support conditions, contact phenomena dynamic properties of individual parts) are considered.
The model is parameterized in order to enable computations with varying geometry and material parameters.
After calibrating the FE-model with the help of measurements using model updating techniques dimensionless parameters are defined based on the Buckingham-π- Theorem and computations are carried out in order to specify guidelines for various systems. The radiation of sound is computed in a post processing using Integral Transform Methods.
Die mithilfe der Abklingmethode ermittelten Verlustfaktoren sind bei mehreren Eigenfrequenzen pro Frequenzband zuverlässig. Die Ergebnisse der Resonanzbreitenmethode beziehen sich dagegen auf die Eigenfrequenzen und sind nur bei einer geringen Modenüberlappung zuverlässig. Beide Methoden sind gleichwertig, wenn mehrere Eigenschwingungen im Frequenzband vorhanden sind und die Modenüberlappung gleichzeitig gering ist. Für einseitig überlagerte Resonanzkurven wurde eine einfache Alternative der Resonanzbreitenmethode vorgeschlagen.
Die Ergebnisse wurden im Rahmen des gemeinsam von der TU München, der HS Rosenheim und dem ift Rosenheim durchgef¨uhrten DFG-AiF Forschungsvorhabens ”Vibroakustik im Planungsprozess für Holzbauten” erarbeitet. Das IGF-Vorhaben 17328N/1 der Forschungsvereinigung HS Rosenheim wurde über die AiF im Rahmen des Programms zur Förderung der Industriellen Gemeinschaftsforschung (IGF) vom Bundesministerium für Wirtschaft und Energie aufgrund eines Beschlusses des Deutschen Bundestages gefördert.
Es wurden Stoßstellendämm-Maße Kij für verschiedene Bauteilverbindungen von BSPH-Elementen gemessen. Diese zeigen eine gute Übereinstimmung zu anderen Werten aus der Literatur.
Bei den Stoßstellen wurde der Einfluss von Elastomerlagern untersucht.
Die Ergebnisse zeigen einen deutlichen Einfluss auf die Kij. Eine Berechnung der Kij mithilfe von Kopplungsverlustfaktoren ηij, welche aus einem SEAModell resultieren, zeigen eine ausreichende Übereinstimmung.
Weitere Schritte der Modellierung zur Überprüfung dieser Erkenntnisse und zur Abbildung von Elastomeren sind notwendig. Der Beitrag ist Teil des gemeinsam von der TU München, der HS Rosenheim und dem ift Rosenheim durchgeführten DFG-AiF Forschungsvorhabens Vibroakustik im Planungsprozess für Holzbauten.
Das IGF-Vorhaben 17328 N/1 der Forschungsvereinigung HS Rosenheim wurde über die AiF im Rahmen des Programms zur Förderung der Industriellen Gemeinschaftsforschung (IGF) vom Bundesministerium für Wirtschaft und Energie aufgrund eines Beschlusses des Deutschen Bundestages gefördert.
A trend towards lightweight structures, e.g. timber structures, is noticeable in civil engineering, which implies the necessity to predict vibroacoustic characteristics like the transmission of structure-borne sound in order to fulfil requirements regarding serviceability. This contribution focuses on the investigation of junctions of building components e.g. between wall and ceiling. It is part of a joint research project with the aim to catalogue the coupling for a variety of junctions. The resulting database may serve to predict the transmission of structure-borne sound which is typically carried out either using a Finite Element (FEM) approach, suitable for the low frequency range, or by means of energy methods like the Statistical Energy Analysis (SEA) for the high frequency range. Therefore the so-called mid frequency gap emerges, which is examined and attempted to be closed. In this context SEA-averaging techniques are applied in the postprocessing of FEM calculations to obtain an adapted “SEAlike” approach. By varying the subsystems to be excited it is possible to determine Energy Influence Coefficients (EIC), which describe the specific energy content of the different subsystems with respect to the input power. Using this hybrid approach vibroacoustic predictions can be performed also in the mid frequency range. Inverting the EIC-matrix Coupling Loss Factors as well as Damping Loss Factors of the different subsystems can be calculated if the subsystem definition fulfils the SEA-requirements. The application of the method in combination to a classical SEA calculation and to laboratory measurements is presented.
Background
Multimorbidity in the older population is well acknowledged to negatively affect health-related quality of life (HRQL). Several studies have examined the independent effects of single diseases; however, little research has focused on interaction between diseases. The purpose of this study was to assess the impact of six self-reported major conditions and their combinations on HRQL measured by the EQ-5D.
Methods
The EQ-5D was administered in the population-based KORA-Age study of 4,565 Germans aged 65 years or older. A generalised additive regression model was used to assess the effects of chronic conditions on HRQL and to account for the nonlinear associations with age and body mass index (BMI). Disease interactions were identified by a forward variable selection method.
Results
The conditions with the greatest negative impact on the EQ-5D index were the history of a stroke (regression coefficient -11.3, p < 0.0001) and chronic bronchitis (regression coefficient -8.1, p < 0.0001). Patients with both diabetes and coronary disorders showed more impaired HRQL than could be expected from their separate effects (coefficient of interaction term -8.1, p < 0.0001). A synergistic effect on HRQL was also found for the combination of coronary disorders and stroke. The effect of BMI on the mean EQ-5D index was inverse U-shaped with a maximum at around 24.8 kg/m2.
Conclusions
There are important interactions between coronary problems, diabetes mellitus, and the history of a stroke that negatively affect HRQL in the older German population. Not only high but also low BMI is associated with impairments in health status.
Within the scope of the research project "VibWood", operational vibration analyses of timber floor constructions were carried out. In order to understand the vibration behaviour of and the sound transmission through the layers of the constructions the coupling between them was investigated. The transfer function from the point of excitation to a pattern of receiving positions located on each of the layers of the construction was measured using a swept sine excitation. As a result, the frequency range of decoupling between the base floor and the floating floor and between the base floor and the suspended ceiling could be identified and the individual vibration behavior analyzed. The measurements also included the radiated sound power from the suspended ceiling. There is indication that there is not necessarily a correlation between the eigenmodes of the suspended ceiling and the maxima of the radiated sound power
Im Rahmen des AIF-Forschungsprojektes VibWood werden im Deckenprüfstand der HS Rosenheim unterschiedliche Holzdeckenkonstruktionen hinsichtlich ihres Schwingungsverhaltens im Bereich zwischen 4 Hz und 200 Hz untersucht. Parallel dazu werden diese Holzdeckenkonstruktionen an der TU München mittels FE-Berechnungen modelliert. Für die Untersuchungen steht ein Prüfstand zur Verfügung, welcher die Möglichkeit bietet, Decken oder Deckenelemente mit Abmessungen von max. 5,5 m x 5,5 m auf einer Stahlwinkelkonsole aufzulagern. Die Deckenelemente können so durch Messung der Übertragungsfunktionen hinsichtlich ihrer Schwingungsformen untersucht werden. Ein Ziel der Untersuchungen ist es, die tieffrequenten Schwingungen von Holzdecken mit Hilfe von Schwingungstilgern deutlich zu reduzieren. Es werden erste Ergebnisse der Validierung der FE-Modelle vorgestellt, insbesondere der Einfluss der Auflagerung der Deckenelemente auf die Übertragungsfunktion. Weiterhin werden Messergebnisse für unterschiedliche Anregungsarten diskutiert
Background
A multitude of different rehabilitation interventions and other specific health care services are offered for individuals with disorders of consciousness in long-term care settings. To investigate the association of those services and patient-relevant outcomes, a specific instrument to document the utilization of those services is needed. The purpose of this study was to develop such a questionnaire administered to caregivers in epidemiological studies or patient registries in Germany.
Methods
The development process of the RECAPDOC questionnaire was carried out in three steps. Step 1 consisted of a systematic literature review and an online-based expert survey to define the general content. Step 2 was an expert interview to evaluate the preliminary content of the questionnaire. Step 3 was a pretest including cognitive interviews with caregivers. After each step, the results were combined into a new version of the questionnaire.
Results
The first version of the questionnaire included items on utilization of medical care, medical aids, nursing and therapeutic care. The results of the expert interview led to the integration of five new items and the modification of six other items. The pretest led to some minor modifications of the questionnaire since it was rated as feasible and acceptable. The final questionnaire consisted of 29 items covering the domains “living situation”, “social insurance status”, “utilisation of home health care”, “domestic services”, “outpatient health care”, “specific diagnostic measures”, “adaptive technologies”, “medical aids” and “utilization of therapies”. Also the experience of family support and multidisciplinary collaboration of health professionals is covered.
Conclusions
The developed questionnaire is a first step to make the situation of patients with disorders of consciousness in the long-term care setting accessible for evaluation in epidemiological studies and in the context of patient registries. However, further reliability and validity studies are needed.
Background
As clinical practice guidelines represent the most important evidence-based decision support tool, several strategies have been applied to improve their implementation into the primary health care system. This study aimed to evaluate the effect of intervention methods on the guideline adherence of primary care providers (PCPs).
Methods
The studies selected through a systematic search in Medline and Embase were categorised according to intervention schemes and outcome indicator categories. Harvest plots and forest plots were applied to integrate results.
Results
The 36 studies covered six intervention schemes, with single interventions being the most effective and distribution of materials the least. The harvest plot displayed 27 groups having no effect, 14 a moderate and 21 a strong effect on the outcome indicators in the categories of knowledge transfer, diagnostic behaviour, prescription, counselling and patient-level results. The forest plot revealed a moderate overall effect size of 0.22 [0.15, 0.29] where single interventions were more effective (0.27 [0.17, 0.38]) than multifaceted interventions (0.13 [0.06, 0.19]).
Discussion
Guideline implementation strategies are heterogeneous. Reducing the complexity of strategies and tailoring to the local conditions and PCPs’ needs may improve implementation and clinical practice.
This paper deals with the preparation of the Small GEO mission and the accommodation of a GPS receiver as an experiment. The expected benefits of using the GPS receiver for Small GEO are explained. The feasibility of using GPS for position determination is investigated by simulation using a MosaicGNSS receiver, which was stimulated by a Spirent RF signal generator. A procedure, how to evaluate flight data on ground is outlined. Success criteria of the experiment and the minimal size of the downlink stream required and reserved for the receiver TM are presented.
BACKGROUND: Active performance is crucial for motor learning, and, together with motivation, is believed to be associated with a better rehabilitation outcome. Virtual reality (VR) is an innovative approach to engage and motivate patients during training. There is promising evidence for its efficiency in retraining upper limb function. However, there is insufficient proof for its effectiveness in gait training.
AIM: To evaluate the acceptability of robot-assisted gait training (RAGT) with and without VR and the feasibility of potential outcome measures to guide the planning of a larger randomized controlled trial (RCT).
DESIGN: Single-blind randomized controlled pilot trial with two parallel arms.
SETTING: Rehabilitation hospital.
POPULATION: Twenty subacute stroke patients (64±9 years) with a Functional Ambulation Classification (FAC) ≤2.
METHODS: Twelve sessions (over 4 weeks) of either VR-augmented RAGT (intervention group) or standard RAGT (control group). Acceptability of the interventions (drop-out rate, questionnaire), patients’ motivation (Intrinsic Motivation Inventory [IMI], individual mean walking time), and feasibility of potential outcome measures (completion rate and response to interventions) were determined.
RESULTS: We found high acceptability of repetitive VR-augmented RAGT. The drop-out rate was 1/11 in the intervention and 4/14 in the control group. Patients of the intervention group spent significantly more time walking in the robot than the control group (per session and total walking time; P<0.03). In both groups, motivation measured with the IMI was high over the entire intervention period. The felt pressure and tension significantly decreased in the intervention group (P<0.01) and was significantly lower than in the control group at the last therapy session (r=-0.66, P=0.005). The FAC is suggested as a potential primary outcome measure for a definitive RCT, as it could be assessed in all patients and showed significant response to interventions (P<0.01). We estimated a sample size of 44 for a future RCT.
CONCLUSIONS: VR-augmented RAGT resulted in high acceptability and motivation, and in a reduced drop-out rate and an extended training time compared to standard RAGT. This pilot trial provides guidance for a prospective RCT on the effectiveness of VR-augmented RAGT.
CLINICAL REHABILITATION IMPACT: VR might be a promising approach to enrich and improve gait rehabilitation after stroke.
Electric-current-assisted sintering (ECAS) is a novel process that can potentially replace the conventional sintering method. It is hypothesized that the process can reduce the sintering time and can be used in situ; thus, can be more cost effective. The purpose of this research is to investigate the effect of direct current on the sintered properties of iron-copper powder metal. Experiments were conducted at various conditions to determine the optimal process parameters for this particular powder metal. The parameters investigated were electric current levels and energizing time. Experiments also included sintering the powder using a conventional furnace. Samples from both types of experiments were compared to determine the metallurgical differences due to the sintering process. Mechanical and microstructure examination were conducted to aid in determining the feasibility of ECAS.
Background: Acquired joint contractures have a significant impact on functioning and quality of life in nursing home residents. There is very limited evidence on measures for prevention and treatment of disability due to joint contractures. We have developed the PECAN intervention (Participation Enabling CAre in Nursing) to improve social participation in nursing home residents. A cluster-randomised pilot trial was conducted to assess the feasibility of study procedures in preparation for a main trial according to the UK Medical Research Council (MRC) framework.
Methods: Nursing homes in two regions of Germany were randomly allocated either to the intervention or optimised standard care (control group). All residents with joint contractures aged > 65 years were eligible for the study. The residents’ data were collected through structured face-to-face interviews by blinded assessors at baseline, after 3 and 6 months. The primary outcome was social participation, measured by a subscale of the PaArticular Scales. Secondary outcomes included activities and instrumental activities of daily living, health-related quality of life, falls and fall-related consequences. Data on the trial feasibility were collected via documentation forms.
Results: Seven out of 12 nursing homes agreed to participate and remained in the trial. Of 265 residents who fulfilled the inclusion criteria, 129 were randomised either to the intervention (n = 64) or control group (n = 65) and analysed. A total of 109 (85%) completed the trial after 6 months. The mean age was 85.7 years (SD 7.0), 80% were women. The severity of the residents’ disability differed across the clusters. The completion rate was high (> 95%), apart from the Instrumental Activities of Daily Living Scale. Some items of the PaArticular Scales were not easily understood by residents. The frequency of falls did not differ between study groups.
Conclusion: Our data confirmed the feasibility of the overall study design. We also revealed the need to improve the procedures for the recruitment of residents and for data collection before implementation into a main trial. The next step will be an adequately powered main trial to assess the effectiveness and cost-effectiveness of the intervention.
Die neuen Assistenten
(2019)
Background: Nursing home residents are frequently affected by joint contractures, which impacts their participation and daily activities. A complex intervention, the Participation Enabling Care in Nursing (PECAN), was previously developed and pilot tested to address their needs. Its effectiveness and safety will be evaluated in the present study.
Methods/design: This multicentre cluster-randomised controlled trial will be conducted in 32 nursing homes spread over two regions of Germany. A total of 578 residents over 65 years old with joint contractures will be included. To compare the effect of the PECAN intervention with optimised standard care (usual care and an information session), randomisation will take place at a cluster level.
The individually tailored intervention was designed using the biopsychosocial model in the International Classification of Functioning, Disability and Health (ICF) to reduce activity limitations and participation restrictions resulting from existing joint contractures by addressing barriers and by strengthening supportive factors on an individual level and an organisational level.
The implementation strategy comprises a facilitators’ workshop, a peer mentoring approach including a peer mentor visit and telephone peer counselling, an in-house information event, an information session for the nursing team and a training session on collegial consultation for the facilitators. The in-house information event will also take place in the nursing homes of the control group. The primary outcome is the residents’ participation and activities after 12 months of follow-up as assessed using the PaArticular Scales. The secondary outcome is the residents’ quality of life. A cost-effectiveness analysis (costs per additional resident who experienced a decrease of ten points in the participation or activities subscale of the PaArticular Scales) and a cost–utility analysis (costs per additional quality adjusted life year) will be conducted. We will investigate barriers and facilitators in a comprehensive process evaluation.
Discussion: We expect a clinically relevant improvement of participation and activities in residents with joint contractures. Our findings will provide important insights regarding participation in the situation of the affected individuals.
Die Pflegewissenschaft in Deutschland steht vor der Herausforderung, wissenschaftliche Strukturen und Karrierewege auszubilden. Erschwert wird dies durch einen Mangel an wissenschaftlichem Nachwuchs, der das Potential hat, pflegewissenschaftliche Professuren mit wissenschaftlicher Exzellenz und praktischer Erfahrung zu füllen.
Ziel dieses Beitrags ist es, darzustellen, was auslösende Momente für wissenschaftliche Karrieren sind, die in Professuren pflegebezogener Studiengänge münden, und welche Kontextbedingungen diese Karrieren beeinflussen. Es soll auch aufgezeigt werden, wie wissenschaftliche Nachwuchskräfte vorgehen, um ihre Ziele zu erreichen und welche Konsequenzen sich daraus für sie und für die Pflegewissenschaft ergeben. Auf dieser Grundlage sollen Empfehlungen für die Nachwuchsförderung entwickelt werden, um mehr geeignete Personen für Professuren in pflegebezogenen Studiengängen zu gewinnen.
Vorhandene Daten teilnarrativer Interviews mit ProfessorInnen (n=11) und Masterstudierenden (n=11) sowie Promovierenden (n=10) pflegebezogener Studiengänge wurden im Rahmen einer retrospektiven Datenanalyse mit dem dreistufigen Codierverfahren der Grounded Theory Methodologie ausgewertet.
Die Ergebnisse zeigen, dass in der Pflegepraxis gewonnene Erfahrungen auslösende Momente wissenschaftlicher Karrieren sind. Diese lösen den Drang aus, die dort herrschende Situation zu verändern, wobei sich vier Karrieretypen unterscheiden lassen: Typ A forscht, weil er erlebt hat, dass es für pflegerische Phänomene keine geeigneten Pflegeinterventionen gab. Typ B lehrt, um dazu beizutragen, dass Pflegende zukünftig besser ausgebildet werden. Typ C ist als Pflegeperson von ÄrztInnen nicht ausreichend anerkannt worden und absolviert eine wissenschaftliche Qualifikation, um mit ihnen auf Augenhöhe zu gelangen. Typ D wollte in der Praxis bleiben, ist aber bei Weiterentwicklungsprozessen blockiert worden und nimmt als Kompromiss eine Professur an.
Identifizierte Kontextfaktoren sind u.a. mangelnde Wertschätzung für wissenschaftliches Handeln in der Pflege und das Fehlen von Stellen für hochschulisch qualifizierte Pflegepersonen in der Praxis. Angesichts der bestehenden Bedingungen können hochschulisch qualifizierte Pflegende in der Praxis nicht Fuß fassen. Als Konsequenz für die Pflegewissenschaft als Disziplin zeigt sich, dass in der Pflegepraxis Vorbilder fehlen, die zukünftige Generationen Pflegender dazu anregen könnten, selbst eine wissenschaftliche Karriere in der Pflege einzuschlagen. Dadurch besteht die Gefahr einer Verkümmerung der Pflegewissenschaft.
Auf Grundlage der Ergebnisse wird die durchgängige Implementierung geeigneter Stellen für hochschulisch qualifizierte Pflegepersonen in der Pflegepraxis als Ausgangsbasis wissenschaftlicher Nachwuchsförderung betrachtet. Als Konzept werden Hochschul-Praxis-Partnerschaften skizziert, die beginnend auf Bachelorniveau bis zur Post-doc-Phase Strukturen zu einem systematischen praxisbezogenen wissenschaftlichen Kompetenzauf- und -ausbau für akademisch qualifizierte Pflegende etablieren.
Background
The admission to a nursing home is a critical life-event for affected persons as well as their families. Admission related processes are lacking adequate participation of older people and their families. To improve transitions to nursing homes, context- and country-specific knowledge about the current practice is needed. Hence, our aim was to summarize available evidence on challenges and care strategies associated with the admission to nursing homes in Germany.
Methods
We conducted a scoping review and searched eight major international and German-specific electronic databases for journal articles and grey literature published in German or English language since 1995. Further inclusion criteria were focus on challenges or care strategies in the context of nursing home admissions of older persons and comprehensive and replicable information on methods and results. Posters, only-abstract publications and articles dealing with mixed populations including younger adults were excluded. Challenges and care strategies were identified and analysed by structured content analysis using the TRANSCIT model.
Results
Twelve studies of 1,384 records were finally included. Among those, seven were qualitative studies, three quantitative observational studies and two mixed methods studies. As major challenges neglected participation of older people, psychosocial burden among family caregivers, inadequate professional cooperation and a lack of shared decision-making and evidence-based practice were identified. Identified care strategies included strengthening shared decision-making and evidence-based practice, improvement in professional cooperation, introduction of specialized transitional care staff and enabling participation for older people.
Conclusion
Although the process of nursing home admission is considered challenging and tends to neglect the needs of older people, little research is available for the German health care system. The perspective of the older people seems to be underrepresented, as most of the studies focused on caregivers and health professionals. Reported care strategies addressed important challenges, however, these were not developed and evaluated in a comprehensive and systematic way. Future research is needed to examine perspectives of all the involved groups to gain a comprehensive picture of the needs and challenges. Interventions based on existing care strategies should be systematically developed and evaluated to provide the basis of adequate support for older persons and their informal caregivers.
Cellulosefaserverstärktes Polypropylen – Eigenschaftsbeeinflussung durch die Schmelzeaufbereitung
(2023)
Verarbeitungstemperaturen, Verweilzeit und Scherkräfte sind entscheidend, um die strukturelle Integrität von cellulosebasierten Fasern zu gewährleisten.
In dieser Studie wurden die Einflüsse durch die Schmelzeaufbereitung eines cellulosefaserverstärkten Polypropylens auf die Faser und den Faserverbund untersucht. Die Schmelze wurde in einem Plastographen mit verschiedenen Rotordrehzahlen, Schmelzetemperaturen und Verweilzeiten aufbereitet. Um die Auswirkung der Einspeisungsmethode auf den Faserabbau zu analysieren, wurden die Fasern entweder direkt der thermoplastischen Schmelze oder zusammen mit dem Kunststoffgranulat dem Plastographen zugeführt. Die Zugabe der Fasern in die Schmelze geht mit einer erhöhten thermischen und verminderten mechanischen Belastung der Fasern einher.
Bei der Prüfung der mechanischen Eigenschaften der verschieden aufbereiteten Compounds zeigten sich signifikante Unterschiede. Wurden die Fasern direkt der Schmelze hinzugefügt, so führte dies zu einer deutlich reduzierten Zugfestigkeit. Optische Unterschiede in den Schliffbildern der spritzgegossenen Prüfstäbe sowie in den Faserlängen nach Compoundierung konnten nicht festgestellt werden. Die verminderte Festigkeit wird folglich auf die unterschiedliche thermische Belastung der Faser während der Verarbeitung zurückgeführt.
Hintergrund
Schwindel und/oder Gleichgewichtsstörungen (SG) sind häufige Symptome bei älteren Menschen und beeinträchtigen das tägliche Leben erheblich. Physiotherapie kann eine wichtige Komponente in der Behandlung von SG sein. Aufgrund der multifaktoriellen Ursachen sind die physiotherapeutische Diagnostik und Therapie komplex, werden aber in der Ausbildung kaum thematisiert. Klar strukturierte und evidenzbasierte Schulungen für die differentialdiagnostische Herangehensweise können den Clinical-Reasoning-Prozess und die Therapie von SG verbessern. Eine entsprechende evidenzbasierte Schulung wurde in einem Interventionszweig der multizentrischen Cluster-RCT MobilE-PHY2 begleitend zu einem Decision Tree (DT) für den Clinical-Reasoning-Prozess in der Physiotherapie konzipiert und durchgeführt.
Methodik
Die Schulung wurde aus den Ergebnissen der Pilotstudie (MobilE-PHY1) und deren Prozessevaluation sowie auf der Grundlage einer dreitägigen Fortbildung von und mit einem Schwindelexperten entwickelt. Inhalte waren die Anwendung des DT, theoretische Grundlagen über Schwindel sowie praktische Übungsanteile. Bei der eintägigen Schulung konnten die Physiotherapeut*innen entweder online oder in Präsenz teilnehmen. Zudem wurde eine Online-Lernplattform bereitgestellt, die neben umfassendem Vor- und Nachbereitungsmaterial die Möglichkeit bot, Feedback z. B. in Form einer Videoanalyse zu bekommen. Die Evaluation erfolgte durch Fragebögen und leitfadengestützte Interviews und ist Teil der Prozessevaluation von MobilE-PHY2. Die Auswertung ab Juni 2023 wird im Mixed-Methods-Design nach Rädiker stattfinden.
Ergebnis und Schlussfolgerung
Es konnten neun Physiotherapiepraxen am Studienstandort Bayern in die Studie eingeschlossen werden. Aus diesen nahmen 17 Therapeut*innen an den insgesamt drei Schulungen teil. Es wurden zehn Therapeut*innen online und sieben in Präsenz geschult. Basierend auf Interviews mit sechs Therapeut*innen sowie dreizehn Fragebögen werden wichtige Erkenntnisse gewonnen, inwiefern die Schulung (begleitend zum DT) eine geeignete Methode darstellt, die evidenzbasierte physiotherapeutische Versorgung für Patient*innen mit SG zu verbessern. Zudem können Vor- und Nachteile der Online- und Präsenzlehre diskutiert werden.
Introduction Mobility limitations have a multitude of different negative consequences on elderly patients including decreasing opportunities for social participation, increasing the risk for morbidity and mortality.
However, current healthcare has several shortcomings regarding mobility sustainment of older adults, namely a narrow focus on the underlying pathology, fragmentation of care across services and health professions and deficiencies in personalising care based on patients’ needs and experiences. A tailored healthcare strategy targeted at mobility of older adults is still missing.
Objective The objective is to develop multiprofessional care pathways targeted at mobility sustainment and social participation in patients with vertigo/dizziness/balance disorders (VDB) and osteoarthritis (OA) .
Methods Data regarding quality of life, mobility limitation, pain, stiffness and physical function is collected in a longitudinal observational study between 2017 and 2019. General practitioners (GPs) recruit their patients with VDB or OA.
Patients who visited their GP in the last quarter will be identified in the practice software based on VDB and OA-related International Classification of Diseases 10th Revision. Study material will be sent from the practice to patients by mail. Six months and 12 months after baseline, all patients will receive a mail directly from the study team containing the follow-up questionnaire. GPs fill out questionnaires regarding patient diagnostics, therapy and referrals.
Ethics and dissemination The study was approved by the ethical committee of the Ludwig-Maximilians-Universität München and of the Technische Universität Dresden. Results will be published in scientific, peer-reviewed journals and at national and international conferences. Results will be disseminated via newsletters, the project website and a regional conference for representatives of local and national authorities.
BACKGROUND
Vertigo, dizziness or balance disorders (VDB) affect the mobility and participation of many older people and are also one of the most frequent reasons for visiting the general practitioner's (GP) practice due to multifactorial causes. Physiotherapy (PT) can be crucial for the complex care of people with VDB but is rarely prescribed by GPs. So we developed an evidence-based, multidisciplinary care pathway as a complex intervention following the UK Medical Research Council guideline, which was piloted and is now being evaluated for effectiveness, accompanied by a process evaluation.
METHOD
The care pathway of the multicentre cluster-RCT (MobilE-PHY2) included decision aids and training for PTs and GPs in the intervention group and optimised standard care in the control group. A mixed-methods process evaluation following Grant’s framework for designing process evaluations examined barriers, facilitating factors and mechanisms of impact in recruiting and reaching participants, implementing the intervention and the response of all participants. Therefore, a logic model was developed illustrating the relationship between the planned work to implement the intervention, the expected mechanism of impact (based on the behaviour change wheel as a change theory), the intended results (output, outcome and impact), and categories of possible influencing factors. The underlying assumption is that a behavioural change in PT and GP is a prerequisite for a change in patient behaviour, which can lead to improved mobility and participation (outcome of MobilE-PHY2). Guided interviews were conducted with patients before the intervention and after six months and with PTs and GPs after six months. Additionally, the training evaluations, completed decision aids and structural questionnaires will be analysed from June 2023.
RESULTS AND CONCLUSION
At one study site, a total of 37 patients, 17 PTs and nine GPs were included. Interviews were conducted with 16 patients, six PTs and GPs. In the intervention group, 12 PTs and 18 GPs completed decision aids, 13 PTs and two GPs completed evaluation forms, and eight PTs and four GPs completed structural data. The preliminary results of the process evaluation will be reported at the Congress. The results are intended to give indications for a broad implementation of the care pathway, including and promoting physiotherapy and therefore contributing to improved evidence-based healthcare for older people with VDB.
Background
Vertigo, dizziness or balance disorders (VDB) are common leading symptoms in older people, which can have a negative impact on their mobility and participation in daily live, yet, diagnosis is challenging and specific treatment is often insufficient. An evidence-based, multidisciplinary care pathway (CPW) in primary care was developed and pilot tested in a previous study. The aim of the present study is to evaluate the effectiveness and safety of the CPW in terms of improving mobility and participation in community-dwelling older people with VDB in primary care.
Methods
For this multicentre cluster randomised controlled clinic trial, general practitioners (GP) will be recruited in two regions of Germany. A total of 120 patients over 60 years old with VDB will be included. The intervention is an algorithmized CPW. GPs receive a checklist for standardise clinical decision making regarding diagnostic screening and treatment of VDB. Physiotherapists (PT) receive a decision tree for evidence-based physiotherapeutic clinical reasoning and treatment of VDB. Implementation strategies comprises educational trainings as well as a workshop to give a platform for exchange for the GPs and PTs, an information meeting and a pocket card for home care nurses and informal caregivers and telephone peer counselling to give all participants the capability, opportunity and the motivation to apply the intervention. In order to ensure an optimised usual care in the control group, GPs get an information meeting addressing the national guideline. The primary outcome is the impact of VDB on participation and mobility of patients after 6 month follow-up, assessed using the Dizziness Handicap Inventory (DHI) questionnaire. Secondary outcomes are physical activity, static and dynamic balance, falls and fear of falling as well as quality of life. We will also evaluate safety and health economic aspects of the intervention. Behavioural changes of the participants as well as barriers, facilitating factors and mechanisms of impact of the implementation will be investigated with a comprehensive process evaluation in a mixed-methods design.
Discussion
With our results, we aim to improve evidence-based health care of community-dwelling older people with VDB in primary care.
Hintergrund
Schwindel und/oder Gleichgewichtsstörungen (S/G) sind komplexe Gesundheitsprobleme bei älteren Menschen und häufige Beratungsanlässe in der Hausarztpraxis. Physiotherapie kann einen positiven Einfluss auf das Gleichgewicht und Sturzrisiko bei Patient*innen mit S/G haben. In der S3-DEGAM-Leitlinie „Akuter Schwindel in der Hausarztpraxis“ werden Empfehlungen für Physiotherapie bei bestimmten Schwindeldiagnosen gegeben. Ob hausärztliche Physiotherapieverordnungen den Empfehlungen der Leitlinie entsprechen, ist nicht bekannt. Bisher liegen keine Daten vor, wie häufig diese Physiotherapieverordnungen tatsächlich durch Patient*innen in Anspruch genommen werden.
Ziel
Ermittlung von Anteil und Inanspruchnahme hausärztlich verordneter Physiotherapie bei älteren Patient*innen mit S/G innerhalb der Kohortenstudie MobilE-TRA und Untersuchung, ob diese den Empfehlungen der S3-DEGAM-Leitlinie entsprechen.
Methode
Die Sekundäranalyse beruht auf Daten der Kohortenstudie MobilE-TRA, in der Patient*innen ab 65 Jahren mit S/G in 17 Hausarztpraxen in Bayern und Sachsen befragt wurden. Die Datenerhebung fand von 09/2017–10/2019 statt. Die hausärztliche Verordnung und patientenseitige Inanspruchnahme von Physiotherapie wurden mittels validierten sowie selbstentwickelten Fragebögen erhoben. Die Daten wurden deskriptiv (Mittelwerte, Häufigkeiten) und Verteilungsunterschiede mittels exaktem Test nach Fisher analysiert.
Ergebnisse
Die Stichprobe umfasste 158 Patient*innen mit S/G. 16 % der Patient*innen hatten aufgrund von S/G Physiotherapie verordnet bekommen. Dabei entsprachen 14,2 % der Physiotherapieverordnungen den Empfehlungen der S3-DEGAM-Leitlinie. 32 % (Bayern 53,8 %; Sachsen 8,3 %) der Patient*innen hatten die Physiotherapie nicht in Anspruch genommen. Dabei lag ein signifikanter regionaler Verteilungsunterschied (p = 0,030; Phi = 0,487 [95 % KI = 0,129–0,846]) vor.
Schlussfolgerung
Mit 16 % ist die Häufigkeit hausärztlicher Physiotherapieverordnungen bei S/G in der Altersgruppe der über 65-Jährigen vergleichsweise hoch. Die Gründe für die Nichtinanspruchnahme wurden nicht erfasst, weshalb nur Vermutungen bezüglich des regionalen Unterschiedes angestellt werden konnten (z. B. Verfügbarkeit von Physiotherapie). Im Sinne der Planung einer adhärenten Therapie und zur Vermeidung von Versorgungsunterschieden scheint es sinnvoll, sich zukünftig auch mit Gründen einer Nichtinanspruchnahme von Therapien zu beschäftigen.