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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.