Improve implementation of a novel paediatric therapy programme : taking theories of human behaviour into account

Background: ‘COPing with and CAring for Infants with special Needs’ (COPCA) is a novel family-centred early intervention programme in paediatric physiotherapy. COPCA differs from well-known approaches, e.g. the therapist takes on the role of a coach and uses hands-off approaches. This implies, that to become a COPCA-coach, the therapist needs to change behaviour. Thus, it may be assumed that for successful implementation of new approaches, theories of human behaviour have to be taken into account. Purpose: The study aims to measure behaviour changes in therapists following a COPCA course in order to identify the challenges that interfere with the implementation of the COPCA program in daily practice. Methods: Data were collected during a three-part COPCA course over 6 months (with two months intervals between parts) in which 15 therapists learned to become a COPCA-coach. To document behaviour changes four treatment sessions (one prior to part I T0), one in each interval (T1, T2), and one after part III (T3) of each participant (n=60) were video-recorded and analysed quantitatively with the Groningen Observation Protocol version 2 (GOP 2.0). The videos were randomized and masked to the chronology of recording moment. GOP 2.0 is a quantitative tool to assess therapeutic behaviour in different categories, e.g. “educational actions toward caregivers” or “neuromotor actions”. It allows for a quantification of the relative duration of therapeutic actions (percentage of total treatment time) during a session. Interrater reliability of the GOP 2.0 was evaluated. The first author analysed changes in therapeutic behaviour over time with the Wilcox-sign rank test. Median changes and corresponding non-parametric confidence intervals were computed using the Hodges-Lehmann estimator (HL). Results: Interrater reliability of the GOP 2.0 (ICC2) was 0.48-1.00 (median 0.92). Course participation was associated especially with changes in “educational actions toward caregivers” and “ neuromotor actions”. Time spent on ‘caregiver coaching’ increased: between T0 and T1 by 77.9% (99% confidence interval (CI) 48.7-99.1) and between T0 and T3 by 96.1% (99%CI 51.7-100). Also time spent on hands-off techniques increased, 37.9% (99%CI 18.8-59.5) between T0 and T1 and 40.3% (99%CI 17.8-57.7) between T0 and T3. The implementation of hands-off approaches developed at a slower rate and somewhat less sustainable than that of coaching. Conclusions: Behaviours with a slower and less sustainable rate of change represented strong habits. The neural substrate of strong habits is located subcortically, making them relatively resistant to cognitive input. To overcome this challenge, future COPCA courses need to be adapted, by including (1) more modelling of desired behaviour and (2) more repetition and practice for the behaviours in the neuromotor domain. Implication: Quantitative analysis of therapeutic behaviour is a useful method to monitor changes in behaviour of therapists and – by doing so – may assist the implementation of new approaches. To implement new approaches successfully, theories of human behaviour have to be taken into account. The Behaviour Change Wheel of Michie et al., a method to characterise and design behaviour change in interventions, is a helpful framework to understand the nature of behaviour and to overcome behaviour change barriers

Prescription of the first prosthesis and later use in children with congenital unilateral upper limb deficiency: A systematic review

Background: The prosthetic rejection rates in children with an upper limb transversal reduction deficiency are considerable. It is unclear whether the timing of the first prescription of the prosthesis contributes to the rejection rates. Objective: To reveal whether scientific evidence is available in literature to confirm the hypothesis that the first prosthesis of children with an upper limb deficiency should be prescribed before two years of age. We expect lower rejection rates and better functional outcomes in children fitted at young age. Methods: A computerized search was performed in several databases (Medline, Embase, Cinahl, Amed, Psycinfo, PiCarta and the Cochrane database). A combination of the following keywords and their synonyms was used: "prostheses, upper limb, upper extremity, arm and congenital''. Furthermore, references of conference reports, references of most relevant studies, citations of most relevant studies and related articles were checked for relevancy. Results: The search yielded 285 publications, of which four studies met the selection criteria. The methodological quality of the studies was low. All studies showed a trend of lower rejection rates in children who were provided with their first prosthesis at less than two years of age. The pooled odds ratio of two studies showed a higher rejection rate in children who were fitted over two years of age ( pooled OR 3.6, 95% CI 1.6-8.0). No scientific evidence was found concerning the relation between the age at which a prosthesis was prescribed for the first time and functional outcomes. Conclusion: In literature only little evidence was found for a relationship between the fitting of a first prosthesis in children with a congenital upper limb deficiency and rejection rates or functional outcomes. As such, clinical practice of the introduction of a prosthesis is guided by clinical experience rather than by evidence-based medicine

The impact of type 2 diabetes and Microalbuminuria on future cardiovascular events in patients with clinically manifest vascular disease from the Second Manifestations of ARTerial Disease (SMART) study

Aims Type 2 diabetes mellitus and microalbuminuria are important risk factors for cardiovascular disease (CVD). Whether these two complications are important and independent risk factors for future CVD events in a high-risk population with clinically manifest vascular disease is unknown. The objectives of this study were to examine the impact of Type 2 diabetes and microalbuminuria on future CVD events. Methods Patients with clinically manifest vascular disease (coronary, cerebral and peripheral vascular disease) from the Second Manifestation of Arterial disease study were followed up for 4 years. Data obtained from 1996–2006 were analysed. At baseline, there were 804 patients with Type 2 diabetes mellitus (mean age 60 years) and 2983 patients without. Incident CVD (n = 458) was defined as hospital-verified myocardial infarction, stroke, vascular death and the composite of these vascular events. Results Both Type 2 diabetes [hazard ratio (HR) 1.42, 95% confidence interval (CI) 1.16, 1.75] and microalbuminuria (HR 1.86, 95% CI 1.49, 2.33) increased the risk of new cardiovascular events in univariate analyses. From multivariable models, presence of diabetes remained significantly and independently related to incident CVD (HR 1.42, 95% CI 1.11, 1.80). Presence of microalbuminuria also remained significantly independently related to incident CVD (HR 1.38, 95% CI 1.07, 1.77). In diabetes-stratified analyses, the effect of microalbuminuria on CVD risk was observed only in patients with diabetes. In microalbuminuria-stratified analyses, the significant and independent effect of diabetes on CVD risk was shown only in the non-microalbuminuric group. Conclusions In this high-risk population, both microalbuminuria and Type 2 diabetes are important and independent risk factors for future CV

Prospective cohort study of routine use of risk assessment scales for prediction of pressure ulcers

Objective To evaluate whether risk assessment scales can be used to identify patients who are likely to get pressure ulcers.Design Prospective cohort study.Setting Two large hospitals in the Netherlands.Participants 1229 patients admitted to the surgical, internal, neurological, or geriatric wards between January 1999 and June 2000.Main outcome measure Occurrence of a pressure ulcer of grade 2 or worse while in hospital.Results 135 patients developed pressure ulcers during four weeks after admission. The weekly incidence of patients with pressure ulcers was 6.2% (95% confidence interval 5.2% to 7.2%). The area under the receiver operating characteristic curve was 0.56 (0.51 to 0.61) for the Norton scale, 0.55 (0.49 to 0.60) for the Braden scale, and 0.61 (0.56 to 0.66) for the Waterlow scale; the areas for the subpopulation, excluding patients who received preventive measures without developing pressure ulcers and excluding surgical patients, were 0.71 (0.65 to 0.77), 0.71 (0.64 to 0.78), and 0.68 (0.61 to 0.74), respectively. In this subpopulation, using the recommended cut­off points, the positive predictive value was 7.0% for the Norton, 7.8% for the Braden, and 5.3% for the Waterlow scale.Conclusion Although risk assessment scales predict the occurrence of pressure ulcers to some extent, routine use of these scales leads to inefficient use of preventive measures. An accurate risk assessment scale based on prospectively gathered data should be developed

Dipyridamole plus aspirin versus aspirin alone in the secondary prevention after TIA or stroke: a meta-analysis by risk

Objectives: Our aim was to study the effect of combination therapy with aspirin and dipyridamole (A+D) over aspirin alone (ASA) in secondary prevention after transient ischemic attack or minor stroke of presumed arterial origin and to perform subgroup analyses to identify patients that might benefit most from secondary prevention with A+D. Data sources: The previously published meta-analysis of individual patient data was updated with data from ESPRIT (N=2,739); trials without data on the comparison of A+D versus ASA were excluded. Review methods: A meta-analysis was performed using Cox regression, including several subgroup analyses and following baseline risk stratification. Results: A total of 7,612 patients (5 trials) were included in the analyses, 3,800 allocated to A+D and 3,812 to ASA alone. The trial-adjusted hazard ratio for the composite event of vascular death, non-fatal myocardial infarction and non-fatal stroke was 0.82 (95% confidence interval 0.72-0.92). Hazard ratios did not differ in subgroup analyses based on age, sex, qualifying event, hypertension, diabetes, previous stroke, ischemic heart disease, aspirin dose, type of vessel disease and dipyridamole formulation, nor across baseline risk strata as assessed with two different risk scores. A+D were also more effective than ASA alone in preventing recurrent stroke, HR 0.78 (95% CI 0.68 – 0.90). Conclusion: The combination of aspirin and dipyridamole is more effective than aspirin alone in patients with TIA or ischemic stroke of presumed arterial origin in the secondary prevention of stroke and other vascular events. This superiority was found in all subgroups and was independent of baseline risk. ---------------------------7dc3521430776 Content-Disposition: form-data; name="c14_creators_1_name_family" Halke