The development and implementation of a regional network of physiotherapists for exercise therapy in patients with peripheral arterial disease, a preliminary report

BACKGROUND: Exercise therapy (ET) is the main conservative and proven effective treatment of patients with intermittent claudication. Currently, the most frequent exercise prescription is a single 'go home and walk' advise, without supervision or follow-up. There is no evidence to support the efficacy of this advise and compliance is known to be low. Therefore, a systematic approach was used to guarantee quality and standardisation of treatment, optimal guideline adherence and improved of inter-professional communication between vascular surgeons and physiotherapists. In this preliminary report we would like to outline the steps taken for the development and implementation of the Network Exercise Therapy Parkstad METHODS: In October 2003 all 59 regional physiotherapy practices were invited to attend a symposium regarding ET in a physiotherapeutic setting. Attending physiotherapists interested in providing ET and willing to follow a certified course on ET, were asked to register. Three tastkgroups were formed to accomplish the set targets: Exercise therapy education, Exercise therapy implementation and continuity, and Inter-professional communication in the Parkstad region. RESULTS: In total 27 physiotherapists, from 22 different practices followed the educational program and are now trained and accredited to provide ET according to the guideline of the Royal Dutch Society for Physiotherapy. A web-based database wasdesigned to contain information on disease specific items provided by the vascular surgery department, and aspects with respect to ET registered by the physiotherapist. The information is regularly updated and available online. Access tothe database is restricted to vascular surgeons and physiotherapists in the network. The secondary purpose of the database is to register essential benchmark data for future analysis of ET in a physiotherapeutic setting in the Netherlands and to enable physiotherapists continuous feedback on patient performance. A triage system was developed to detect patients with a compromised cardiac history. This group receives ET at the in-hospital department of revalidation with the possibility of immediate consultation of a cardiologist in case of cardiac complications or even CPR. CONCLUSION: The Network Exercise Therapy Parkstad of supervised ET is the first initiative in the Netherlands to provide ET close to the patient's home environment. With the implementation of supervised ET in an outpatient physiotherapeutic setting for all eligible patients with symptomatic PAD, the access to care has been improved. A web-based communication system provides physiotherapists and vascular surgeons with all the necessary and continues updated patient information. Future research, currently in progress, will investigate the therapeutic benefits and cost-effectiveness of exercise therapy in a physiotherapeutic setting

Functional claudication distance: a reliable and valid measurement to assess functional limitation in patients with intermittent claudication

BACKGROUND: Disease severity and functional impairment in patients with intermittent claudication is usually quantified by the measurement of pain-free walking distance (intermittent claudication distance, ICD) and maximal walking distance (absolute claudication distance, ACD). However, the distance at which a patient would prefer to stop because of claudication pain seems a definition that is more correspondent with the actual daily life walking distance. We conducted a study in which the distance a patient prefers to stop was defined as the functional claudication distance (FCD), and estimated the reliability and validity of this measurement. METHODS: In this clinical validity study we included patients with intermittent claudication, following a supervised exercise therapy program. The first study part consisted of two standardised treadmill tests. During each test ICD, FCD and ACD were determined. Primary endpoint was the reliability as represented by the calculated intra-class correlation coefficients. In the second study part patients performed a standardised treadmill test and filled out the Rand-36 questionnaire. Spearman's rho was calculated to assess validity. RESULTS: The intra-class correlation coefficients of ICD, FCD and ACD were 0.940, 0.959, and 0.975 respectively. FCD correlated significantly with five out of nine domains, namely physical function (rho = 0.571), physical role (rho = 0.532), vitality (rho = 0.416), pain (rho = 0.416) and health change (rho = 0.414). CONCLUSION: FCD is a reliable and valid measurement for determining functional capacity in trained patients with intermittent claudication. Furthermore it seems that FCD better reflects the actual functional impairment. In future studies, FCD could be used alongside ICD and ACD

Hot deformation studies on discontinuously reinforced Ti-Alloys

Titanium alloys exhibit high specific strength and stiffness that fit structural applications demanding lightweight. The microstructure of the alpha-beta titanium alloys can be changed by thermomechanical processes such as heat treatments and pre-forging to achieve a certain ductility. Ceramic reinforcements can improve specific strength and stiffness, and also the wear resistance. In Situ particle reinforcement introduces neither further anisotropy to titanium alloys nor large internal stresses. The particulate reinforced titanium alloys (PRTi) are cheaper than the fiber reinforced materials and can be hot deformed. The present work-studies the effect of thermomechanical processes on the microstructure of the PRTi produced in-situ by powder metallurgy from Ti-6Al-4V-powders with additions of 1.0%wt of B and 0.1%wt of C. In the as received material TiB is precipitated as needle like reinforcement in the Ti-6Al-4V-0.1C matrix. Hot compression tests on this PRTi and on conventional Ti64 (pre-deformed) were carried out between 850 and 1100°C at strain rates between 0.001 and 10/s using a servohydraulic Gleeble® device. The stability of the alpha and beta phases and of the TiB precipitates was studied by heat treatments before deformation. The beta transus temperature of the composite increases with respect to that of the Ti64 matrix indicating changes in composition. The microstructures before and after deformation were studied by SEM and light microscopy. Some broken particles are found in the deformed samples at lower and some porosity in the matrix at higher temperatures, respectively. These results are compared with those of TiC-particle reinforced Ti64 produced by Cold-Hot Isostatic Pressing (CHIP)

Processing maps of Ti662 unreinforced and reinforced with TiC particles according to dynamic models

Ti-6Al-6V-2Sn produced by powder metallurgy by Dynamet unreinforced (CermeTi®-C-662) and reinforced with 12 vol.% of TiC particles (CermeTi®-C-12-662), and ingot Ti662 are deformed at high temperatures. The processing maps of these materials are derived using the dynamic material model (DMM) developed by Prasad et al., and the modified DMM developed by Murty and Rao. Although both models result in similar power dissipation values, the instability zones predicted by them are quite different. The processing maps predicted by the modified DMM can be correlated to the deformation behaviour of these materials, with respect to the shape of their flow curves and to their microstructure after deformation. The concentration of stresses produced during compression is released by cracking at the triple junction of grain boundaries in the CermeTi®-C-662, whereas in the CermeTi®-C-12-662 by fracture or debonding of the reinforcing particles