Usability and feasibility of a tablet-based e-coach for older adults in rehabilitation units to improve nutrition and physical activity: a prospective pilot study.

BACKGROUND: For older adults (≥ 70 years), it is often challenging to maintain new nutrition and physical activity behaviours learned in rehabilitation. To minimize the risk of negative health consequences when returning home, an e-coach can be helpful. Aligning the program with an established concept such as the Transtheoretical Model of Behaviour Change (TTM) and guidance from healthcare professionals can optimize behaviour change. OBJECTIVE: This prospective single-arm pilot study aimed to assess the usability and feasibility of a nutrition and mobility e-coach for older adults during and after rehabilitation for a period of 9 weeks. In addition, we examined the change in the TTM phase as an indicator of the participant's readiness to change or the changes made. METHODS: Older adults (≥ 70 years) with nutrition deficits and/ or mobility limitations were recruited in a rehabilitation centre. Participants' phases of behaviour change in the TTM were identified by comparing current nutrition and physical activity habits via self-report with age-specific nutrition and physical activity recommendations. They received a tablet with the e-coach containing educational and interactive elements on the topics of nutrition and physical activity in older age. Participants used the e-coach and received support from healthcare professionals. The TTM phases were assessed at five times; the e-coach content was adjusted accordingly. Usability was assessed using the System Usability Scale (SUS, Score range: 0-100). Timestamps were used to evaluate how frequently participants used the e-coach: high (≥ 67% of the days), medium (66 - 33% of the days), and low (< 33% of the days). RESULTS: Approximately 140 patients were approached and n = 30 recruited. Complete data sets of n = 21 persons were analysed (38% female, mean age 79.0 ± 6.0 years). The SUS was 78.6 points, 11 participants (42%) were classified as high users, 6 (39%) as medium users and 4 (19%) as low users. After nine weeks, 15 participants (71%) achieved the physical activity recommendations (baseline: 33%, n = 7). Nutrition recommendations were achieved by 14 participants (66%) after nine weeks (baseline: 24%, n = 5). CONCLUSION: The e-coach seems to be usable and feasible for older adults. We identified some optimization potentials for our application that can be transferred to the development of comparable e-health interventions for vulnerable older adults.

Adherence to evidence-based practice across healthcare professionals in Germany: results from a cross-sectional, nationwide survey.

BACKGROUND: Adherence to evidence-based practice (EBP) is considered a key competence to improve healthcare quality. In this study, we aimed to describe the EBP adherence of healthcare professionals working in Germany and to explore barriers and facilitators regarding the implementation of EBP in clinical practice. METHODS: A nationwide online survey was performed among healthcare professionals in Germany from January to April 2018 using the German version of the Evidence-based Practice Inventory (EBPI) questionnaire for a comprehensive assessment of adherence to EBP. Univariate logistic regression analyses were performed to explore the association between demographic and professional determinants and each EBPI dimension. RESULTS: We analysed data of 889 participants, including 318 physical therapists, 154 occupational therapists, 137 midwifes and 280 participants of six other healthcare professions. Approximately 70% of the participants generally demonstrated a positive attitude towards EBP and believed that EBP was useful in clinical practice. Broadly, 80% of the respondents evaluated themselves as being able to enact EBP behaviour in clinical practice. In contrast, less than 70% preferred to use quantitative information instead of their intuition to inform their habitual clinical behaviour. Still, 20 to 30% reported that EBP did not sufficiently account for their clinical experience and differences between patients. The strongest facilitators to EBP adherence across at least three dimensions of the EBPI were the availability of ≥ 60 min for scientific literature at work (OR: 9.67; 95% CI: 5.86; 16.30), followed by a master or higher academic degree (OR: 9.09, 95% CI: 5.86; 14.28) and the involvement in ≥ 1 scientific publication (OR: 7.06, 95% CI: 5.10; 9.85). CONCLUSIONS: This study showed that healthcare professionals in Germany in general had a positive attitude towards EBP although they currently do not consider EBP principles in its entirety. The most important determinant positively influencing a healthcare professional's decision to perform EBP was the time available for scientific literature at work. German healthcare professionals experience similar barriers towards the implementation of EBP in clinical practice compared to other international healthcare settings. These barriers should be targeted by future research. TRIAL REGISTRATION: German Clinical Trials Register (DRKS00013792). Registered 19 January 2018.

Iterative Development and Applicability of a Tablet-Based e-Coach for Older Adults in Rehabilitation Units to Improve Nutrition and Physical Activity: Usability Study.

BACKGROUND: Maintaining nutrition and exercise strategies after rehabilitation can be difficult for older people with malnutrition or limited mobility. A technical assistance system such as an e-coach could help to positively influence changes in dietary and exercise behavior and contribute to a sustainable improvement in one's nutrition and mobility status. Most apps do not provide a combination of nutrition and exercise content. In most cases, these apps were evaluated with healthy individuals aged <70 years, making transferability to vulnerable patients, with functional limitations and an assumed lower affinity for technology, in geriatric rehabilitation unlikely. OBJECTIVE: This study aims to identify the potential for optimization and enhance usability through iterative test phases to develop a nutrition and mobility e-coach suitable for older adults (≥65 years) based on individual health behavior change stages in a rehabilitation setting. METHODS: Iterative testing was performed with patients aged ≥65 years in a rehabilitation center. During testing, participants used an e-coach prototype with educational elements and active input options on nutrition and mobility as a 1-time application test. The participants performed navigation and comprehension tasks and subsequently provided feedback on the design aspects. Hints were provided by the study team when required, documented, and used for improvements. After testing, the participants were asked to rate the usability of the prototype using the System Usability Scale (SUS). RESULTS: In all, 3 iterative test phases (T1-T3) were conducted with 49 participants (24/49, 49% female; mean 77.8, SD 6.2 years). Improvements were made after each test phase, such as adding explanatory notes on overview screens or using consistent chart types. The use of the user-centered design in this specific target group facilitated an increase in the average SUS score from 69.3 (SD 16.3; median 65) at T1 to 78.1 (SD 11.8; median 82.5) at T3. Fewer hints were required for navigation tasks (T1: 14.1%; T2: 26.5%; T3: 17.2%) than for comprehension questions (T1: 30.5%; T2: 21.6%; T3: 20%). However, the proportion of unsolved tasks, calculated across all participants in all tasks, was higher for navigation tasks (T1: 0%, T2: 15.2%, T3: 4.3%) than for comprehension tasks (T1: 1.9%, T2: 0%, T3: 2.5%). CONCLUSIONS: The extensive addition of explanatory sentences and terms, instead of shorter keywords, to make it easier for users to navigate and comprehend the content was a major adjustment. Thus, good usability (SUS: 80th-84th percentile) was achieved using iterative optimizations within the user-centered design. Long-term usability and any possible effects on nutritional and physical activity behavior need to be evaluated in an additional study in which patients should be able to use the e-coach with increasing independence, thereby helping them to gain access to content that could support their long-term behavior change.

[Adherence to and influencing factors of evidence-based practice in physiotherapeutic care in Germany: a cross-sectional study]. / Adhärenz und Einflussfaktoren evidenzbasierter Praxis in der physiotherapeutischen Versorgung in Deutschland ­ eine Querschnittstudie.

BACKGROUND: The implementation of evidence-based practice (EBP) is a central goal in health care. As in other areas, the transfer of scientific knowledge into clinical practice is very delayed or incomplete in physiotherapy. The primary aim of the present study is to describe the adherence to EBP among physiotherapists working in Germany. The secondary goal is the exploratory analysis of selected factors influencing the implementation of EBP. METHODS: The present exploratory analysis is based on the data of physiotherapists who participated in a cross-sectional study on the use of EBP by health care professionals (study registration no.: DRKS00013792). The participants in the online survey completed the "Evidence-based Practice Inventory", a questionnaire with five dimensions used to quantify the adherence to EBP. Univariable and multivariable regression analysis was used to examine the associations between various sociodemographic characteristics and EBP. RESULTS: 318 physiotherapists participated in the survey (age: 37±12 years; 60 % female; professional experience: 14±11 years). Approximately 70-80 % of the participants, in principle, had a positive attitude towards EBP and perceived EBP as helpful and useful in clinical practice. About 60 % of the respondents felt able to apply the principles of the EBP (e. g., acquisition, appraisal and application of external evidence). However, the data also showed that the implementation of EBP in clinical physiotherapeutic care is insufficient. For example, only 20 % of the respondents reported that their facility paid great attention to applying the principles of the EBP in decision-making, and only about a third of the respondents said that they frequently searched for or used external evidence. The strongest facilitators of EBP include the participation in scientific publications and more than one hour per week to read scientific literature at work. CONCLUSION: In principle, physiotherapists in Germany have a positive attitude towards EBP, but currently do not adequately take into account the principles of EBP. These factors should be further analyzed and targeted through effective interventions.

What do geriatric rehabilitation patients and experts consider relevant? Requirements for a digitalised e-coach for sustainable improvement of nutrition and physical activity in older adults - a qualitative focus group study.

BACKGROUND: During geriatric rehabilitation, attempts are made to increase the patients' health and functional capacity. In order to maintain these improvements in the medium- and long-term, behavioural changes regarding mobility and nutrition are also targeted, but these are often not sustainable. International studies show positive effects on the sustainability of the improvement of physical activity behaviour in healthy seniors through the use of electronic devices and software applications. Comparable approaches that include nutrition topics or combine them and were additionally developed for geriatric rehabilitation patients (≥70 years) to date are not known. The aim of this study was to identify what geriatric rehabilitation patients require from an electronic coaching system (e-coach) to support them in improving their nutritional and physical activity behaviour, and what content and features physiotherapists and dieticians consider relevant. METHOD: Focus group interviews (09-11/2019) were conducted in a geriatric rehabilitation centre in Germany with patients aged 70 years and older, relatives and experts (physiotherapists and nutritionists). The focus groups were recorded, transcribed verbatim and analysed using content analysis. RESULTS: Three focus groups with patients and relatives (n = 17, 65% female, 16 (94%) in age category 70-99 years) and one focus group with experts (2 dieticians and 1 physiotherapist) were conducted. Relevant contents and feedback elements for nutrition and physical activity in old age were identified. The patients' comments show that an e-coach must offer obvious benefits for the older persons and promote motivation in order to be used. The willingness to change nutrition and physical activity behaviour and the previous experiences in these areas are very heterogeneous, therefore content should be adaptable to different requirements. CONCLUSION: Experts and patients identified quite similar contents, barriers and facilitators for a nutrition and physical activity e-coach. The e-coach needs to be able to address different points of behaviour change, enable adaptations to the individual patient and convince the older person that using it will help them to improve their nutrition and physical activity. It is also important that the e-coach is easy to use and can be easily integrated into the patient's everyday life after rehabilitation.

Physical therapy for patients with low back pain in Germany: a survey of current practice.

BACKGROUND: Low back pain (LBP) is one of the most common musculoskeletal disorders worldwide. The National Disease Management Guideline (NVL) "Non-specific LBP" is a practical decision-making aid for both physicians and non-medical professionals in Germany to improve quality of health care. Although LBP is the most frequent diagnosis resulting in physical therapy treatment, information on the current management of patients with LBP and guideline adherence is limited. The objective of this study was to evaluate the current physical therapy management of patients with LBP in Germany, and to explore guideline adherence to the NVL "Non-specific LBP" recommendations. METHODS: An online survey among physical therapists working in Germany was conducted based on the recommendations given in the NVL "Non-specific LBP". Participants were recruited using a snowball sampling approach and invited to complete the questionnaire. Guideline adherence was evaluated by comparing the survey findings with the recommendations of the NVL. RESULTS: In total, 1361 physical therapists (41 years of age (SD 11); 839 female, 514 male; 16 years of clinical experience (SD 10)) completed the survey. Fifty percent (n = 675) of our respondents adhered to the recommendations of the NVL on the therapeutic diagnostic process, and 72% (n = 973) to the recommendations concerning treatment. The guideline adherence across the entire management process (i.e., both diagnosis and treatment) of LBP was 38% (n = 513). German physical therapists predominantly provide active interventions, e.g., exercise therapy, but also use interventions with low or conflicting evidence, respectively. Massage and Kinesio Taping were frequently used despite being not recommended. Less than one third of study participants (n = 400, 29%) answered to know the NVL or had dealt with its recommendations. CONCLUSIONS: In the management of LBP, overall guideline adherence among German physical therapists was 38% with higher adherence in the treatment section than in the physical therapeutic diagnostic process. Widespread employment of implementation strategies and removal of existing barriers against the application of evidence-based guidelines could facilitate the transfer of scientific evidence into clinical practice and contribute to optimize the quality of health care. TRIAL REGISTRATION: German Clinical Trials Register (DRKS00012607). Registered 04 October 2017.

[Feasibility and acceptance of video-based physiotherapy : New medical care provision for older people during the COVID-19 pandemic]. / Machbarkeit und Akzeptanz videobasierter Physiotherapie : Neues Versorgungsangebot für ältere Menschen während der COVID-19-Pandemie.

BACKGROUND AND OBJECTIVE: Restrictions in public life during the COVID-19 pandemic mainly addressed the safety of high-risk older multimorbid patients to protect them from infection. Nevertheless, detrimental aspects of the lockdown for older people are a reduction in physical activity and limited access to physiotherapy, which are likely to have a negative impact on the health status. This study examined the feasibility of video-based physiotherapy (VT) and the subjective rating of VT by patients and therapists. METHODS: From April to June 2020, 4 facilities with 9 patients (6 women, 64-82 years old) participated in the study and were provided with technical equipment. Semistructured telephone interviews were conducted in eight patients to assess physical activity, functional ability and participation before and during the restrictions. Both patients and therapists were asked about their subjective experiences with VT. RESULTS: A total of 92 VT sessions took place. Performance of the exercises and comprehension of instructions were rated as good to very good. The level of acceptance was high. Of the patients four described a perceived reduction in their physical activities due to the public restrictions; however, in the questionnaires no substantial differences in participation and physical activity were found. DISCUSSION: The use of VT is feasible in older patients. Only minor technical support is needed. In pandemic situations or in other contexts VT appears to be a promising supplement or alternative to normal physiotherapy. Further studies are needed to identify suitable patient groups, to prove efficacy and to develop further content-related aspects of VT.

Cross-cultural adaptation, internal consistency, test-retest reliability and feasibility of the German version of the evidence-based practice inventory.

BACKGROUND: A psychometrically robust measurement instrument is prerequisite to tailor and monitor interventions aiming to improve evidence-based practice (EBP). The recently developed "Evidence-based Practice Inventory" (EBPI) questionnaire (five dimensions) provides a sound inventory for a comprehensive assessment of adherence to EBP, and identification of barriers and facilitators for EBP. The aims of this study were to establish a German language version of the EBPI and to examine the instrument's reliability in a diverse sample of healthcare professionals. METHODS: The English version of the EBPI was translated, adopted and subsequently test-retest reliability of the German language EBPI was examined in a nationwide online survey. Participants working in Germany were invited to complete the questionnaire twice. For each EBPI dimension, internal consistency reliability (Cronbach's alpha) and the relative test-retest reliability (intraclass correlation coefficient, ICC) were calculated. The standard error of measurement, limits of agreement and minimal detectable change values were estimated to quantify measurement error. RESULTS: A German language version of the EBPI was established. In the online survey, the EBPI was initially completed by 889 healthcare professionals. At follow-up, 344 individuals (39%) completed the questionnaire (74% female; mean work experience: 13.6 years). The ICCs for the five dimensions varied between 0.78 and 0.86. The standard error of measurement varied between 6.5 and 8.8% of the respective dimension scale range, and the limits of agreement between 24 and 37%. For internal consistency reliability, alpha varied between 0.64 and 0.90. There were neither floor nor ceiling effects, nor any other relevant feasibility issues. CONCLUSIONS: The German language EBPI can be used to assess EBP adherence of healthcare professionals in clinical practice, and to identify barriers and facilitators for an EBP conform behaviour. Results on test-retest reliability indicate that the EBPI produces reliable scores when used for group comparisons, but the questionnaire seems insufficiently reliable for individual measurements over time. Methods of item response theory or Rasch measurement theory should be used for further evaluation and revision of the EBPI, informed by the results of this study. TRIAL REGISTRATION: German Clinical Trials Register ( DRKS00013792 ). Registered 19 January 2018.

Prevalence of frailty in older adults in outpatient physiotherapy in an urban region in the western part of Germany: a cross-sectional study.

OBJECTIVE: To investigate the prevalence of frailty in older people in outpatient physiotherapy services in an urban region in the western part of Germany. DESIGN: Cross-sectional study. SETTING: Outpatient physiotherapy clinics were recruited in the municipal area of the city of Bochum, Germany, and selected randomly. PARTICIPANTS: Older adults aged 65 years and older seeking outpatient physiotherapy. PRIMARY AND SECONDARY OUTCOME MEASURES: Prevalence of frailty was assessed based on the frailty phenotype model of physical frailty and the accumulation of deficit model, expressed as a Frailty Index. Prevalence was calculated for the whole sample and according to age-related, sex-related and diagnosis-related subgroups. RESULTS: A total of 258 participants (74±6 years, 62% female) from 11 out of 130 (8%) different physiotherapy clinics were included. Participants' main indication for physiotherapy was an orthopaedic or surgical condition (75%). According to the model of a physical frailty phenotype, 17.8% (95% CI 13.2 to 22.5) participants were frail and 43.4% (95% CI 37.4 to 49.5) were prefrail. The Frailty Index identified 31.0% (95% CI 25.4 to 36.7) of individuals as frail. In both models, prevalence increased with age and was higher in women than in men. Slow gait speed (34%), reduced muscle strength (34%) and exhaustion (28%) were the most prevalent indicators of physical frailty. CONCLUSIONS: Frailty is comparatively common in older patients attending physiotherapy care in Germany, with one out of three individuals being frail and every second individual being physically frail or prefrail. TRIAL REGISTRATION NUMBER: DRKS00009384; Results.