Bridging the gap between public health and primary care in prevention of cardiometabolic diseases; background of and experiences with the Prevention Consultation in The Netherlands.

BACKGROUND: There is an increasing need for programmatic prevention of cardiometabolic diseases (cardiovascular disease, type 2 diabetes and chronic kidney disease). Therefore, in the Netherlands, a prevention programme linked to primary care has been developed. This initiative was supported by the national professional organizations of GPs and occupational physicians as well as three large health foundations. OBJECTIVES: To describe and discuss the content, structure of and first experiences with this initiative. METHODS: Description of context, risk assessment tool, guideline, content of the Prevention Consultation and pilot studies. RESULTS: Preceding surveys revealed a need for proactive disease prevention, linked to primary care. An evidence-based guideline was developed using a validated eight-question screening list. According to the guideline, high-risk participants were advised to attend two consultations at the general practice, for completing the risk assessment and for tailored advice. Three pilot studies revealed that the programme was feasible and that (sufficient) participants with a condition requiring treatment were detected. We learned that with a 'passive' recruitment (with only posters and brochures), screening uptake is limited. A more active approach with a personal invitation from the GP is more effective. Both an Internet as written questionnaire should be available and reminders are necessary. The need for a consultation with the GP practice after a high-risk test result should be emphasized. The first consultation can be performed by a practice nurse. CONCLUSIONS: A national systematic screening programme for cardiometabolic diseases linked to primary care is feasible. The cost-effectiveness still has to be established.

Using consensus methods in developing clinical guidelines for exercise in managing persistent low back pain.

OBJECTIVES: To generate expert consensus evidence for the purpose of developing more complete guidelines for people with persistent low back pain than is possible using current research evidence alone. Gaps in research evidence lead to incomplete practice recommendations unless a scientific process can provide supplementary consensus evidence that is a basis for additional recommendations. DESIGN: A modified Nominal Group Technique (NGT). This followed a systematic review indicating incomplete research evidence. SETTING: UK-wide coordinated by the Chartered Society of Physiotherapy. PARTICIPANTS: Twenty-three individuals selected for their expertise as clinicians, researchers, managers and patients. METHODS: Three stages: a first-round questionnaire of clinical questions unanswered by the systematic review; an electronic conference for outstanding questions unanswered by the first questionnaire; and a second-round questionnaire for these outstanding questions. All three stages were carried out electronically. RESULTS: Of 17 clinical questions unanswered by the systematic review, consensus evidence was generated for 14 questions by the modified NGT and this led to 14 recommendations for practice. Consensus was not reached for the remaining three questions. CONCLUSIONS: The modified NGT was a practical and cost-effective way of generating consensus evidence from a UK-wide group. The consensus evidence was the basis of appropriately graded recommendations for effective care of people with persistent low back pain. Consensus methods have been little used in physiotherapy to date but are likely to be valuable in developing clinically useful, evidence-based tools for future practice.

Oxygen consumption during functional electrical stimulation-assisted exercise in persons with spinal cord injury: implications for fitness and health.

A lesion in the spinal cord leads in most cases to a significant reduction in active muscle mass, whereby the paralysed muscles cannot contribute to oxygen consumption (VO2) during exercise. Consequently, persons with spinal cord injury (SCI) can only achieve high VO2 values by excessively stressing the upper body musculature, which might increase the risk of musculoskeletal overuse injury. Alternatively, the muscle mass involved may be increased by using functional electrical stimulation (FES). FES-assisted cycling, FES-cycling combined with arm cranking (FES-hybrid exercise) and FES-rowing have all been suggested as candidates for cardiovascular training in SCI. In this article, we review the levels of VO2 (peak [VO2peak] and sub-peak [VO2sub-peak]) that have been reported for SCI subjects using these FES exercise modalities. A systematic literature search in MEDLINE, EMBASE, AMED, CINAHL, SportDiscus and the authors' own files revealed 35 studies that reported on 499 observations of VO2 levels achieved during FES-exercise in SCI. The results show that VO2peak during FES-rowing (1.98 L/min, n = 17; 24.1 mL/kg/min, n = 11) and FES-hybrid exercise (1.78 L/min, n = 67; 26.5 mL/kg/min, n = 35) is considerably higher than during FES-cycling (1.05 L/min, n = 264; 14.3 mL/kg/min, n = 171). VO2sub-peak values during FES-hybrid exercise were higher than during FES-cycling. FES-exercise training can produce large increases in VO2peak; the included studies report average increases of +11% after FES-rowing training, +12% after FES-hybrid exercise training and +28% after FES-cycling training. This review shows that VO2 during FES-rowing or FES-hybrid exercise is considerably higher than during FES-cycling. These observations are confirmed by a limited number of direct comparisons; larger studies to test the differences in effectiveness of the various types of FES-exercise as cardiovascular exercise are needed. The results to date suggest that FES-rowing and FES-hybrid are more suited for high-intensity, high-volume exercise training than FES-cycling. In able-bodied people, such exercise programmes have shown to result in superior health and fitness benefits. Future research should examine whether similar high-intensity and high-volume exercise programmes also give persons with SCI superior fitness and health benefits. This kind of research is very timely given the high incidence of physical inactivity-related health conditions in the aging SCI population.

The feasibility of functional electrical stimulation indoor rowing for high-energy training and sport.

Objectives. To explore the potential of functional electrical stimulation (FES)-assisted indoor rowing to enable spinal cord individuals to participate in indoor rowing competitions and to achieve high exercise intensities and volumes. Materials and Methods. Six spinal cord injured subjects used a newly developed four-channel, manually controlled, FES-rowing system for training and competition. Results. Four paraplegics and two quadriplegics used the newly developed FES-rowing system for long-term training. Moreover, they competed successfully with able-bodied rowers in major indoor rowing events; the 2004-2006 British and 2006 World Indoor Rowing Championships. The current best FES-rowing time for the official 2000 meter distance is 10:28. Steady state VO(2) values of 2.5 L/min (> 35 mL/kg/min) and weekly training volumes of 1150 kcal/week (4814 kJ/week) have been achieved. Conclusions. For the first time, individuals with spinal cord injury have participated, on an equal basis, in major indoor rowing events using FES. The FES-rowers attained high levels of exercise volume and intensity. These levels are higher than have been previously reported for FES exercise and are similar to those that have been associated with significant health benefits in the general population.