Monitoring handgrip strength to motivate lifestyle choices for patients with diabetes type 2 - a pragmatic randomised controlled trial.

METHODS: Measurement of HGS with Jamar dynamometers was added to annual check-ups for patients with T2DM by diabetes nurses in primary care with feedback about normal values for age and sex in the intervention group. The control group had standard check-ups. Change in self-reported PA level was measured with questionnaires. RESULTS: Seven clinics and 334 patients participated. The intervention led to similar effects on PA in both groups. Patients with T2DM had comparable HGS to the general public. Regression analyses showed statistically significantly higher HGS in the intervention group than in the control group at follow-up and no improvement in PA, HbA1c, or waist circumference. Increased HGS was found for older people, men, and people with normal-to-high inclusion HGS, while patients with low inclusion HGS reduced their strength levels. CONCLUSIONS: Measuring HGS and giving feedback to patients with T2DM can lead to increased HGS but does not seem to affect general PA level, HbA1c, or waist circumference. People over 65 years, men, and people with normal-to-high HGS were influenced positively by the intervention. Patients with low HGS may need personalised support to increase physical activity and improve function.ClinicalTrials registration: NCT03693521.

MediYoga compared to physiotherapy treatment as usual for patients with stress-related symptoms in primary care rehabilitation: A randomized controlled trial.

OBJECTIVE: The purpose of this study was to compare the effect of MediYoga as a group treatment to conventional treatment provided by a physiotherapist for people with perceived stress-related symptoms. DESIGN: Randomized controlled trial. SETTINGS: Primary care rehabilitation, Gothenburg Sweden. SUBJECTS: Fifty-five patients with stress-related symptoms were invited to participate. Nine patients declined, and a total of 46 patients aged 26-70 years (mean 47), 44 women and two men were randomized, 23 to the MediYoga group and 23 to the physiotherapy treatment as usual group. INTERVENTIONS: The MediYoga group performed MediYoga for one hour a week during an 8-week period. The control group received physiotherapy treatment as usual. MAIN MEASURES: Data were mainly collected by self-reported questionnaires. For primary outcome the Swedish version of the Perceived Stress Scale (PSS) was used. Secondary outcomes were the Hospital Anxiety and Depression Scale (HADS), EuroQol-5D (EQ-5D) and EuroQol-Visual Analog Scale (EQ-VAS). Thoracic excursion was the only physical measurement. Mixed effect model was used for analyse. RESULTS: For the primary outcome PSS, there was a close to statistically significant group effect over time advantaging MediYoga over physiotherapy (P = 0.06). For secondary outcomes, the group effect over time was statistically significant in HADS anxiety (P = 0.01) and EQ-VAS (P = 0.03). There was a group trend over time advantaging MediYoga in HADS depression (P = 0.08). CONCLUSION: Despite a large dropout in both groups, MediYoga can be recommended as a treatment option for people suffering from stress-related symptoms. TRIAL REGISTRATION: Registered in: ClinicalTrials.gov NCT02907138.

Experiences of rehabilitation coordination among people on sick leave with mental health problems.

PURPOSE: Return to work often requires collaboration between different stakeholders. Rehabilitation coordination is a resource in coordinating efforts during sick leave to facilitate return to work. The purpose of the present study was to describe how people at risk for sick leave or on sick leave with mental health problems experienced rehabilitation coordination. MATERIALS AND METHOD: The study had a qualitative approach using qualitative content analysis as described by Graneheim and Lundman. Eleven semi-structured interviews were conducted with persons at risk for sick leave or on sick leave due to mental health problems and with experience of rehabilitation coordination. RESULTS: The participants experience of rehabilitation coordination were described by the overarching theme Building a bridge with many bricks between the person and society. The theme was formed by four categories and eleven subcategories reflecting the complex context of rehabilitation coordination. The categories were Collaboration in a new setting, Unburdened within certain limits, The way back to work is a joint project and Recognising challenges beyond the person. CONCLUSIONS: People with mental health problems experienced rehabilitation coordination as a meaningful link between healthcare and work. However, rehabilitation coordination needs to be more recognised within healthcare to increase accessibility. It seems important that interventions are directed not only towards the person, but also include the workplace for a sustainable return to work.

It is important to make rehabilitation coordination visible within primary health care and actively inform people on sick leave with mental health problems that it is an option, as they often have difficulties finding information. It will increase their accessibility and enable autonomous decisions.A respectful interplay based on a person-centred care approach seems fundamental for rehabilitation coordination. The interplay with rehabilitation coordinators and with other stakeholders affects the sick leave process and all parties need to collaborate for a sustainable return to work.Three-party meetings with the person on sick leave, the rehabilitation coordinator and the employer, as well as teamwork, may provide better conditions for return to work as this can ensure that all stakeholders are working towards prioritised goals.Targeted interventions at the workplace seem to be important and rehabilitation coordination could be a valuable bridge between healthcare and work for creating sustainable conditions for return to work.

Prevention of sickness absence through early identification and rehabilitation of at-risk patients with musculoskeletal disorders (PREVSAM): short term effects of a randomised controlled trial in primary care.

PURPOSE: To evaluate short-term effects of the PREVention of Sickness Absence for Musculoskeletal disorders (PREVSAM) model on sickness absence and patient-reported health outcomes. METHODS: Patients with musculoskeletal disorders were randomised to rehabilitation according to PREVSAM or treatment as usual (TAU) in primary care. Sickness absence and patient-reported health outcomes were evaluated after three months in 254 participants. RESULTS: The proportion of participants remaining in full- or part-time work were 86% in PREVSAM vs 78% in TAU (p = 0.097). The PREVSAM group had approximately four fewer sickness benefit days during three months from baseline (p range 0.078-0.126). No statistically significant difference was found in self-reported sickness absence days (PREVSAM 12.4 vs TAU 14.5; p = 0.634), nor were statistically significant differences between groups found in patient-reported health outcomes. Both groups showed significant improvements from baseline to three months, except for self-efficacy, and only the PREVSAM group showed significantly reduced depression symptoms. CONCLUSIONS: The findings suggest that for sickness absence, the PREVSAM model may have an advantage over TAU, although the difference did not reach statistical significance at the p < 0.05 level, and similar positive effects on patient-reported health outcomes were found in both groups. Long-term effects must be evaluated before firm conclusions can be drawn.

Early identification of at-risk patients and team-based rehabilitation within primary care to prevent sickness absence and long-term problems due to acute/subacute musculoskeletal disorders has been scarcely studied.The PREVSAM model provides a framework for team-based interventions in primary care rehabilitation.The PREVSAM model may be used in the management of acute/subacute musculoskeletal disorders in the prevention of sickness absence.

The PREVSAM model, "prevention of sickness absence through early identification and rehabilitation of at-risk patients with musculoskeletal disorders", is seen as beneficial for patients risking persistent musculoskeletal disorders but may be difficult to implement - a focus group study.

PURPOSE: The rehabilitation model "Prevention of sickness absence through early identification and rehabilitation of at-risk patients with musculoskeletal disorders" (PREVSAM) was tested in a randomised controlled trial. This study aimed to explore participating healthcare professionals' experiences of working according to the PREVSAM model, and their perceptions of its clinical benefit and feasibility in primary care rehabilitation. METHODS: A focus group study including 12 healthcare professionals from five primary care rehabilitation clinics was analysed according to the focus group methodology described by Krueger and Casey. RESULTS: Four themes were identified. A clear framework describes how PREVSAM facilitates person-centred teamwork. The value of teamwork highlights benefits and challenges with teamwork. Through thick and thin discusses perceived patient benefits. In the ideal world focusses on feasibility of implementing the model. CONCLUSIONS: The participants experienced that the PREVSAM model may be beneficial for the patients, for their own work situation and workplace, and for society. Identifying psychological risk factors was perceived as helpful, but not enough to capture patients in need of team-based rehabilitation. While considered feasible, barriers for implementing the model were identified. Managers and healthcare policy makers must prioritise and create appropriate conditions for team-based musculoskeletal rehabilitation in primary care.

Rehabilitation of musculoskeletal disorders is common in primary care and rehabilitation models to identify patients at risk and prevent persistent pain and sickness absence are needed.Working according to the PREVSAM model, 'Prevention of sickness absence through early identification and rehabilitation of at-risk patients with musculoskeletal disorders', with a person-centred approach to assess the patients' needs, motivation, and resources for team-based interventions were considered beneficial for the target group of patients.The PREVSAM model may contribute to increased job satisfaction and reduce the team members' workload.The PREVSAM model requires managers at all levels, as well as healthcare policy makers, to prioritise team-based rehabilitation.

The Swedish version of the pain self-efficacy questionnaire short form, PSEQ-2SV: Cultural adaptation and psychometric evaluation in a population of patients with musculoskeletal disorders.

OBJECTIVES: Measuring pain self-efficacy is suggested as relevant in patients with musculoskeletal disorders (MSDs) in a primary care setting. However, there is no pain self-efficacy questionnaire (PSEQ) available in Swedish. The aim of this study was to translate and culturally adapt PSEQ-2 to Swedish and evaluate reliability and validity in a population of patients with MSDs. METHODS: A translation and cultural adaptation together with psychometric evaluation of reliability and validity were performed according to guidelines with three groups of participants with MSDs. First, a convenient sample of 25 individuals were interviewed in the translation process. Next, 61 participants completed the test-retest survey via social media or QR codes in waiting rooms in rehabilitation clinics. Finally, to evaluate construct validity questionnaires were obtained from 132 participants with MSDs in an ongoing randomized controlled trial. RESULTS: The Swedish version of PSEQ-2 showed adequate face and content validity. The results of 0.805 on Cohen's weighted kappa indicate that the reliability of PSEQ-2SV in a group of adults with MSDs is on the border between substantial and almost perfect. The point estimate regarding relative rank variance, measuring the individual variation within the group, and relative concentration, the systematic change in how the assessments are concentrated on the scale's categories, shows minor systematic differences and some random differences not neglectable. The construct validity of pre-defined hypotheses was met to some degree. CONCLUSION: The PSEQ-2SV has been accurately linguistically translated and tested for reliability and validity, in a population of MSDs, and is deemed to be able to be used in the clinic and in research. As there were some concerns regarding measurement error and systematic bias, more research could be of value.

Evaluation of novel radiation protection devices during radiologically guided interventions.

BACKGROUND: In radiologically guided interventions, medical practitioners are subjected to radiation exposure, which may lead to radiation-induced diseases. In this study, novel radiation shields for the head and neck were evaluated for their potential to reduce radiation exposure. METHOD: An anthropomorphic phantom was exposed on its left side to scattered radiation from beneath to simulate the exposure of an operator in a x-ray operating room. Thermoluminescent dosimeters (TLDs) were positioned at different depths in five slices in the phantom, measuring personal dose equivalent. Two different set up situations were evaluated: a head protector designed to reduce radiation in the upper section of the head; and a novel thyroid protector prototype extended in the front and on both sides, designed to reduce radiation in the lower and middle sections of the head. A standard thyroid collar prototype and a ceiling mounted lead glass shield were used as comparisons. Furthermore, the head protector was evaluated in a clinical study in which TLDs were positioned to measure scattered radiation exposure to the heads of operators during endovascular interventions. RESULTS: The extended thyroid protector reduced the scattered radiation in the throat, chin, and ear slices. Some shielding effect was seen in the brain and skull slices. The head protector showed a shielding effect in the skull slice up to two cm depth where it covered the phantom head. As expected, the ceiling mounted lead glass shield reduced the scattered radiation in all measuring points. CONCLUSIONS: A ceiling mounted lead glass shield is an effective radiation protection for the head, but in clinical practice, optimal positioning of a ceiling mounted lead shield may not always be possible, particularly during complex cases when radiation protection may be most relevant. Added protection using these novel guards may compliment the shielding effect of the ceiling mounted lead shield. The head protector stand-alone did not provide sufficient protection of the head. The extended thyroid protector stand-alone provided sufficient protection in the lower and middle sections of the head and neck.

The Impact of Exercising on Pelvic Symptom Severity, Pelvic Floor Muscle Strength, and Diastasis Recti Abdominis After Pregnancy: A Longitudinal Prospective Cohort Study.

OBJECTIVE: The objective of this study was to evaluate whether early postpartum exercise is associated with changes in pelvic symptom severity, pelvic floor muscle strength, and diastasis recti abdominis (DRA) from 3 to 12 months postpartum. METHODS: In this prospective cohort study, 504 participants with and without pelvic symptoms (pelvic girdle pain, stress urinary incontinence, vaginal heaviness) were followed. At 3, 6, 9, and 12 months postpartum, we assessed pelvic symptoms, exercise behavior (by questionnaires), pelvic floor muscle strength (by vaginal palpation), and DRA (by caliper measurement). Based on the 3-months questionnaire, participants were categorized as nonexercisers (n = 105), minimal low-impact exercisers (n = 249), regular low-impact exercisers (n = 117), and high-impact exercisers (n = 32). Between-group differences and within-group changes from 3 to 12 months were calculated using Chi-square tests, Kruskal-Wallis tests, and Friedman analysis of variance. RESULTS: At 3 months, no differences in symptom prevalence were seen between the groups. Nonexercisers reported higher pelvic girdle pain severity and had weaker pelvic floor muscles. The within-group analysis showed that pelvic girdle pain severity did not change in nonexercisers or high-impact exercisers, but decreased in minimal and regular low-impact exercisers. Stress urinary incontinence increased in nonexercisers from 3 to 12 months, while it remained unchanged in regular low-impact and high-impact exercisers, and decreased in minimal low-impact exercisers. Across all groups, vaginal heaviness and DRA decreased, and pelvic floor strength increased from 3 to 12 months. CONCLUSION: The study indicates that early low-impact exercising is associated with reduced pelvic girdle pain severity during the first postpartum year. Minimal low-impact exercisers also showed a slight reduction in stress urinary incontinence. Conversely, nonexercisers reported an increase in stress urinary incontinence between 3 and 12 months postpartum. IMPACT: Physical therapists should encourage women to start with low-impact exercise early after pregnancy. LAY SUMMARY: This study highlights the positive effects of starting gentle, low-impact exercise early after childbirth to reduce pelvic girdle pain and urinary incontinence.

Digital physiotherapy assessment vs conventional face-to-face physiotherapy assessment of patients with musculoskeletal disorders: A systematic review.

BACKGROUND: This systematic review aimed to assess the certainty of evidence for digital versus conventional, face-to-face physiotherapy assessment of musculoskeletal disorders, concerning validity, reliability, feasibility, patient satisfaction, physiotherapist satisfaction, adverse events, clinical management, and cost-effectiveness. METHODS: Eligibility criteria: Original studies comparing digital physiotherapy assessment with face-to-face physiotherapy assessment of musculoskeletal disorders. Systematic database searches were performed in May 2021, and updated in May 2022, in Medline, Cochrane Library, Cinahl, AMED, and PEDro. Risk of bias and applicability of the included studies were appraised using the Quality Assessment of Diagnostic Accuracy Studies-2 tool and the Quality Appraisal of Reliability Studies tool. Included studies were synthesised narratively. Certainty of evidence was evaluated for each assessment component using GRADE. RESULTS: Ten repeated-measures studies were included, involving 193 participants aged 23-62 years. Reported validity of digital physiotherapy assessment ranged from moderate/acceptable to almost perfect/excellent for clinical tests, range of motion, patient-reported outcome measures (PROMs), pain, neck posture, and management decisions. Reported validity for assessing spinal posture varied and was for clinical observations unacceptably low. Reported validity and reliability for digital diagnosis ranged from moderate to almost perfect for exact+similar agreement, but was considerably lower when constrained to exact agreement. Reported reliability was excellent for digital assessment of clinical tests, range of motion, pain, neck posture, and PROMs. Certainty of evidence varied from very low to high, with PROMs and pain assessment obtaining the highest certainty. Patients were satisfied with their digital assessment, but did not perceive it as good as face-to-face assessment. DISCUSSION: Evidence ranging from very low to high certainty suggests that validity and reliability of digital physiotherapy assessments are acceptable to excellent for several assessment components. Digital physiotherapy assessment may be a viable alternative to face-to-face assessment for patients who are likely to benefit from the accessibility and convenience of remote access. TRIAL REGISTRATION: The review was registered in the PROSPERO database, CRD42021277624.

Cost-Effectiveness of Prolonged Physical Activity on Prescription in Previously Non-Complying Patients: Impact of Physical Activity Mediators.

In Sweden, physical activity on prescription (PAP) is used to support patients in increasing their levels of physical activity (PA). The role of healthcare professionals in supporting PA behavior change requires optimization in terms of knowledge, quality and organization. This study aims to evaluate the cost-effectiveness of support from a physiotherapist (PT) compared to continued PAP at a healthcare center (HCC) for patients who remained insufficiently active after 6-month PAP treatment at the HCC. The PT strategy was constituted by a higher follow-up frequency as well as by aerobic physical fitness tests. The analysis was based on an RCT with a three-year time horizon, including 190 patients aged 27-77 with metabolic risk factors. The cost per QALY for the PT strategy compared to the HCC strategy was USD 16,771 with a societal perspective (including individual PA expenses, production loss and time cost for exercise, as well as healthcare resource use) and USD 33,450 with a healthcare perspective (including only costs related to healthcare resource use). Assuming a willingness-to-pay of USD 57,000 for a QALY, the probability of cost-effectiveness for the PT strategy was 0.5 for the societal perspective and 0.6 for the healthcare perspective. Subgroup analyses on cost-effectiveness based on individual characteristics regarding enjoyment, expectations and confidence indicated potential in identifying cost-effective strategies based on mediating factors. However, this needs to be further explored. In conclusion, both PT and HCC interventions are similar from a cost-effectiveness perspective, indicating that both strategies are equally valuable in healthcare's range of treatments.

Can Clinical Postpartum Muscle Assessment Help Predict the Severity of Postpartum Pelvic Girdle Pain? A Prospective Cohort Study.

OBJECTIVE: The purpose of this study was to evaluate whether the clinical assessment of pelvic floor muscles and the diastasis recti abdominis could predict the severity of pelvic girdle pain during the first year postpartum. METHODS: Between 2018 and 2020, 504 women were recruited to this prospective longitudinal cohort study. At 2 to 3 months postpartum, their pelvic floor muscles and diastasis recti abdominis were assessed using vaginal palpation, observation, and caliper measurement. The participants completed the Pelvic Girdle Questionnaire (PGQ) at 2 to 3, 6, 9, and 12 months postpartum. Mixed-effect models were used to determine how the results of pelvic floor muscle and diastasis recti abdominis assessments predicted the PGQ score. A sub-analysis for middle to high PGQ scores was conducted. RESULTS: Maximal voluntary pelvic floor muscle contractions ≥3 (Modified Oxford Scale, scored from 0 to 5) predicted a decreased PGQ score (ß = -3.13 [95% CI = -5.77 to -0.48]) at 2 to 3 months postpartum, with a higher prediction of a middle to high PGQ score (ß = -6.39). Diastasis recti abdominis width did not have any significant correlation with the PGQ score. A sub-analysis showed that a diastasis recti abdominis width ≥35 mm predicted an increased PGQ score (ß = 5.38 [95% CI = 1.21 to 9.55]) in women with pelvic girdle pain. CONCLUSION: The distinction between weak and strong maximal voluntary pelvic floor muscle contractions is an important clinical assessment in women with postpartum pelvic girdle pain. The exact diastasis recti abdominis width, measured in millimeters, showed no clinical relevance. However, a diastasis recti abdominis width ≥35 mm was associated with a higher PGQ score, and further research about this cutoff point in relation to pain is needed. IMPACT: This study highlights the importance of clinical assessment of pelvic floor muscles in patients with postpartum pelvic girdle pain. A better understanding of the role of this muscle group will enable more effective physical therapist treatment of pelvic girdle pain.

The effects of a 5-year physical activity on prescription (PAP) intervention in patients with metabolic risk factors.

BACKGROUND: Increased physical activity (PA) has positive effects on health and longevity. In Swedish healthcare, the physical activity on prescription (PAP) method reportedly increases patients' PA levels for up to 12 months, but long-term follow ups are lacking. As it remains difficult to maintain lifestyle changes, our aim was to evaluate adherence and clinical effects at a 5-year follow-up of PAP treatment in primary healthcare. METHODS: This longitudinal, prospective cohort study included 444 patients, (56% female), aged 27-85 years, with at least one metabolic risk factor. Participants were offered PAP by nurses or physiotherapists. The PAP intervention included an individualised dialogue, a PA recommendation by written prescription, and individually adjusted follow-up over 5 years, according to the Swedish PAP model. Patient PA level, metabolic risk factors, and health related quality of life (HRQoL) were measured at baseline and at the 6-month, 1.5-year, 2.5-year, 3.5-year, and 5-year follow-ups. Estimated latent growth curves were used to examine levels and rates of change in the outcomes. RESULTS: The study dropout rate was 52%, with 215 of 444 patients completing the 5-year follow-up. At follow-up, the mean PA level had increased by 730 MET-minutes per week or 3 hours of moderate-intensity PA/week when compared to baseline. During the 5-year intervention, we observed significant positive changes (p ≤ 0.05) in 9 of 11 metabolic risk factors and HRQoL parameters: body mass index, waist circumference, systolic and diastolic blood pressure, fasting plasma glucose, triglycerides, cholesterol, high-density lipoprotein, and mental component summary. CONCLUSION: This first evaluation of a 5-year PAP intervention in primary care demonstrated positive long-term (5 years) effects regarding PA level, metabolic health, and HRQoL. The recorded long-term adherence was ~50%, which is in line with medical treatment. Despite limitations, PAP can have long-term effects in an ordinary primary care setting.

Implementation of physical activity on prescription for children with obesity in paediatric health care (IMPA): protocol for a feasibility and evaluation study using quantitative and qualitative methods.

BACKGROUND: Physical inactivity is a main cause of childhood obesity which tracks into adulthood obesity, making it important to address early in life. Physical activity on prescription (PAP) is an evidence-based intervention that has shown good effect on physical activity levels in adults, but has not been evaluated in children with obesity. This project aims to evaluate the prerequisites, determinants, and feasibility of implementing PAP adapted to children with obesity and to explore children's, parents', and healthcare providers' experiences of PAP. METHODS: In the first phase of the project, healthcare providers and managers from 26 paediatric clinics in Region Västra Götaland, Sweden, will be invited to participate in a web-based survey and a subset of this sample for a focus group study. Findings from these two data collections will form the basis for adaptation of PAP to the target group and context. In a second phase, this adapted PAP intervention will be evaluated in a clinical study in a sample of approximately 60 children with obesity (ISO-BMI > 30) between 6 and 12 years of age and one of their parents/legal guardians. Implementation process and clinical outcomes will be assessed pre- and post-intervention and at 8 and 12 months' follow-up. Implementation outcomes are the four core constructs of the Normalization Process Theory; coherence, cognitive participation, collective action, and reflexive monitoring; and appropriateness, acceptability, and feasibility of the PAP intervention. Additional implementation process outcomes are recruitment and attrition rates, intervention fidelity, dose, and adherence. Clinical outcomes are physical activity pattern, BMI, metabolic risk factors, health-related quality of life, sleep, and self-efficacy and motivation for physical activity. Lastly, we will explore the perspectives of children and parents in semi-structured interviews. Design and analysis of the included studies are guided by the Normalization Process Theory. DISCUSSION: This project will provide new knowledge regarding the feasibility of PAP for children with obesity and about whether and how an evidence-based intervention can be fitted and adapted to new contexts and populations. The results may inform a larger scale trial and future implementation and may enhance the role of PAP in the management of obesity in paediatric health care in Sweden. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT04847271 , registered 14 April 2021.

Clinical assessment of pelvic floor and abdominal muscles 3 months post partum: an inter-rater reliability study.

OBJECTIVES: Evaluation of the inter-rater reliability of clinical assessment methods for pelvic floor muscles and diastasis recti abdominis post partum. DESIGN: A multicentre inter-rater reliability study. SETTING: Three primary care rehabilitation centres in Sweden. PARTICIPANTS: A total of 222 participants were recruited via advertising at Swedish maternity care units and social media. Eligibility for participation included female gender, ≥18 years, at maximum 3 months after childbirth. Exclusion criteria were chronic pelvic girdle pain and/or low back pain and/or pelvic floor tear grade III/IV. At each centre, 2 physiotherapists, with training and experience in pelvic floor assessment, assessed the 222 women according to a standardised protocol in random order. OUTCOME MEASURES: Inter-rater reliability of the assessment of pelvic floor muscle function (involuntary and voluntary contraction and voluntary relaxation) and diastasis recti abdominis (width, depth and bulging). RESULTS: Vaginal palpation of maximal voluntary contraction revealed a kappa value of 0.69 (95% CI 0.62 to 0.76). Assessments of involuntary contraction and voluntary relaxation yielded inconsistent results, with slight-to-moderate weighted kappa values ranging from 0.10 to 0.51. After 2 months of training in applying this method, diastasis recti abdominis width measured at the umbilicus by calliper yielded an intraclass correlation coefficient value of 0.83 (95% CI 0.76 to 0.87). Assessments of diastasis recti abdominis depth and bulging showed moderate kappa values, with reservation for some inconsistency between the centres. CONCLUSIONS: Vaginal palpation of pelvic floor muscle strength is a reliable method for the postpartum muscle assessment. Additional research is needed to identify reliable assessment method for other pelvic floor muscle functions like involuntary contraction and voluntary relaxation. With some training, a calliper is a reliable instrument for measuring the postpartum diastasis recti abdominis width. This study provides novel thoughts about how to measure diastasis recti abdominis depth and bulging. TRIAL REGISTRATION NUMBER: NCT03703804.

Tailored physical activity on prescription with follow-ups improved motivation and physical activity levels. A qualitative study of a 5-year Swedish primary care intervention.

OBJECTIVE: To explore how physically inactive patients, with metabolic risk factors, experienced long term treatment with physical activity on prescription. DESIGN: Qualitative content analysis of individual interviews after strategical sampling of respondents. SETTING: Fifteen primary health care centres in Gothenburg, Sweden. SUBJECTS: Twenty physically inactive patients, with one or more metabolic syndrome components, 9 women, 11 men, mean age 58 years (25-73); 10 patients were responders and 10 non-responders to the intervention. MAIN OUTCOME MEASURES: Categories describing treatment effect and successful intervention. RESULTS: The interviews revealed three categories of effect. First, individual adjustments contributed to increased physical activity. Second, follow-up and support were valuable aids for prioritising and maintaining lifestyle changes. Third, motivation could be higher if patients make their own choices and experienced positive health effects. The overarching emerging theme was 'tailored physical activity on prescription with regular follow-ups can contribute to increased and maintained motivation and physical activity levels.'Conclusion Physical activity on prescription in a Swedish primary care setting was successful when the recommended physical activity and follow up was individually adapted. KEY POINTS Individually adapted physical activity on prescription gave insight to increase physical activity levels in a 5-year Swedish primary care intervention directed towards inactive patients with the metabolic syndrome Motivation increased for patients designing their own routines for physical activity. Experiences of positive health effects helped maintain or increase physical activity levels, and follow-up and support from healthcare professionals helped to prioritise life style changes.

Long-term physical activity on prescription intervention for patients with insufficient physical activity level-a randomized controlled trial.

BACKGROUND: Physical activity (PA) can be used to prevent and treat diseases. In Sweden, licensed healthcare professionals use PA on prescription (PAP) to support patients to increase their PA level. The aim of this randomized controlled trial was to evaluate a 2-year intervention of two different strategies of PAP treatment for patients with insufficient PA level, after a previous 6-month period of ordinary PAP treatment in a primary health care setting. METHODS: We included 190 patients, 27-77 years, physically inactive with metabolic risk factors where the patients were not responding to a previous 6-month PAP treatment with increased PA. The patients were randomized to either enhanced support from a physiotherapist (PT group) or continued ordinary PAP treatment at the health care centre (HCC group). The PAP treatment included an individualized dialogue; an individually dosed PA recommendation, including a written prescription; and a structured follow-up. In addition to PAP, the PT group received aerobic fitness tests and more frequent scheduled follow-ups. The patient PA level, metabolic health, and health-related quality of life (HRQOL) were measured at baseline and at 1- and 2-year follow-ups. RESULTS: At the 2-year follow-up, 62.9% of the PT group and 50.8% of the HCC group had increased their PA level and 31.4% vs. 38.5% achieved ≥ 150 min of moderate-intensity PA/week (difference between groups n.s.). Over 2 years, both groups displayed increased high-density lipoproteins (HDL) (p = 0.004 vs. baseline), increased mental health status (MCS) (p = 0.036), and reduced body mass index (BMI) (p = 0.001), with no difference between groups. CONCLUSION: During long-term PAP interventions, the PA level, metabolic health, and HRQOL increased in patients at metabolic risk without significant differences between groups. The results indicate to be independent of any changes in pharmacological treatment. We demonstrated that the PAP treatment was feasible in ordinary primary care. Both the patients and the healthcare system benefitted from the improvement in metabolic risk factors. Future studies should elucidate effective long-term PAP-treatment strategies. TRIAL REGISTRATION: ClinicalTrials.gov NCT03012516 . Registered on 30 December 2016-retrospectively registered.

Effects of exercise therapy in patients with acute low back pain: a systematic review of systematic reviews.

BACKGROUND: Acute low back pain is associated with pain and disability, but symptoms are often self-healing. The effectiveness of exercise therapy for acute low back pain remains uncertain with conflicting evidence from systematic reviews. The aim of this systematic review of systematic reviews was to assess the overall certainty of evidence for the effects of exercise therapy, compared with other interventions, on pain, disability, recurrence, and adverse effects in adult patients with acute low back pain. METHODS: PubMed, the Cochrane library, CINAHL, PEDro, Open Grey, Web of Science, and PROSPERO were searched for systematic reviews of randomized controlled trials. Methodological quality was assessed independently by two authors using AMSTAR. Meta-analyses were performed if possible, using data from the original studies. Data for pain, disability, recurrence, and adverse effects were analyzed. Certainty of evidence was assessed using GRADE. RESULTS: The searches retrieved 2602 records, of which 134 publications were selected for full-text screening. Twenty-four reviews were included, in which 21 randomized controlled trials (n = 2685) presented data for an acute population, related to 69 comparisons. Overlap was high, 76%, with a corrected covered area of 0.14. Methodological quality varied from low to high. Exercise therapy was categorized into general exercise therapy, stabilization exercise, and McKenzie therapy. No important difference in pain or disability was evident when exercise therapy was compared with sham ultrasound, nor for the comparators usual care, spinal manipulative therapy, advice to stay active, and educational booklet. Neither McKenzie therapy nor stabilization exercise yielded any important difference in effects compared with other types of exercise therapy. Certainty of evidence varied from very low to moderate. CONCLUSIONS: The findings suggest very low to moderate certainty of evidence that exercise therapy may result in little or no important difference in pain or disability, compared with other interventions, in adult patients with acute low back pain. A limitation of this systematic review is that some included reviews were of low quality. When implementing findings of this systematic review in clinical practice, patients' preferences and the clinician's expertise also should be considered, to determine if and when exercise therapy should be the intervention of choice. SYSTEMATIC REVIEW REGISTRATION: PROSPERO: CRD46146, available at: https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=46146 .

Implementation of a novel return-to-work approach for persons with affective disorders in a traditional vocational rehabilitation context: a case study.

BACKGROUND: The person-centred Individual Enabling and Support (IES) model is a novel return-to-work (RTW) intervention for people with affective disorders that was developed from evidence-based supported employment for persons with severe mental illness. Typically, supported employment is integrated into mental healthcare and provides a network around the service user and close collaboration with employment and insurance services and employers. Introducing integrated models into a highly sectored welfare system that includes traditional mental healthcare and vocational rehabilitation is challenging. Greater knowledge is needed to understand how facilitating or hindering factors influence this introduction. The aim of this study was to investigate essential components in implementation of the IES model. METHODS: A case-study was conducted and included four mental healthcare services. Data collection was comprised of semi-structured interviews with 19 key informants, documentation from meetings, and reflection notes. Analyses were performed according to directed content analysis, using the components of the Consolidated Framework of Implementation Research (CFIR) as a guiding tool. Fidelity assessments were performed at 6 and 12 months. RESULTS: Anticipating RTW support for the target group, and building collaborative relationships and a network with employment specialists that engaged staff in every organization were components that resulted in the greatest facilitation if IES implementation. Barriers consisted of difficulty in integrating employment specialists into the mental healthcare teams, insufficient engagement of first line managers, reorganization and differing perceptions of the IES model fit into a traditional vocational context. Delivery of the IES model had good fidelity. CONCLUSIONS: The IES model can be implemented with good fidelity, several model advantages, and context adaptation. Team integration difficulties and negative perceptions of model fit in a traditional vocational rehabilitation context can be overcome to a certain degree, but this is insufficient for sustainable implementation on a larger scale. Policy and guidelines need to promote integrative and person-centred RTW approaches rather than a segregated stepwise approach. Further implementation studies in the traditional vocational rehabilitation context are needed.

Gothenburg Very Early Supported Discharge study (GOTVED): a randomised controlled trial investigating anxiety and overall disability in the first year after stroke.

BACKGROUND AND PURPOSE: Early supported discharge (ESD) has been shown to be efficient and safe as part of the stroke care pathway. The best results have been seen with a multidisciplinary team and after mild to moderate stroke. However, how very early supported discharge (VESD) works has not been studied. The aim of this study was to investigate whether VESD for stroke patients in need of ongoing individualized rehabilitation affects the level of anxiety and overall disability for the patient compared with ordinary discharge routine. METHODS: A randomized controlled trial was performed with intention to treat analyses comparing VESD and ordinary discharge from hospital. All patients admitted at the stroke care unit at Sahlgrenska University Hospital of Gothenburg between August 2011 and April 2016 were screened. Inclusion occurred on day 4 using a block randomization of 20 and with a blinded assessor. Assessments were made 5 days post-stroke and 3 and 12 months post-stroke. Patients in the VESD group underwent continued rehabilitation in their homes with a multidisciplinary team from the stroke care unit for a maximum of 1 month. The patients in the control group had support as usual after discharge when needed such as home care service and outpatient rehabilitation. The primary outcome was anxiety as assessed by the Hospital Anxiety and Depression Scale-Anxiety subscale (HADS-A). The secondary outcome was the patients' degree of overall disability, measured by the modified Rankin Scale (mRS). RESULTS: No significant differences were found between the groups regarding anxiety at three or 12 months post-stroke (p = 0.811). The overall disability was significantly lower in the VESD group 3 months post-stroke (p = 0.004), compared to the control group. However, there was no significant difference between the groups 1 year post-stroke. CONCLUSIONS: The VESD does not affects the level of anxiety compared to ordinary rehabilitation. The VESD leads to a faster improvement of overall disability compared to ordinary rehabilitation. We suggest considering coordinated VESD for patients with mild to moderate stroke in addition to ordinary rehabilitation as part of the service from a stroke unit. TRIAL REGISTRATION: Clinical Trials.gov: NCT01622205. Registered 19 June 2012 (retrospectively registered).

More cost-effective management of patients with musculoskeletal disorders in primary care after direct triaging to physiotherapists for initial assessment compared to initial general practitioner assessment.

BACKGROUND: A model for triaging patients in primary care to provide immediate contact with the most appropriate profession to treat the condition in question has been developed and implemented in parts of Sweden. Direct triaging of patients with musculoskeletal disorders (MSD) to physiotherapists at primary healthcare centres has been proposed as an alternative to initial assessment by general practitioners (GPs) and has been shown to have many positive effects. The aim of this study was to evaluate the cost-effectiveness from the societal perspective of this new care-pathway through primary care regarding triaging patients with MSD to initial assessment by physiotherapists compared to standard practice with initial GP assessment. METHODS: Nurse-assessed patients with MSD (N = 55) were randomised to initial assessment and treatment with either physiotherapists or GPs and were followed for 1 year regarding health-related quality of life, utilization of healthcare resources and absence from work for MSD. Quality-adjusted life-years (QALYs) were calculated based on EQ5D measured at 5 time-points. Costs for healthcare resources and production loss were compiled. Incremental cost-effectiveness ratios (ICERS) were calculated. Multiple imputation was used to compensate for missing values and bootstrapping to handle uncertainty. A cost-effectiveness plane and a cost-effectiveness acceptability curve were construed to describe the results. RESULTS: The group who were allocated to initial assessment by physiotherapists had slightly larger gains in QALYs at lower total costs. At a willingness-to-pay threshold of 20,000 €, the likelihood that the intervention was cost-effective from a societal perspective including production loss due to MSD was 85% increasing to 93% at higher thresholds. When only healthcare costs were considered, triaging to physiotherapists was still less costly in relation to health improvements than standard praxis. CONCLUSION: From the societal perspective, this small study indicated that triaging directly to physiotherapists in primary care has a high likelihood of being cost-effective. However, further larger randomised trials will be necessary to corroborate these findings. TRIAL REGISTRATION: ClinicalTrials.gov NCT02218749 . Registered August 18, 2014.