Randomized Clinical-Trial of Manipulative Therapy and Physiotherapy for Persistent Back and Neck Complaints - Results of One Year Follow-Up

Objective - To compare the effectiveness of manipulative therapy, physiotherapy, treatment by the general practitioner, and placebo therapy in patients with persistent non-specific back and neck complaints. Design - Randomised clinical trial. Setting-Primary health care in the Netherlands. Patients-256 patients with non-specific back and neck complaints of at least six weeks' duration who had not received physiotherapy or manipulative therapy in the past two years. Interventions - At the discretion of the manipulative therapists, physiotherapists, and general practitioners. Physiotherapy consisted of exercises, massage, and physical therapy (heat, electrotherapy, ultrasound, shortwave diathermy). Manipulative therapy consisted of manipulation and mobilisation of the spine. Treatment by general practitioners consisted of drugs (for example, analgesics), advice about posture, home exercises, and (bed)rest. Placebo treatment consisted of detuned shortwave diathermy (10 minutes) and detuned ultrasound (10 minutes). Main outcome measures - Changes in severity of the main complaint and limitation of physical functioning measured on 10 point scales by a blinded research assistant and global perceived effect measured on a 6 point scale by the patients. Results - Many patients in the general practitioner and placebo groups received other treatment during follow up. Improvement in the main complaint was larger with manipulative therapy (4·5) than with physiotherapy (3·8) after 12 months' follow up (difference 0·9; 95% confidence interval 0·1 to 1·7). Manipulative therapy also gave larger improvements in physical functioning (difference 0·6; -0·1 to 1·3). The global perceived effect after six and 12 months' follow up was similar for both treatments. Conclusions - Manipulative therapy and physiotherapy are better than general practitioner and placebo treatment. Furthermore, manipulative therapy is slightly better than physiotherapy after 12 months

Methods used for research regarding iteration in instructional design

This paper focuses on the search for suitable research methods for research regarding iteration in instructional design. More specifically my research concerned the question how instructional designers can be supported during an iterative design process. Although instructional design and development models are very useful, they do not help instructional designers to customise and continuously adapt the design process itself. They also do not help them to deal with the large variety of pragmatic factors (ranging from financial constraints to conflicts in the design team). Now, at the end of my own Ph.D. research, I understand why I did not find research studies regarding iteration in instructional design in the literature: iteration is difficult to observe and measure. Studying iteration during the design process requires a longer time-span, a case that is realistic in size and complexity, and the occurrence of the kind of events that would trigger iteration in practice. Thus, controlled laboratory studies are not suitable, which is unfortunate because think-aloud protocols would give the most information about why and how designers iterate. Case studies, on the other hand, would be long and labour-intensive, and they give the researcher no control over what happens. Furthermore, the differences between cases are likely to be so large that it will be difficult to compare them in order to come to a more general theory regarding iteration. In my own evaluation studies the use of an existing instructional design method and prototype tool, and a realistic case offered an environment in which it was possible to define and study iteration. The empirical setting allowed some control over what happened and made it possible to record a considerable amount of information about the subjects' design process. The results of two empirical evaluation studies were subsequently compared to case studies concerning real design problems

Iteration in design processes

Ideally, specifications for all products should be based on a systematic analysis of what prospective users need to do, and how they can do it most effectively and efficiently. In practice, the design process is disturbed by many 'pragmatic' factors, such as conflicting constraints, interference from management, personnel changes in design teams and technological progress leading to new possibilities. Therefore, design is an iterative process. In this paper the design task of training simulator specification is used to illustrate the iterative nature of design processes. The results of two empirical studies show no clear relation between the amount of iteration and the quality of the resulting designs. Frequent iteration can be part of both an effective and an ineffective design style. In order to develop support for managing iteration during the design process it is necessary to understand in which circumstances iteration needs to occur, and how these circumstances can be predicted or recognised. For this purpose, a list of triggers for iteration is described. Finally, a number of measures to help designers to manage an iterative design process is proposed

Which events can cause iteration in instructional design? An empirical study of the design process

Instructional design is not a linear process: designers have to weigh the advantages and disadvantages of alternative solutions, taking into account different kinds of conflicting and changing constraints. To make sure that they eventually choose the most optimal one, they have to keep on collecting information, reconsidering continuously whether their own decisions are still justified in the light of the latest insights. We have studied the role of iteration during instructional design. For our research, we have used an ISD-based method for the specification of training simulators. During our empirical evaluation study, we introduced five events that are likely to cause iteration. The results show that the quality of the designs is not directly related to the amount of iteration. We conclude that there are different kinds of iteration, triggered by different kinds of actions and events. We propose a list of triggers for iteration some of which originate from outside (new information, new opinions/arguments and acquisition procedures); others are caused by, or evolve from interaction with the design process itself (discovery of missing input, need to repair errors, new insights based on work later on in the design process, and new ideas of the designers)

Designing needs statements in a systematic iterative way

Designing specifications for technically advanced instructional products, such as e-learning, simulations or simulators requires different kinds of expertise. The SLIM method proposes to involve all stakeholders from the beginning in a series of workshops under the guidance of experienced instructional designers. These instructional designers ensure that specifications are designed in a systematic, iterative, way based on instructional design and development models. The workshop participants, however, bring in all the necessary information and they take all the decisions. The SLIM method is geared towards the first phase of the instructional design process: designing a needs statement in the form of a first set of global user requirements. It has been used in eight case studies. The results of these case studies have led to improvements to the method and suggestions for further research

Out of sight, out of mind? A qualitative study of patients' perspectives on cross-border healthcare in a European border region

ABSTR A C T Objective: To improve our understanding of patients' needs in cross-border healthcare, with a specific focus on handover. Methods: In this qualitative study, we conducted narrative interviews with 8 patients who had experienced cross-border healthcare, including handover. Based on an inductive analysis, we crafted stories representing participants' perspectives. Crafted stories attend to the personal character of patients' experiences. Results: We crafted 3 stories relating patients' cross-border healthcare pathways. We identified 3 recurring issues in these stories: (1) Patient involvement in the decision-making process regarding their healthcare; (2) Communication with their healthcare providers; and (3) Information throughout the healthcare process. Conclusion: The said issues, albeit no novelty in healthcare, seem to be amplified by cross-border barriers, such as system, language, and cultural differences. To empower patients to be involved in their own healthcare process, these issues should become a topic of conversation between patients and healthcare professionals. Practice implications: The patient stories in this article could help raise awareness among professionals and patients about the issues patients face in cross-border healthcare. Awareness is a first step in overcoming these issues. (c) 2021 The Authors. Published by Elsevier B.V

Problem-Based Learning in a MOOC Exploring an Innovative Instructional Design at a Large Scale

This paper describes a MOOC about PBL which is designed -as far as possible in the setting of a MOOC-in line with modern learning principles that are also at the basis of PBL: constructive, contextual, collaborative and self-directed learning: Problem-Based Learning: Principles and design. Students at the centre! The course is centred around a set of authentic 'problems' organized in three different tracks ( tutoring, designing, and implementing PBL) targeted at different types of participants. Small group work is essential in this MOOC. Students can either form teams themselves or be assigned to a team automatically. Each team has team space with chat facilities, file exchange, and facilities to schedule online meetings. However, teams can decide themselves how they want to collaborate and communicate, synchronously or asynchronously. A pilot study brought forward strong and weak points, which were used to further improve the design. This paper describes the pilot study, the changes made in the design and some first impressions of the first run of the MOOC. Preliminary conclusions are that MOOCs require careful instructional design. Stimulating online small group learning in a MOOC, i.e. following PBL learning principles to an extent but without tutors for each team, is possible, but not easy