Improve implementation of a novel paediatric therapy programme : taking theories of human behaviour into account

Background: ‘COPing with and CAring for Infants with special Needs’ (COPCA) is a novel family-centred early intervention programme in paediatric physiotherapy. COPCA differs from well-known approaches, e.g. the therapist takes on the role of a coach and uses hands-off approaches. This implies, that to become a COPCA-coach, the therapist needs to change behaviour. Thus, it may be assumed that for successful implementation of new approaches, theories of human behaviour have to be taken into account. Purpose: The study aims to measure behaviour changes in therapists following a COPCA course in order to identify the challenges that interfere with the implementation of the COPCA program in daily practice. Methods: Data were collected during a three-part COPCA course over 6 months (with two months intervals between parts) in which 15 therapists learned to become a COPCA-coach. To document behaviour changes four treatment sessions (one prior to part I T0), one in each interval (T1, T2), and one after part III (T3) of each participant (n=60) were video-recorded and analysed quantitatively with the Groningen Observation Protocol version 2 (GOP 2.0). The videos were randomized and masked to the chronology of recording moment. GOP 2.0 is a quantitative tool to assess therapeutic behaviour in different categories, e.g. “educational actions toward caregivers” or “neuromotor actions”. It allows for a quantification of the relative duration of therapeutic actions (percentage of total treatment time) during a session. Interrater reliability of the GOP 2.0 was evaluated. The first author analysed changes in therapeutic behaviour over time with the Wilcox-sign rank test. Median changes and corresponding non-parametric confidence intervals were computed using the Hodges-Lehmann estimator (HL). Results: Interrater reliability of the GOP 2.0 (ICC2) was 0.48-1.00 (median 0.92). Course participation was associated especially with changes in “educational actions toward caregivers” and “ neuromotor actions”. Time spent on ‘caregiver coaching’ increased: between T0 and T1 by 77.9% (99% confidence interval (CI) 48.7-99.1) and between T0 and T3 by 96.1% (99%CI 51.7-100). Also time spent on hands-off techniques increased, 37.9% (99%CI 18.8-59.5) between T0 and T1 and 40.3% (99%CI 17.8-57.7) between T0 and T3. The implementation of hands-off approaches developed at a slower rate and somewhat less sustainable than that of coaching. Conclusions: Behaviours with a slower and less sustainable rate of change represented strong habits. The neural substrate of strong habits is located subcortically, making them relatively resistant to cognitive input. To overcome this challenge, future COPCA courses need to be adapted, by including (1) more modelling of desired behaviour and (2) more repetition and practice for the behaviours in the neuromotor domain. Implication: Quantitative analysis of therapeutic behaviour is a useful method to monitor changes in behaviour of therapists and – by doing so – may assist the implementation of new approaches. To implement new approaches successfully, theories of human behaviour have to be taken into account. The Behaviour Change Wheel of Michie et al., a method to characterise and design behaviour change in interventions, is a helpful framework to understand the nature of behaviour and to overcome behaviour change barriers

The impact of type 2 diabetes and Microalbuminuria on future cardiovascular events in patients with clinically manifest vascular disease from the Second Manifestations of ARTerial Disease (SMART) study

Aims Type 2 diabetes mellitus and microalbuminuria are important risk factors for cardiovascular disease (CVD). Whether these two complications are important and independent risk factors for future CVD events in a high-risk population with clinically manifest vascular disease is unknown. The objectives of this study were to examine the impact of Type 2 diabetes and microalbuminuria on future CVD events. Methods Patients with clinically manifest vascular disease (coronary, cerebral and peripheral vascular disease) from the Second Manifestation of Arterial disease study were followed up for 4 years. Data obtained from 1996–2006 were analysed. At baseline, there were 804 patients with Type 2 diabetes mellitus (mean age 60 years) and 2983 patients without. Incident CVD (n = 458) was defined as hospital-verified myocardial infarction, stroke, vascular death and the composite of these vascular events. Results Both Type 2 diabetes [hazard ratio (HR) 1.42, 95% confidence interval (CI) 1.16, 1.75] and microalbuminuria (HR 1.86, 95% CI 1.49, 2.33) increased the risk of new cardiovascular events in univariate analyses. From multivariable models, presence of diabetes remained significantly and independently related to incident CVD (HR 1.42, 95% CI 1.11, 1.80). Presence of microalbuminuria also remained significantly independently related to incident CVD (HR 1.38, 95% CI 1.07, 1.77). In diabetes-stratified analyses, the effect of microalbuminuria on CVD risk was observed only in patients with diabetes. In microalbuminuria-stratified analyses, the significant and independent effect of diabetes on CVD risk was shown only in the non-microalbuminuric group. Conclusions In this high-risk population, both microalbuminuria and Type 2 diabetes are important and independent risk factors for future CV

Evaluation of Motor Function in Young Infants by Means of the Assessment of General Movements:A Review

Purpose: Optimal management of children with developmental disorders, such as cerebral palsy (CP), requires detection at an early age. The purpose of this paper is to review the predictive value of various forms of traditional neonatal neurological examination and that of a new form of neuromotor assessment of young infants, based on the assessment of the quality of general movements (GMs).Summary of Key Points: The technique of GM assessment is presented and the features of normal, mildly abnormal and definitely abnormal GMs discussed. Essential to GM assessment is the Gestalt evaluation of movement complexity and variation. The quality of GMs at two to four months postterm has been found to have the highest predictive value. The presence of definitely abnormal GMs at this age, ie, GMs devoid of complexity and variation, puts a child at very high risk for CP.Conclusions: This implies that definitely abnormal GMs at two to four months are an indication for early physical therapy intervention.</p