Exercise therapy in medical rehabilitation: Study protocol of a national survey at facility and practitioner level with a mixed method design

Concept and study protocol of the process evaluation of a pragmatic randomized controlled trial to promote physical activity in outpatients with heterogeneous mental disorders-the ImPuls study

BACKGROUND

Evidence suggests that patients suffering from different mental disorders benefit from exercise programs combined with behavior change techniques. Based on this evidence, we have developed an exercise program (ImPuls) specifically designed to provide an additional treatment option in the outpatient mental health care system. The implementation of such complex programs into the outpatient context requires research that goes beyond the evaluation of effectiveness, and includes process evaluation. So far, process evaluation related to exercise interventions has rarely been conducted. As part of a current pragmatic randomized controlled trial evaluating ImPuls treatment effects, we are therefore carrying out comprehensive process evaluation according to the Medical Research Council (MRC) framework. The central aim of our process evaluation is to support the findings of the ongoing randomized controlled trial.

METHODS

The process evaluation follows a mixed-methods approach. We collect quantitative data via online-questionnaires from patients, exercise therapists, referring healthcare professionals and managers of outpatient rehabilitative and medical care facilities before, during, and after the intervention. In addition, documentation data as well as data from the ImPuls smartphone application are collected. Quantitative data is complemented by qualitative interviews with exercise therapists as well as a focus-group interview with managers. Treatment fidelity will be assessed through the rating of video-recorded sessions. Quantitative data analysis includes descriptive as well as mediation and moderation analyses. Qualitative data will be analyzed via qualitative content analysis.

DISCUSSION

The results of our process evaluation will complement the evaluation of effectiveness and cost-effectiveness and will, for example, provide important information about mechanisms of impact, structural prerequisites, or provider qualification that may support the decision-making process of health policy stakeholders. It might contribute to paving the way for exercise programs like ImPuls to be made successively available for patients with heterogeneous mental disorders in the German outpatient mental health care system.

TRIAL REGISTRATION

The parent clinical study was registered in the German Clinical Trials Register (ID: DRKS00024152, registered 05/02/2021, https://drks.de/search/en/trial/DRKS00024152 ).

[Physical Activity Promotion in Exercise Therapy in Medical Rehabilitation: Consequences of the Nationwide Survey for Quality Development]

AIM

This article aims to summarize the status quo of exercise therapy in medical rehabilitation with regard to the establishment of the biopsychosocial understanding of health with a special focus on physical activity promotion; based on this, consequences for the optimization of exercise therapy are derived.

METHODOLOGY

A three-step procedure was chosen, which builds on the elaboration of quality dimensions and quality-relevant areas of physical activity promotion in exercise therapy: 1.) the analysis of the current status quo of exercise therapy with regard to the quality-relevant characteristics. This is based on the current results from the project "Exercise therapy in medical rehabilitation: a national survey at facility and practitioner level" (BewegtheReha); 2.) the elaboration of optimization potential and 3.) the derivation of consequences for the systematic quality development of exercise therapy.

RESULTS

We analyzed the status quo of exercise therapy for the following areas: Assessment and information gathering, targets and impact areas, therapeutic contents, working methods and implementation, therapy control as well as allocation to exercise therapy (step 1). The results show that the physical activity promoting potential of exercise therapy within medical rehabilitation has not yet been optimally exploited. In particular, there is a need for more interdisciplinarity, more patient orientation, therapeutic work on the basis of theory- and evidence-based biopsychosocial therapy concepts with stronger manualization and standardization (step 2). Starting points for quality improvement can be found at the therapist level as well as at the program level and the system level. The derived recommendations for quality improvement of physical activity promotion in exercise therapy (step 3) refer to three levels: a) human resource development, e. g. with regard to improved use and quality of the education system, b) organizational development, e. g. promotion of interprofessional cooperation, and c) provision of resources, e. g. access to information.

CONCLUSION

The derived consequences form the basis for the systematic further development and optimization of physical activity in exercise therapy in the context of medical rehabilitation. Based on the results, next steps for improving quality of exercise therapy with a focus on the goal of physical activity promotion can be identified and initiated.

Bewegungstherapie und Bewegungsförderung in der Rehabilitation – Aufgaben und Ziele für Forschung und Entwicklung

Während bewegungstherapeutische Maßnahmen einen Großteil der Leistungen in der medizinischen Rehabilitation ausmachen, war die wissenschaftliche Auseinandersetzung mit Bewegungstherapie in der Rehabilitation lange Zeit vergleichsweise gering ausgeprägt. Dieses Missverhältnis war 2009 Anlass zur Gründung einer Arbeitsgruppe Bewegungstherapie in der Deutschen Gesellschaft für Rehabilitationswissenschaft (DGRW). Dadurch sollte eine differenzierte wissenschaftliche Auseinandersetzung gefördert und ein Beitrag zur Sicherung einer qualitativ hochwertigen Bewegungstherapie geleistet werden. Mehr als ein Jahrzehnt nach der Gründung ist die Evidenz für Gesundheitswirkungen körperlicher Aktivität weiter erheblich gewachsen. Es sind zahlreiche nationale und internationale Initiativen zur Stärkung der Bewegungsförderung entstanden. Vor diesem Hintergrund verfolgt dieser Beitrag 2 Zielsetzungen: Erstens soll ein Überblick über bisherige Aktivitäten und Arbeitsschwerpunkte der Arbeitsgruppe Bewegungstherapie gegeben werden, der sich (a) auf die Förderung der Rehabilitationsforschung mit Bewegungsbezug, (b) auf den Austausch zwischen Wissenschaft und Reha-Praxis sowie (c) auf die wissenschaftlich fundierte Qualitätsentwicklung in der Bewegungstherapie bezieht. Zweitens werden darauf aufbauend aktuelle und zukünftige Handlungsbedarfe und Fragestellungen für Forschung und Reha-Praxis aus Sicht der AG Bewegungstherapie formuliert.

Exercise Therapy Teamwork in German Rehabilitation Settings: Results of a National Survey Using Mixed Methods Design

A key prerequisite for implementing biopsychosocial exercise therapy concepts as parts of multimodal rehabilitation programs is interprofessional teamwork. Based on a nationwide survey of exercise therapy using a mixed methods design, it is of interest to determine to what extent there are links between team-related processes (e.g., interprofessional exchange) and structural features of the exercise therapy departments (e.g., department size) and the individual rating of interprofessional teamwork. The first part of the study involved a questionnaire-based survey, where exercise therapy heads of 1146 rehabilitation facilities were contacted. In the second part of the study, 58 exercise therapy heads held discussions in six focus groups. The results from both parts showed that interprofessional teamwork was rated positively overall. Team meetings were seen as the central platform for exchange. However, particularly in larger facilities, the hierarchical position of medical management and lacking resources were negatively associated with interprofessional exchange. The results affirm empirically that a more binding provision of adequate structural and organizational conditions, such as sufficient time slots for liaising on content, are essential for effective teamwork. This would facilitate and improve the promotion of physical activity in multimodal rehabilitation programs.

Competencies for a Healthy Physically Active Lifestyle-Reflections on the Model of Physical Activity-Related Health Competence

BACKGROUND

The World Health Organization's Global Action Plan on Physical Activity 2018-2030 states that physical activity interventions should strengthen peoples' competencies for health. Yet, frameworks that bundle pivotal competencies for a healthy and physically active lifestyle have not been extensively discussed in the past.

RESULTS

In the present article, the authors therefore present the model of Physical Activity-related Health Competence (PAHCO), an integrative structure model including the 3 areas of movement competence, control competence, and self-regulation competence. After providing a rationale for the use of the competence concept, the authors focus on implications from the PAHCO model to guide interventions for the promotion of a healthy and physically active lifestyle. The authors argue that the PAHCO model is located at the interface between health literacy and physical literacy, research areas that have gained increasing scholarly attention in recent years. In addition, PAHCO appears to be compatible with the concept of health capability because it can represent the important aspect of agency.

CONCLUSIONS

The article concludes with a scientific positioning of model components and some empirical results that have been accumulated so far.

Physical activity promotion in daily exercise therapy: the perspectives of exercise therapists in German rehabilitation settings

Background

This study aims to explore exercise therapists' perspectives on the topic of physical activity promotion (PAP) with a focus on identifying (i) the intervention content and methodological approaches used for promoting physical activity (PA) in daily practice and (ii) the barriers and facilitators that affect PAP.

Methods

This qualitative study comprised the heads of exercise therapy departments (n = 58; 41% women; mean age = 45 years) from different rehabilitation clinics in Germany. Each participant took part in a semi-structured focus-group discussion on PAP in exercise therapy. The findings of the focus groups were processed and interpreted using a conventional qualitative content analysis.

Results

The exercise therapists demonstrated detailed didactic-methodological strategies and action orientations for PAP. The identified core topics of the content and methods of PAP were (1) conceptualization, (2) exercise and PA for enjoyment and pleasure, (3) education with practice-theory combinations, (4) media and materials for self-directed training, and (5) strategies to enhance personal responsibility and independence. The core topics for the associated barriers and facilitators were (1) structural conditions, (2) the role of exercise therapists, (3) the interdisciplinary rehabilitation team, (4) rehabilitant experiences and expectations, and (5) aftercare services.

Conclusion

The topic of PAP is addressed with a high level of variability; exercise therapists involved in this study identify various methods and content for the promotion of PA within their individual practices. However, they display a limited awareness of existing evidence- and theory-based concepts for the promotion of PA as well as underlying theories of behavioural change. This variability may be due to the lack of a defined common framework for promoting PA, insufficient emphasis being placed on PA promotion in the current curricula and training, or extensive conceptual differences within German exercise therapy departments (e.g. different weighting of PAP).

The role of physical activity promotion in typical exercise therapy concepts: a latent class analysis based on a national survey in German rehabilitation settings

Purpose: Contemporary multidisciplinary rehabilitation programs include the promotion of physical activity as a central goal. Exercise therapy is an essential element in rehabilitation programs working towards this goal. However, little is known about the role of physical activity promotion in exercise therapy practice in rehabilitation settings. The aim is to identify typical exercise therapy concepts in rehabilitation programs regarding the role of physical activity promotion. Further, we want to assess the representation of physical activity promotion among exercise therapy departments across Germany and in relation to different diagnostic categories.Methods: Heads of 713 exercise therapy departments participated in a nationwide questionnaire-based survey collecting information on therapy goals, contents, and methods. Participating facilities treated health conditions in the areas of cardiology, orthopedics, neurology, oncology, psychosomatics and addiction. We applied factor analyses to identify behavior-oriented goals, contents and methods of exercise therapy concepts and used latent class analyses to categorize typical exercise therapy concepts.Results: Six typical exercise therapy concepts were identified. Two of the classes (together 45% of the departments) emphasized physical activity promotion and used related methods. Other concepts focused primarily on physical functioning and exercise or focused on psychosocial goals and positive experiences with physical activity. Typical exercise therapy concepts are only partially determined by the type of health condition.Conclusions: The dissemination of content and methods for a substantial physical activity promotion in exercise therapy, has so far partly taken place in Germany. The results imply that the different status quo in rehabilitation facilities have to be considered to foster the knowledge exchange between science and practice.Implications for rehabilitationThe results on typical exercise therapy concepts give a structured overview of different priorities with regard to aims, content, and methods of exercise therapy in the light of the International Classification of Functioning, Disability, and Health.The study reveals that the dissemination of theoretically sound, evidence-based concepts for physical activity promotion has reached a half of the institutions in German rehabilitation settings. This national example generally suggests that there is a need for an increased exchange of knowledge between science and practice related to exercise therapy in rehabilitation settings.The results enable practitioners to reflect on their exercise therapy concepts with respect to contemporary exercise therapy concepts that integrate physical activity promotion appropriately.Stakeholders and rehabilitation professionals can use the results to design strategies for quality development, taking into account the different status quo of therapy concepts in the "real world" of rehabilitation practice.The results of the survey provide the basis for a scientifically-based comparison of exercise therapy across countries and health care systems.