Just-in-Time Prompts for Running, Walking, and Performing Strength Exercises in the Built Environment: 4-Week Randomized Feasibility Study

Background

App-based mobile health exercise interventions can motivate individuals to engage in more physical activity (PA). According to the Fogg Behavior Model, it is important that the individual receive prompts at the right time to be successfully persuaded into PA. These are referred to as just-in-time (JIT) interventions. The Playful Active Urban Living (PAUL) app is among the first to include 2 types of JIT prompts: JIT adaptive reminder messages to initiate a run or walk and JIT strength exercise prompts during a walk or run (containing location-based instruction videos). This paper reports on the feasibility of the PAUL app and its JIT prompts.

Objective

The main objective of this study was to examine user experience, app engagement, and users’ perceptions and opinions regarding the PAUL app and its JIT prompts and to explore changes in the PA behavior, intrinsic motivation, and the perceived capability of the PA behavior of the participants.

Methods

In total, 2 versions of the closed-beta version of the PAUL app were evaluated: a basic version (Basic PAUL) and a JIT adaptive version (Smart PAUL). Both apps send JIT exercise prompts, but the versions differ in that the Smart PAUL app sends JIT adaptive reminder messages to initiate running or walking behavior, whereas the Basic PAUL app sends reminder messages at randomized times. A total of 23 participants were randomized into 1 of the 2 intervention arms. PA behavior (accelerometer-measured), intrinsic motivation, and the perceived capability of PA behavior were measured before and after the intervention. After the intervention, participants were also asked to complete a questionnaire on user experience, and they were invited for an exit interview to assess user perceptions and opinions of the app in depth.

Results

No differences in PA behavior were observed (Z=−1.433; P=.08), but intrinsic motivation for running and walking and for performing strength exercises significantly increased (Z=−3.342; P<.001 and Z=−1.821; P=.04, respectively). Furthermore, participants increased their perceived capability to perform strength exercises (Z=2.231; P=.01) but not to walk or run (Z=−1.221; P=.12). The interviews indicated that the participants were enthusiastic about the strength exercise prompts. These were perceived as personal, fun, and relevant to their health. The reminders were perceived as important initiators for PA, but participants from both app groups explained that the reminder messages were often not sent at times they could exercise. Although the participants were enthusiastic about the functionalities of the app, technical issues resulted in a low user experience.

Conclusions

The preliminary findings suggest that the PAUL apps are promising and innovative interventions for promoting PA. Users perceived the strength exercise prompts as a valuable addition to exercise apps. However, to be a feasible intervention, the app must be more stable.

Mobile App (WHEELS) to Promote a Healthy Lifestyle in Wheelchair Users With Spinal Cord Injury or Lower Limb Amputation: Usability and Feasibility Study

BACKGROUND

Maintaining a healthy lifestyle is important for wheelchair users' well-being, as it can have a major impact on their daily functioning. Mobile health (mHealth) apps can support a healthy lifestyle; however, these apps are not necessarily suitable for wheelchair users with spinal cord injury or lower limb amputation. Therefore, a new mHealth app (WHEELS) was developed to promote a healthy lifestyle for this population.

OBJECTIVE

The objectives of this study were to develop the WHEELS mHealth app, and explore its usability, feasibility, and effectiveness.

METHODS

The WHEELS app was developed using the intervention mapping framework. Intervention goals were determined based on a needs assessment, after which behavior change strategies were selected to achieve these goals. These were applied in an app that was pretested on ease of use and satisfaction, followed by minor adjustments. Subsequently, a 12-week pre-post pilot study was performed to explore usability, feasibility, and effectiveness of the app. Participants received either a remote-guided or stand-alone intervention. Responses to semistructured interviews were analyzed using content analysis, and questionnaires (System Usability Score [SUS], and Usefulness, Satisfaction, and Ease) were administered to investigate usability and feasibility. Effectiveness was determined by measuring outcomes on physical activity, nutrition, sleep quality (Pittsburgh Sleep Quality Index), body composition, and other secondary outcomes pre and post intervention, and by calculating effect sizes (Hedges g).

RESULTS

Sixteen behavior change strategies were built into an app to change the physical activity, dietary, sleep, and relaxation behaviors of wheelchair users. Of the 21 participants included in the pilot study, 14 participants completed the study. The interviews and questionnaires showed a varied user experience. Participants scored a mean of 58.6 (SD 25.2) on the SUS questionnaire, 5.4 (SD 3.1) on ease of use, 5.2 (SD 3.1) on satisfaction, and 5.9 (3.7) on ease of learning. Positive developments in body composition were found on waist circumference (P=.02, g=0.76), fat mass percentage (P=.004, g=0.97), and fat-free mass percentage (P=.004, g=0.97). Positive trends were found in body mass (P=.09, g=0.49), BMI (P=.07, g=0.53), daily grams of fat consumed (P=.07, g=0.56), and sleep quality score (P=.06, g=0.57).

CONCLUSIONS

The WHEELS mHealth app was successfully developed. The interview outcomes and usability scores are reasonable. Although there is room for improvement, the current app showed promising results and seems feasible to deploy on a larger scale.

A Focus Group Study Among Inactive Adults Regarding the Perceptions of a Theory-Based Physical Activity App

Background: Despite the increasing attention for the positive effects of physical activity (PA), nearly half of the Dutch citizens do not meet the national PA guidelines. A promising method for increasing PA are mobile exercise applications (apps), especially if they are embedded with theoretically supported persuasive strategies (e.g., goal setting and feedback) that align with the needs and wishes of the user. In addition, it is argued that the operationalization of the persuasive strategies could increase the effectiveness of the app, such as the actual content or visualization of feedback. Although much research has been done to examine the preferences for persuasive strategies, little is known about the needs, wishes, and preferences for the design and operationalization of persuasive strategies.

Objective: The purpose of this study was to get insight in the needs, wishes, and preferences regarding the practical operationalization of persuasive strategies in a mobile application aimed at promoting PA in healthy inactive adults.

Methods: Five semistructured focus groups were performed. During the focus groups, the participants were led into a discussion about the design and operationalization of six predefined theory-based persuasive strategies (e.g., self-monitoring, feedback, goal setting, reminders, rewards, and social support) directed by two moderators. The audio-recorded focus groups were transcribed verbatim and analyzed following the framework approach.

Results: Eight men and 17 women between 35 and 55 years (mean age, 49.2) participated in the study. Outcomes demonstrated diverse preferences for implementation types and design characteristics of persuasive strategies in mobile applications. Basic statistics (such as distance, time and calories), positive feedback based on easy-to-achieve goals that relate to health guidelines, and motivating reminders on a relevant moment were preferred. Participants had mixed preferences regarding rewards and a social platform to invite other users to join PA.

Conclusions: Findings indicated that in mHealth applications for healthy but inactive adults, persuasive strategies should be designed and implemented in a way that they relate to health guidelines. Moreover, there is a need for an app that can be adapted or can learn based on personal preferences as, for example, preferences with regard to timing of feedback and reminders differed between people.

Reinforcement Learning to Send Reminders at Right Moments in Smartphone Exercise Application: A Feasibility Study

Just-in-time adaptive intervention (JITAI) has gained attention recently and previous studies have indicated that it is an effective strategy in the field of mobile healthcare intervention. Identifying the right moment for the intervention is a crucial component. In this paper the reinforcement learning (RL) technique has been used in a smartphone exercise application to promote physical activity. This RL model determines the 'right' time to deliver a restricted number of notifications adaptively, with respect to users' temporary context information (i.e., time and calendar). A four-week trial study was conducted to examine the feasibility of our model with real target users. JITAI reminders were sent by the RL model in the fourth week of the intervention, while the participants could only access the app's other functionalities during the first 3 weeks. Eleven target users registered for this study, and the data from 7 participants using the application for 4 weeks and receiving the intervening reminders were analyzed. Not only were the reaction behaviors of users after receiving the reminders analyzed from the application data, but the user experience with the reminders was also explored in a questionnaire and exit interviews. The results show that 83.3% reminders sent at adaptive moments were able to elicit user reaction within 50 min, and 66.7% of physical activities in the intervention week were performed within 5 h of the delivery of a reminder. Our findings indicated the usability of the RL model, while the timing of the moments to deliver reminders can be further improved based on lessons learned.

Predictors of Walking App Users With Comparison of Current Users, Previous Users, and Informed Nonusers in a Sample of Dutch Adults: Questionnaire Study

Background

The last decade has seen a substantial increase in the use of mobile health apps and research into the effects of those apps on health and health behaviors. In parallel, research has aimed at identifying population subgroups that are more likely to use those health apps. Current evidence is limited by two issues. First, research has focused on broad health apps, and little is known about app usage for a specific health behavior. Second, research has focused on comparing current users and current nonusers, without considering subgroups of nonusers.

Objective

We aimed to provide profile distributions of current users, previous users, and informed nonusers, and to identify predictor variables relevant for profile classification.

Methods

Data were available from 1683 people who participated in a Dutch walking event in Amsterdam that was held in September 2017. They provided information on demographics, self-reported walking behavior, and walking app usage, as well as items from User Acceptance of Information Technology, in an online survey. Data were analyzed using discriminant function analysis and multinomial logistic regression analysis.

Results

Most participants were current walking app users (899/1683, 53.4%), while fewer participants were informed nonusers (663/1683, 39.4%) and very few were previous walking app users (121/1683, 7.2%). Current walking app users were more likely to report walking at least 5 days per week and for at least 30 minutes per bout (odds ratio [OR] 1.44, 95% CI 1.11-1.85; P=.005) and more likely to be overweight (OR 1.72, 95% CI 1.24-2.37; P=.001) or obese (OR 1.49, 95% CI 1.08-2.08; P=.005) as compared with informed nonusers. Further, current walking app users perceived their walking apps to be less boring, easy to use and retrieve information, and more helpful to achieve their goals. Effect sizes ranged from 0.10 (95% CI 0.08-0.30) to 1.58 (95% CI 1.47-1.70).

Conclusions

The distributions for walking app usage appeared different from the distributions for more general health app usage. Further, the inclusion of two specific subgroups of nonusers (previous users and informed nonusers) provides important information for health practitioners and app developers to stimulate continued walking app usage, including making information in those apps easy to understand and making it easy to obtain information from the apps, as well as preventing apps from becoming boring and difficult to use for goal attainment.

The Design and Development of a Personalized Leisure Time Physical Activity Application Based on Behavior Change Theories, End-User Perceptions, and Principles From Empirical Data Mining

Introduction: Many adults do not reach the recommended physical activity (PA) guidelines, which can lead to serious health problems. A promising method to increase PA is the use of smartphone PA applications. However, despite the development and evaluation of multiple PA apps, it remains unclear how to develop and design engaging and effective PA apps. Furthermore, little is known on ways to harness the potential of artificial intelligence for developing personalized apps. In this paper, we describe the design and development of the Playful data-driven Active Urban Living (PAUL): a personalized PA application.

Methods: The two-phased development process of the PAUL apps rests on principles from the behavior change model; the Integrate, Design, Assess, and Share (IDEAS) framework; and the behavioral intervention technology (BIT) model. During the first phase, we explored whether location-specific information on performing PA in the built environment is an enhancement to a PA app. During the second phase, the other modules of the app were developed. To this end, we first build the theoretical foundation for the PAUL intervention by performing a literature study. Next, a focus group study was performed to translate the theoretical foundations and the needs and wishes in a set of user requirements. Since the participants indicated the need for reminders at a for-them-relevant moment, we developed a self-learning module for the timing of the reminders. To initialize this module, a data-mining study was performed with historical running data to determine good situations for running.

Results: The results of these studies informed the design of a personalized mobile health (mHealth) application for running, walking, and performing strength exercises. The app is implemented as a set of modules based on the persuasive strategies “monitoring of behavior,” “feedback,” “goal setting,” “reminders,” “rewards,” and “providing instruction.” An architecture was set up consisting of a smartphone app for the user, a back-end server for storage and adaptivity, and a research portal to provide access to the research team.

Conclusions: The interdisciplinary research encompassing psychology, human movement sciences, computer science, and artificial intelligence has led to a theoretically and empirically driven leisure time PA application. In the current phase, the feasibility of the PAUL app is being assessed.

What Are Good Situations for Running? A Machine Learning Study Using Mobile and Geographical Data

Running is a popular form of physical activity. Personal, social, and environmental determinants influence the engagement of the individual. To get insight in the relation between running behavior and external situations for different types of users, we carried out an extensive data mining study on large-scale datasets. We combined 4 years of historical running data (collected by a mobile exercise application from over 10K participants) with weather, topographical and demographical datasets. We introduce weighted frequent item mining for the analysis of the data. In this way, we capture temporal and environmental situations that frequently associate with different running performances. The results show that specific temporal and environmental situations (hour in a day, day in a week, temperature, distance to residential areas, and population density) influence the running performance of users more than other situational features. Hierarchical agglomerative clustering on the running data is used to split runners in two clusters (with sustained and less sustained running behavior). We compared the two groups of runners and found that runners with less sustained behavior are more sensitive to the environmental situations (especially several weather and location related features, such as temperature, weather type, distance to the nearest park) than regular runners. Further analysis focused on the situational features for the less sustained runners. Results show that specific feature values correspond to a better or worse running distance. Not only the influence of individual features was examined but also the interplay between features. Our findings provide important empirical evidence that the role of external situations in the running behavior of individuals can be derived from analysis of the combined historical datasets. This opens up a large potential to take those situations specifically into consideration when supporting individuals which show less sustained behavior.

Tailoring digital apps to support active ageing in a low income community

Despite physical activity being one of the determinants of healthy aging, older people tend to become less active over the years. Maintaining physical activity levels during the life course is a motivational challenge. Digital tools have been used to change this pattern, such as smartphone applications to support physical activity; but there is a lack of in-depth research on the diversity of user's experiences, especially considering older users or non-users of information and communication technologies.

OBJECTIVE

Our goal was to identify requirements for designing a mobile app to encourage physical activity in a low-income community population of older people in Brazil (i.e. over 40 years old).

METHOD

We conducted a qualitative focus group study, involving by co-design of a physical activity application (Pacer)®. Seventeen volunteers were divided into 2 focus groups of physical active and insufficiently active, and 2 further 4 subgroups in each characterised by digital engagement. The following procedures were performed: (i) baseline assessments; (ii) a focus group with physically active older people and a focus group with insufficiently active older people (iii) design activities with both groups to re-design Pacer.

RESULTS

Developing physical activity apps for older people should consider the following features: free application, simple interface, motivational messages using audio and visual information, sharing information among users, multimedia input and sharing and user customisation. In particular, we recommend that exercise apps in low-income communities be tailored to our four categories of users differing in baseline physical activity and digital engagement, to match the social and behavioural preferences we discovered.

Determinants of dietary behaviour in wheelchair users with spinal cord injury or lower limb amputation: Perspectives of rehabilitation professionals and wheelchair users

Objective

This study aims to identify determinants of dietary behaviour in wheelchair users with spinal cord injury or lower limb amputation, from the perspectives of both wheelchair users and rehabilitation professionals. The findings should contribute to the field of health promotion programs for wheelchair users.

Methods

Five focus groups were held with wheelchair users (n = 25), and two with rehabilitation professionals (n = 11). A thematic approach was used for data analysis in which the determinants were categorized using an integrated International Classification of Functioning, Disability and Health and Attitude, Social influence and self-Efficacy model.

Results

Reported personal factors influencing dietary behaviour in wheelchair users were knowledge, boredom, fatigue, stage of life, habits, appetite, self-control, multiple lifestyle problems, intrinsic motivation, goal setting, monitoring, risk perception, positive experiences, suffering, action planning, health condition, function impairments, attitude and self-efficacy. Reported environmental factors influencing dietary behaviour in wheelchair users were unadjusted kitchens, monitoring difficulties, eating out, costs, unfavourable food supply, nutrition education/counselling, access to simple healthy recipes, eating together, cooking for others, and awareness and support of family and friends.

Conclusions

Important modifiable determinants of dietary behaviour in wheelchair users that might be influenced in lifestyle interventions are knowledge, fatigue, habits, self-control, intrinsic motivation, risk perception, attitude and self-efficacy. It is recommended to involve relatives, since they appear to significantly influence dietary behaviour.

Injury incidence and risk factors: a cohort study of 706 8-km or 16-km recreational runners

Objectives

To report (1) the injury incidence in recreational runners in preparation for a 8-km or 16-km running event and (2) which factors were associated with an increased injury risk.

Methods

Prospective cohort study in Amsterdam, the Netherlands. Participants (n=5327) received a baseline survey to determine event distance (8 km or 16 km), main sport, running experience, previous injuries, recent overuse injuries and personal characteristics. Three days after the race, they received a follow-up survey to determine duration of training period, running distance per week, training hours, injuries during preparation and use of technology. Univariate and multivariate regression models were applied to examine potential risk factors for injuries.

Results

1304 (24.5%) participants completed both surveys. After excluding participants with current health problems, no signed informed consent, missing or incorrect data, we included 706 (13.3%) participants. In total, 142 participants (20.1%) reported an injury during preparation for the event. Univariate analyses (OR: 1.7, 95% CI 1.1 to 2.4) and multivariate analyses (OR: 1.7, 95% CI 1.1 to 2.5) showed that injury history was a significant risk factor for running injuries (Nagelkerke R-square=0.06).

Conclusion

An injury incidence for recreational runners in preparation for a running event was 20%. A previous injury was the only significant risk factor for running-related injuries.

Analysis of the Features Important for the Effectiveness of Physical Activity-Related Apps for Recreational Sports: Expert Panel Approach

Background

A large number of people participate in individual or unorganized sports on a recreational level. Furthermore, many participants drop out because of injury or lowered motivation. Potentially, physical activity–related apps could motivate people during sport participation and help them to follow and maintain a healthy active lifestyle. It remains unclear what the quality of running, cycling, and walking apps is and how it can be assessed. Quality of these apps was defined as having a positive influence on participation in recreational sports. This information will show which features need to be assessed when rating physical activity–related app quality.

Objective

The aim of this study was to identify expert perception on which features are important for the effectiveness of physical activity–related apps for participation in individual, recreational sports.

Methods

Data were gathered via an expert panel approach using the nominal group technique. Two expert panels were organized to identify and rank app features relevant for sport participation. Experts were researchers or professionals in the field of industrial design and information technology (technology expert panel) and in the field of behavior change, health, and human movement sciences who had affinity with physical activity–related apps (health science expert panel). Of the 24 experts who were approached, 11 (46%) agreed to participate. Each panel session consisted of three consultation rounds. The 10 most important features per expert were collected. We calculated the frequency of the top 10 features and the mean importance score per feature (0-100). The sessions were taped and transcribed verbatim; a thematic analysis was conducted on the qualitative data.

Results

In the technology expert panel, applied feedback and feedforward (91.3) and fun (91.3) were found most important (scale 0-100). Together with flexibility and look and feel, these features were mentioned most often (all n=4 [number of experts]; importance scores=41.3 and 43.8, respectively). The experts in the health science expert panels a and b found instructional feedback (95.0), motivating or challenging (95.0), peer rating and use (92.0), motivating feedback (91.3), and monitoring or statistics (91.0) most important. Most often ranked features were monitoring or statistics, motivating feedback, works good technically, tailoring starting point, fun, usability anticipating or context awareness, and privacy (all n=3-4 [number of experts]; importance scores=16.7-95.0). The qualitative analysis resulted in four overarching themes: (1) combination behavior change, technical, and design features needed; (2) extended feedback and tailoring is advised; (3) theoretical or evidence base as standard; and (4) entry requirements related to app use.

Conclusions

The results show that a variety of features, including design, technical, and behavior change, are considered important for the effectiveness of physical activity–related apps by experts from different fields of expertise. These insights may assist in the development of an improved app rating scale.

Effects of external rhythmical cueing on gait in patients with Parkinson's disease: a systematic review

Objective: To critically review studies evaluating the effects of external rhythmical cueing on gait in patients with Parkinson's disease.

Methods: Articles published from 1966 to January 2005 were searched by two physiotherapists in MEDLINE, PiCarta, PEDRo, Cochrane, DocOnline, CINAHL and SUMSEARCH. To be included, articles had to investigate the effects of external rhythmical cueing (i.e., auditory, visual or tactile cueing) on gait parameters in patients with idiopathic Parkinson's disease. Both controlled and noncontrolled studies were included. Based on the type of design and methodological quality a meta-analysis or best-evidence synthesis was applied.

Results: Twenty-four studies (total number of patients = 626) out of the 159 screened studies were evaluated in this systematic review. Two out of 24 were randomized controlled trails (RCT), both of high methodological quality. One RCT did not focus specifically on external rhythmical cueing of individual patients with Parkinson's disease, but on group exercises in general, including walking with cues. All other studies were pre-experimental studies. Best-evidence synthesis showed strong evidence for improving walking speed with the help of auditory cues. Insufficient evidence was found for the effectiveness of visual and somatosensory cueing.

Conclusion: Only one high-quality study, specifically focused on the effects of auditory rhythmical cueing, suggesting that the walking speed of patients with Parkinson's disease can be positively influenced. However, it is unclear whether positive effects identified in the laboratory can be generalized to improved activities of daily living (ADLs) and reduced frequency of falls in the community. In addition, the sustainability of a cueing training programme remains uncertain.

Plugs for containing faecal incontinence

BACKGROUND

Faecal incontinence is a distressing disorder with high social stigma. Not all people with faecal incontinence can be cured with conservative or surgical treatment and they may need to rely on containment products, such as anal plugs.

OBJECTIVES

To assess the performance of different types of anal plugs for containment of faecal incontinence.

SEARCH METHODS

We searched the Cochrane Incontinence Group Specialised Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE In-Process, ClinicalTrials.gov, World Health Organization (WHO) ICTRP and handsearching of journals and conference proceedings (searched 26 May 2015). Reference lists of identified trials were searched and plug manufacturers were contacted for trials. No language or other limitations were imposed.

SELECTION CRITERIA

Types of studies: this review was limited to randomised and quasi-randomised controlled trials (including crossovers) of anal plug use for the management of faecal incontinence.

TYPES OF PARTICIPANTS

children and adults with faecal incontinence.Types of interventions: any type of anal plug. Comparison interventions might include no treatment, conservative (physical) treatments, nutritional interventions, surgery, pads and other types or sizes of plugs.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed methodological quality and extracted data from the included trials. Authors of all included trials were contacted for clarification concerning methodological issues.

MAIN RESULTS

Four studies with a total of 136 participants were included. Two studies compared the use of plugs versus no plugs, one study compared two sizes of the same brand of plug, and one study compared two brands of plugs. In all included studies there was considerable dropout (in total 48 (35%) dropped out before the end of the study) for varying reasons. Data presented are thus subject to potential bias. 'Pseudo-continence' was, however, achieved by some of those who continued to use plugs, at least in the short-term. In a comparison of two different types of plug, plug loss was less often reported and overall satisfaction was greater during use of polyurethane plugs than polyvinyl-alcohol plugs.

AUTHORS' CONCLUSIONS

The available data were limited and incomplete, and not all pre-specified outcomes could be evaluated. Consequently, only tentative conclusions are possible. The available data suggest that anal plugs can be difficult to tolerate. However, if they are tolerated they can be helpful in preventing incontinence. Plugs could then be useful in a selected group of people either as a substitute for other forms of management or as an adjuvant treatment option. Plugs come in different designs and sizes; the review showed that the selection of the type of plug can impact on its performance.

Patient burden of colonoscopy after positive fecal immunochemical testing for colorectal cancer screening

BACKGROUND

Irrespective of the primary test used in colorectal cancer (CRC) screening, colonoscopy needs to be performed in positive screenees. This procedure is generally perceived as burdensome.We aimed to explore the burden of the colonoscopy in fecal immunochemical test (FIT)-positive screenees.

TRIAL REGISTRATION NUMBER

NTR1327.

METHODS

Two weeks after their colonoscopy, a random sample of screenees in the Dutch CRC screening pilot who underwent colonoscopy after a positive FIT were asked to rate their experience on a five-point scale (1=not at all, 5=very) for embarrassment, pain, and burden. Aspects that would add to satisfaction and the level of disturbance of daily activity and sleep were also assessed.

RESULTS

Of 373 invited individuals, 273 (73 %)completed the questionnaire; 53% were men,mean age was 63 years (standard deviation [SD]7). The bowel preparation received the highest burden score (mean score 2.87, SD 1.28) and was chosen as the most burdensome aspect by 56%.The highest levels of pain were assigned to postcolonoscopy abdominal complaints (2.55, SD1.03). The procedure was rated as only slightly embarrassing (1.49, SD 0.68). Adequate explanation of the procedure, immediate discussion of preliminary colonoscopy results, and a short waiting time between FIT result and colonoscopy were selected most often as potential contributors to satisfaction.

CONCLUSION

Bowel preparation and postcolonoscopy abdominal complaints are experienced as the most burdensome elements by persons undergoing colonoscopy in a FIT screening program. A more easily tolerable bowel preparation, carbondioxide insufflation, and adequate and timely communication are seen as measures to alleviate the burden and increase satisfaction with the procedure.

Assessing knowledge and attitudes towards screening among users of Faecal Immunochemical Test (FIT)

BACKGROUND

Informed decision making is recognized as important in screening. Invitees should be provided with relevant information, enabling them to make an informed decision. This may be more difficult in ethnic minority and low socio-economic status groups. We aimed to assess the proportion of informed decisions to participate in a faecal immunochemical test (FIT)-based colorectal cancer (CRC) screening pilot and to explore differences in knowledge and attitude across various subgroups.

METHODS

Asymptomatic persons aged 50-74 were invited to a second round of a Dutch FIT-based pilot screening programme for CRC. An information leaflet containing all information relevant to enable informed decision making accompanied the invitation. Informed choice was assessed by a mailed questionnaire. Knowledge was elicited through 18 items and attitude towards screening through four items. Main outcome measure was the proportion of informed decision makers among participants. Differences between subgroups were evaluated using logistic regression.

RESULTS

Of 5367 screening participants, 2774 (52%) completed the questionnaire. Knowledge was adequate in 2554 (92%); 2736 (99%) showed a positive attitude towards screening. A total of 2525 persons had made an informed choice (91%); male gender, low education level, non-Dutch ethnicity and not speaking Dutch at home were negatively associated with having adequate knowledge in multivariable analysis.

CONCLUSION

In FIT-based screening for CRC, the majority of responders made an informed decision to participate. However, we did not succeed in equally providing all population subgroups with sufficient information. Future initiatives should be aimed at reaching these groups to further enable informed decision making.

The effect of exercise on prescription on physical activity and wellbeing in a multi-ethnic female population: A controlled trial

Background

In Western countries, individuals from multi-ethnic disadvantaged populations are less physically active than the Western population as a whole. This lack of physical activity (PA) may be one of the factors explaining disparities in health. Exercise on Prescription” (EoP), is an exercise program to which persons are referred by primary care. It has been developed to suit the needs of physically inactive women from diverse ethnic backgrounds living in deprived neighborhoods in the Netherlands. The effectiveness of this program has however, not yet been proven.

Methods

A total of 514 women from diverse ethnic backgrounds were included in this study (192 EoP, 322 control group). Women in the EoP group participated in 18 sessions of supervised PA. The control group received care as usual. At baseline, 6 and 12 months the women attended an interview and a physical examination. Outcome measures were PA, BMI, weight circumference, fat percentage, oxygen uptake, mental well-being, subjective health and use of care.

Results

Of the participants 59% had a low educational level and 90% of the women were overweight or obese. Compliance was high, only 14% dropped out during the course of the program. Total PA did not change, PA during leisure time increased at 6 and at 12 months and PA during household activities increased at 12 months (P_EoPvsControl < 0.05). EoP had no significant effect on the other outcome variables.

Conclusions

EoP was successful in recruiting its target population and compliance was high. The effect of EoP on PA, health and mental well-being was limited. In this format EoP does not seem to be effective for increasing PA and the health status of non-Western migrant women.

Trial registration

Dutch Trial register: NTR1294

Patient satisfaction with the colonoscopy procedure: endoscopists overestimate the importance of adverse physical symptoms

BACKGROUND

Colonoscopy is a frequently performed procedure associated with a substantial burden for the patient. Most of what is known about patient satisfaction stems from surveys that target issues doctors believe to be important. It has been noticed that patients often focus on different aspects.

AIM

To have patients and endoscopists rate the extent to which each of a list of patient-generated issues-of-concern contributes to patient satisfaction with the colonoscopy procedure.

SUBJECTS

A sample of consecutive patients undergoing colonoscopy in a Dutch tertiary teaching hospital and a convenience sample of endoscopists.

METHODS

Colonoscopy patients and endoscopists were asked to rate on a five-point Likert scale the importance of 55 items concerning the colonoscopy procedure for patient satisfaction. Items were derived from focus group sessions with colonoscopy patients. Endoscopists were invited to rate the importance of the same set of items from a patient perspective. An analysis was carried out of whether patients and endoscopists rated the importance of items differently.

RESULTS

69 patients and 34 endoscopists completed the questionnaire. The ratings of the endoscopists were significantly different from those of patients (p<0.0001). Endoscopists underestimated the importance of involving patients in decisions, discussing risks and complications, providing the opportunity for substantive questions and offering a comfortable temperature in the examination room. Endoscopists overestimated the importance of adverse physical symptoms, such as pain and abdominal cramps, and the role of the treating doctor.

CONCLUSIONS

Endoscopists do not have a good perception of the items that contribute most to patient satisfaction with the colonoscopy procedure. Overcoming this gap may be an essential step towards improving patient satisfaction by targeting those concerns most relevant to patients.

Plugs for containing faecal incontinence

BACKGROUND

Faecal incontinence is a distressing disorder with high social stigma. Not all people with faecal incontinence can be cured with conservative or surgical treatment and they may need to rely on containment products, such as anal plugs.

OBJECTIVES

To assess the performance of different types of anal plugs for containment of faecal incontinence.

SEARCH METHODS

We searched the Cochrane Incontinence Group Specialised Register (searched 29 February 2012). Reference lists of identified trials were searched and plugs manufacturers were contacted for trials. No language or other limitations were imposed.

SELECTION CRITERIA

Types of studies: This review was limited to randomised and quasi-randomised controlled trials (including crossovers) of anal plug use for the management of faecal incontinence.

TYPES OF PARTICIPANTS

Children and adults with faecal incontinence.Types of interventions: Any type of anal plug. Comparison interventions might include no treatment, conservative (physical) treatments, nutritional interventions, surgery, pads and other types or sizes of plugs.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed methodological quality and extracted data from the included trials. Authors of all included trials were contacted for clarification concerning methodological issues.

MAIN RESULTS

Four studies with a total of 136 participants were included. Two studies compared the use of plugs versus no plugs, one study compared two sizes of the same brand of plug, and one study compared two brands of plugs. In all included studies there was considerable dropout (in total 48 (35%) dropped out before the end of the study) for varying reasons. Data presented are thus subject to potential bias. 'Pseudo-continence' was, however, achieved by some of those who continued to use plugs, at least in the short-term. In a comparison of two different types of plug, plug loss was less often reported and overall satisfaction was greater during use of polyurethane plugs than polyvinyl-alcohol plugs.

AUTHORS' CONCLUSIONS

The available data were limited and incomplete, and not all pre-specified outcomes could be evaluated. Consequently, only tentative conclusions are possible. The available data suggest that anal plugs can be difficult to tolerate. However, if they are tolerated they can be helpful in preventing incontinence. Plugs could then be useful in a selected group of people either as a substitute for other forms of management or as an adjuvant treatment option. Plugs come in different designs and sizes; the review showed that the selection of the type of plug can impact on its performance.

Effectiveness of a web-based health risk assessment with individually-tailored feedback on lifestyle behaviour: study protocol

Background

Physical inactivity, unhealthy dietary habits, smoking and high alcohol consumption are recognized risk factors for cardiovascular disease and cancer. Web-based health risk assessments with tailored feedback seem promising in promoting a healthy lifestyle. This study evaluates the effectiveness of a web-based health risk assessment with individually-tailored feedback on lifestyle behaviour, conducted in a worksite setting.

Methods/Design

The web-based health risk assessment starts with a questionnaire covering socio-demographic variables, family and personal medical history, lifestyle behaviour and psychological variables. Prognostic models are used to estimate individual cardiovascular risks. In case of high risk further biometric and laboratory evaluation is advised. All participants receive individually-tailored feedback on their responses to the health risk assessment questionnaire. The study uses a quasi-experimental design with a waiting list control group. Data are collected at baseline (T0) and after six months (T1). Within each company, clusters of employees are allocated to either the intervention or the control group. Primary outcome is lifestyle behaviour, expressed as the sum of five indicators namely physical activity, nutrition, smoking behaviour, alcohol consumption, and symptoms of burnout. Multilevel regression analysis will be used to answer the main research question and to correct for clustering effects. Baseline differences between the intervention and control group in the distribution of characteristics with a potential effect on lifestyle change will be taken into account in further analyses using propensity scores.

Discussion

This study will increase insight into the effectiveness of health risk assessments with tailored feedback and into conditions that may modify the effectiveness. This information can be used to design effective interventions for lifestyle behaviour change among employees.

Trial registration

Dutch Trial Register NTR8148.

Lower risk of advanced neoplasia among patients with a previous negative result from a fecal test for colorectal cancer

BACKGROUND & AIMS

Consecutive rounds of fecal occult blood tests (FOBTs) are used to screen for colorectal cancer (CRC); they detect precursor lesions and early-stage disease. We assessed whether the positivity rate and the positive predictive values (PPVs) for advanced neoplasia and CRC decrease with repeated testing by using fecal immunochemical tests (FITs).

METHODS

Data were collected from 2 rounds of screening. In the first round, average-risk persons (50 to 74 years old) were randomly assigned to groups that received the guaiac FOBT or FIT. In the second round, the subjects received only FIT (1594 received FIT after guaiac FOBT and 2022 received FIT after FIT). The positivity rate and PPV for advanced neoplasia and CRC were compared between second-round participants with a previous negative test result (FIT after guaiac FOBT or FIT after FIT) and first-round participants (guaiac FOBT or FIT).

RESULTS

The rate of positive results from FIT was 7.4% in the FIT-after-FIT group, compared with 8.1% in the first-round FIT group (P = .34). A significant decrease was observed in the PPV for advanced neoplasia between the first and second round from 55% (132/239) to 44% (112/252; P = .017). The PPV for CRC was 8% (20/239) in the first round versus 4% (9/252) in the second round (P = .024). Ten interval cancers were diagnosed. There were no significant differences in stages of cancers detected in the first and second round or the interval cancers.

CONCLUSIONS

The rate of positive results from FIT does not decrease after repeated CRC screening, but the PPVs of FIT for advanced neoplasia and for CRC are significantly lower among second-round participants who tested negative in the first round.

Comparison of guaiac and immunological fecal occult blood tests in colorectal cancer screening: the patient perspective

OBJECTIVE

Colorectal cancer (CRC) screening programs can decide upon the type of fecal occult blood test (FOBT): the guaiac FOBT (g-FOBT) or the immunological FOBT (i-FOBT). The effectiveness of any screening program depends not only on the diagnostic performance of the screening test but also on the compliance and general acceptance of the test by the public. Any decision on the type of FOBT for CRC screening should also take acceptation and perception into account. The aim of the present study was to study differences in patient perception between i-FOBT and g-FOBT and differences in perception and participation rates among relevant subgroups in a population based study.

MATERIAL AND METHODS

Differences in patient perception of i-FOBT and g-FOBT and differences in perception and participation rates among relevant subgroups were investigated (n = 20,623) by sending a short questionnaire to all invited to the first Dutch CRC screening trial.

RESULTS

i-FOBT was perceived significantly more favorable than g-FOBT. About 1275 (32%) participants reported the g-FOBT not easy to use, not easy to perform, disgusting or shameful compared to 742 (16%) for the i-FOBT (p < 0.001). The participation rate was significantly higher in those who received i-FOBT compared to the g-FOBT group: 6159 of 10,322 (60%) versus 4839 of 10,301 (47%) (p < 0.001).

CONCLUSIONS

These findings support the selection of i-FOBT as the more appropriate test for population screening programs.

Inconclusive psychometric properties of the Vaizey score in fecally incontinent patients: a prospective cohort study

AIM

To determine the psychometric properties of the total Vaizey score and its individual items.

METHODS

The study was conducted as part of a prospective cohort study assessing the outcome of pelvic floor rehabilitation in patients with fecal incontinence.

RESULTS

One hundred ninety-four patients were analyzed, 53 of whom provided data on the global perceived effect (GPE) score. Pelvic floor rehabilitation resulted in a significant reduction of the total Vaizey score and most individual items. The total Vaizey scores changed in agreement with the GPE scores. The total Vaizey score was responsive, but some individual items yielded inconsistent results for three different measures. The test-retest reliability was adequate or excellent for six individual items and the total Vaizey score. The internal consistency was low for the total Vaizey score at baseline, in contrast to the follow-up and change scores. The estimates for the minimally important change (MIC) and smallest detectable change yielded moderately consistent results. An MIC of -5 points seemed preferable and yielded the lowest misclassification rate.

CONCLUSIONS

More research is required to confirm conclusions on the psychometric properties of the total Vaizey score and its individual items, and to justify its use in research and routine clinical practice.

Study protocol: population screening for colorectal cancer by colonoscopy or CT colonography: a randomized controlled trial

Background

Colorectal cancer (CRC) is the second most prevalent type of cancer in Europe. Early detection and removal of CRC or its precursor lesions by population screening can reduce mortality. Colonoscopy and computed tomography colonography (CT colonography) are highly accurate exams and screening options that examine the entire colon. The success of screening depends on the participation rate. We designed a randomized trial to compare the uptake, yield and costs of direct colonoscopy population screening, using either a telephone consultation or a consultation at the outpatient clinic, versus CT colonography first, with colonoscopy in CT colonography positives.

Methods and design

7,500 persons between 50 and 75 years will be randomly selected from the electronic database of the municipal administration registration and will receive an invitation to participate in either CT colonography (2,500 persons) or colonoscopy (5,000 persons) screening. Those invited for colonoscopy screening will be randomized to a prior consultation either by telephone or a visit at the outpatient clinic. All CT colonography invitees will have a prior consultation by telephone. Invitees are instructed to consult their general practitioner and not to participate in screening if they have symptoms suggestive for CRC. After providing informed consent, participants will be scheduled for the screening procedure. The primary outcome measure of this study is the participation rate. Secondary outcomes are the diagnostic yield, the expected and perceived burden of the screening test, level of informed choice and cost-effectiveness of both screening methods.

Discussion

This study will provide further evidence to enable decision making in population screening for colorectal cancer.

Trial registration

Dutch trial register: NTR1829

Sacral nerve modulation and other treatments in patients with faecal incontinence after unsuccessful pelvic floor rehabilitation: a prospective study

OBJECTIVES

Sacral nerve modulation (SNM) is a minimally invasive technique for the treatment of faecal incontinence. This study investigates the results of SNM after negative outcome of a standardized pelvic floor rehabilitation (PFR) programme for the treatment of faecal incontinence.

METHOD

A prospective cohort study was performed between December 2001 and August 2007. Consecutive patients who visited the outpatient department for faecal incontinence were included in a multicentre study and treated with standardized PFR. Those with an unsuccessful result who were eligible for SNM were included in the present study. Failures at test stimulation or SNM received another treatment. Clinical outcome, Vaizey scores and Hirschsprung's disease/anorectal malformation quality-of-life (EQ-5D and HAQL) were assessed during follow-up in patients with SNM and in patients with other treatments (OT). Adverse events (AE) were documented.

RESULTS

Thirty-five patients (mean age 59.7 years; 31 females) were included. Twenty-one had a successful test stimulation and 19 patients proceeded to a SNM implant. Incontinence episodes per week decreased significantly from 11.1 +/- 11.7 to 1.9 +/- 2.6 during test stimulation (P < 0.0001) and SNM over 24.1 months follow-up. The overall success rate was 49% (17/35). The patients with unsuccessful test stimulation or SNM received OT. The Vaizey score improved in both SNM (18.2 +/- 3.5 vs 13.7 +/- 4.8; P = 0.004) and other treatment (18.2 +/- 3.5 vs 13.9 +/- 6.9; P = 0.019). The HAQL scale improved significantly during SNM in all subscales (P < 0.005), but not in the other treatment group. Eight AE occurred during test stimulation (23%) and six AE after permanent implantation (26%).

CONCLUSION

Sacral nerve modulation improves disease specific quality of life significantly compared with other treatment.

Implementation of population screening for colorectal cancer by repeated fecal occult blood test in the Netherlands

Background

Colorectal cancer (CRC) is the third most prevalent type of cancer in the world. Its prognosis is closely related to the disease stage at the time of diagnosis. Early detection of symptomless CRC or precursor lesions through population screening could reduce CRC mortality. However, screening programs are only effective if enough people are willing to participate. This study aims to asses the uptake of a second round of fecal occult blood test (FOBt) based screening and to explore factors that could potentially increase this uptake.

Methods and design

Two years after the first screening round, 10.000 average risk persons, aged 50 to 75, will again receive an invitation to participate in immunohistochemical FOBt (iFOBt) based screening. Eligible persons will be recruited through a city population database. Invitees will be randomized to receive either an iFOBt with a faeces collection paper or an iFOBt without a collection paper. The iFOBts will be analyzed in a specialized laboratory at the Academic Medical Centre. Positive iFOBts will be followed by a consultation at our outpatient clinic and, in the absence of contra-indications and after informed consent, by a colonoscopy. The primary outcome measure is the participation rate. Secondary outcome measures are the effect of the addition of a collection paper on the participation rate, reasons for participation and non-participation, measures of informed choice and psychological consequences of screening and measures of psychological and physical burden associated with the iFOBt and the colonoscopy. Another secondary outcome measure is the diagnostic yield of the program.

Discussion

In order to implement population screening for colorectal cancer in the Netherlands, information is needed on the uptake of repeated rounds of FOBt-based screening and on factors that could potentially increase this uptake in the future since effectiveness of such a program depends on the willingness of persons to participate. This study will provide information on the actual uptake and perception of a second round of iFOBt-based screening. The results of this study will contribute to the future implementation of a national colorectal screening program in the Netherlands.

Trial registration

Dutch Trial register: NTR1327

Uptake of faecal occult blood test colorectal cancer screening by different ethnic groups in the Netherlands

We investigated the participation rates in CRC screening with a FOBT among various ethnic groups in the Netherlands. Individuals (n = 10 054) were invited by mail and grouped by country of birth. Overall participation rate was 49%. Participation among ethnic minority groups was significantly lower than among ethnic Dutch [adjusted OR for participation: Middle- or Central-East 0.25 (0.18-0.34), African 0.48 (0.34-0.67), Surinamese and Antillean 0.51 (0.43-0.61), South- or South-East Asian 0.56 (0.46-0.69) and 'other Western' 0.78 (0.63-0.96)]. Further studies are needed to explore whether ethnic minority groups are not reached or that low uptake is determined by other causes.

The effectiveness of "Exercise on Prescription" in stimulating physical activity among women in ethnic minority groups in the Netherlands: protocol for a randomized controlled trial

BACKGROUND

Lack of physical activity is an important risk factor for overweight, diabetes, cardiovascular disease and other chronic conditions. In the Netherlands, ethnic minority groups are generally less physically active and rate their own health poorer compared to ethnic Dutch. This applies in particular to women. For this reason women from ethnic minority groups are an important target group for interventions to promote physical activity.In the Netherlands, an exercise referral program ("Exercise on Prescription") seems successful in reaching women from ethnic minority groups, in particular because of referral by the general practitioner and because the program fits well with the needs of these women. However, the effect of the intervention on the level of physical activity and related health outcomes has not been formally evaluated within this population. This paper describes the study design for the evaluation of the effect of "Exercise on Prescription" on level of physical activity and related health outcomes.

METHODS

The randomized controlled trial will include 360 inactive women from ethnic minority groups, with the majority having a non-Western background, aged between 18 and 65 years old, with regular visits to their general practitioner. Participants will be recruited at healthcare centres within a deprived neighbourhood in the city of The Hague, the Netherlands. An intervention group of 180 women will participate in an exercise program with weekly exercise sessions during 20 weeks. The control group (n = 180) will be offered care as usual. Measurements will take place at baseline, and after 6 and 12 months. Main outcome measure is minutes of self reported physical activity per week. Secondary outcomes are the mediating motivational factors regarding physical activity, subjective and objective health outcomes (including wellbeing, perceived health, fitness and body size) and use of (primary) health care. Attendance and attrition during the program will be determined.

CONCLUSION

This trial will provide information on the effectiveness of an exercise referral scheme on the short and long term among women from ethnic minority groups, mainly non-Western, in the Netherlands. The results of this study will contribute to the evidence base for interventions in ethnic minority populations.

[The Dutch National Colesterol Test: participants mainly healthy]

OBJECTIVE

To determine, in people who participated in the Netherlands Heart Foundation's National Cholesterol Test in supermarkets, risk factors for cardiovascular disease and expectations concerning the test result using a questionnaire, and to compare their cholesterol levels with reference values.

DESIGN

Descriptive study and questionnaire survey.

METHOD

Participants who underwent the National Cholesterol Test in 9 supermarkets during the summer of 2007 were invited to complete a short questionnaire about risk factors for cardiovascular disease and expectations concerning the test result. Statements about the intention to change behaviour were offered, and the measured total cholesterol level was recorded.

RESULTS

The average age of the 684 respondents was 57 years (SD: 16); 72% were female. Participants had on average a lower risk of cardiovascular disease than the general population; they suffered less frequently from diabetes, hypertension and being overweight, and smoked less. The measured cholesterol level was 5.0-6.5 mmol/l in 37% and > 6.5 mmoll in 11%. Elevated cholesterol levels were less common in this group than in the general population. The intention to change behaviour was substantial.

CONCLUSION

The results of this study showed that the National Cholesterol Test reached relatively many healthy, somewhat worried people. The intention to change behaviour was substantial.

Getting adequate information across to colorectal cancer screening subjects can be difficult

Objectives

Participation in screening should be the outcome of an informed decision. We evaluated whether invitees in the first Dutch colorectal cancer (CRC) screening programme were adequately informed after having received a detailed information leaflet.

Methods

A total of 20,623 subjects aged 50–75 years were invited to the fecal occult blood test (FOBT) screening programme. All received a detailed information leaflet by mail between May 2006 and January 2007. After two weeks, a reminder letter was sent to all invitees, accompanied by a survey on CRC and screening.

Results

The survey was completed by 9594 invitees (47%). Almost all responders (99%) found the leaflet clear and readable. Almost all indicated that CRC can be treated better if found early (99%). Only 20% of the responders answered all knowledge-related answers correctly. Almost half of the responders (47%) believed that a negative FOBT excludes the presence of CRC. Older age and having a positive family member for CRC were correctly identified as risk factors by 80%.

Conclusion

This study demonstrates that although an information leaflet was reported as being clear and readable, the information provided in it was not always understood well. This suggests that other educational options should be investigated in order to improve general knowledge of CRC in screening invitees.

[Limited predictive value of diagnostic tests for outcomes following pelvic floor physiotherapy in patients with faecal incontinence]

OBJECTIVE

To develop an efficient diagnostic strategy for patients with faecal incontinence to identify subgroups that may benefit from pelvic floor physiotherapy.

DESIGN

Cohort study.

METHOD

Assessment of consecutive patients with faecal incontinence treated at 15 hospitals in a 24-month period. In addition to medical history and physical examination, a complete diagnostic work-up was performed. All patients were then offered standardised pelvic floor physiotherapy. Treatment outcome was evaluated by change in Vaizey incontinence score 3 months after therapy. Linear regression analysis was used to calculate the predictive value of each diagnostic test and combination of tests with regard to treatment outcomes.

RESULTS

Of the 281 patients included (mean age 59 years), 252 were female. The median Vaizey score was 18 at baseline and 16 after therapy (p < 0.001). The Vaizey score improved in 143/239 patients (60%). The presence of perineal or perianal scarring on physical examination or internal anal sphincter atrophy on endoanal MRI were associated with a negative treatment outcome. A high maximal squeeze pressure by anorectal manometry was associated with a positive treatment outcome. The predictive value of information obtained by medical history and additional tests was limited (R2: 0.23; p = 0.02).

CONCLUSION

Pelvic floor physiotherapy provided a modest improvement in symptoms of faecal incontinence. The predictive value of additional tests in predicting outcomes following pelvic floor physiotherapy was limited. Subgroups of patients could not be identified based on diagnostic test information.

Patients' perception of diagnostic tests in the preoperative assessment of esophageal cancer

OBJECTIVE

Defining an optimal staging strategy requires an evaluation of the effectiveness and costs of diagnostic tests and may include the burden of these tests for patients. This study evaluated the burden of cervical ultrasonography (US), endoscopic ultrasonography (EUS), computed tomography (CT) and positron emission tomography (PET) in patients with esophageal carcinoma (EC).

METHODS

Consenting consecutive patients underwent a standard preoperative work-up. Burden of testing was evaluated with a self-report questionnaire addressing anxiety, embarrassment, and discomfort, each measured on a 1(none) to 5 (extreme) point-scale. An overall burden score was calculated by summing the three item scores. In addition, patients were asked to rank the four tests from least to most inconvenient. Statistical analysis was performed with nonparametric tests.

RESULTS

82 patients (67 , 15 ; mean age 64.3 yrs) participated. For most tests and most dimensions of burden, the large majority of subjects was in categories 1 and 2.With respect to anxiety, the rank order (from highest burden to lowest burden) was EUS, US, PET, and CT (average scores 1.7, 1.5, 1.4, and 1.2, respectively). For embarrassment, the rank order was EUS, PET, US, and CT (1.9, 1.5, 1.4, and 1.3 respectively). For discomfort, the rank order was EUS, PET, US and CT (2.0, 1.6, 1.4, and 1.2, respectively). And for total burden, the rank order was EUS, PET, US and CT (5.6, 4.6, 4.2, and 3.7). PET was ranked as least inconvenient by 35% of patients and as most inconvenient by 16% compared with the other tests.

CONCLUSION

Significant but small differences were observed in patient burden for imaging tests to evaluate EC. The perceived burden of PET was lower than that of EUS, but higher than the burden of CT. However absolute values were low for all tests and therefore patient burden will not be a key feature for the construction of an optimal staging algorithm for EC.

The role of endoluminal imaging in clinical outcome of overlapping anterior anal sphincter repair in patients with fecal incontinence

OBJECTIVE

Anterior sphincter repair has become the operation of choice in patients with fecal incontinence who have defects of the external anal sphincter (EAS), but not all patients benefit from surgery. The aim of this study was to investigate whether endoluminal imaging can identify determinants that play a role in the outcome of sphincter repair.

SUBJECTS AND METHODS

Thirty fecal incontinent patients with an EAS defect were included. The severity of incontinence was evaluated pre- and postoperatively using the Vaizey incontinence score. Patients underwent endoanal MRI and endoanal sonography before and after sphincter repair. We evaluated the association between preoperatively assessed EAS measurements with outcome and postoperatively depicted residual defects, atrophy, tissue at overlap, and sphincter overlap with clinical outcome.

RESULTS

After surgery, the mean Vaizey score in 30 patients (97% females; mean age, 50 years) had improved from 18 to 13 (p < 0.001). MRI showed that baseline measurement of preserved EAS thickness correlated with a better outcome (r = 0.42; p = 0.03). Clinical outcome did not differ between patients with and those without a persistent EAS defect (p = 0.54) or EAS atrophy (p = 0.26) depicted on MRI. Patients with a visible overlap and less than 20% fat tissue had a better outcome than patients with nonvisible, fatty overlap (decrease in Vaizey score, 7 vs 2 points, respectively; p = 0.04). Sonography showed that patients with a persistent EAS defect had a worse outcome than those without an EAS defect (17 vs 10 points, respectively; p = 0.003).

CONCLUSION

Endoanal MRI was useful in determining EAS thickness and structure, and endoanal sonography was effective in depicting residual EAS defects.

Anal inspection and digital rectal examination compared to anorectal physiology tests and endoanal ultrasonography in evaluating fecal incontinence

BACKGROUND

Anal inspection and digital rectal examination are routinely performed in fecal incontinent patients but it is not clear to what extent they contribute to the diagnostic work-up. We examined if and how findings of anal inspection and rectal examination are associated with anorectal function tests and endoanal ultrasonography.

METHODS

A cohort of fecal incontinent patients (n=312, 90% females; mean age 59) prospectively underwent anal inspection and rectal examination. Findings were compared with results of anorectal function tests and endoanal ultrasonography.

RESULTS

Absent, decreased and normal resting and squeeze pressures at rectal examination correlated to some extent with mean (+/-SD) manometric findings: mean resting pressure 41.3 (+/-20), 43.8 (+/-20) and 61.6 (+/-23) Hg (p<0.001); incremental squeeze pressure 20.6 (+/-20), 38.4 (+/-31) and 62.4 (+/-34) Hg (p<0.001). External anal sphincter defects at rectal examination were confirmed with endoanal ultrasonography for defects <90 degrees in 36% (37/103); for defects between 90-150 degrees in 61% (20/33); for defects between 150-270 degrees in 100% (6/6). Patients with anal scar tissue at anal inspection had lower incremental squeeze pressures (p=0.04); patients with a gaping anus had lower resting pressures (p=0.013) at anorectal manometry. All other findings were not related to any anorectal function test or endoanal ultrasonography.

CONCLUSIONS

Anal inspection and digital rectal examination can give accurate information about internal and external anal sphincter function but are inaccurate for determining external anal sphincter defects <90 degrees. Therefore, a sufficient diagnostic work-up should comprise at least rectal examination, anal inspection and endoanal ultrasonography.

[The increased availability of self-tests for medical analyses]

A marked increase in the availability of diagnostic tests for use at home has been observed in recent years. There are regulations concerning the development and application of these tests. The question whether the increased use of self-tests is a positive or negative development cannot be answered easily. In some cases serious diseases may be detected in people who are reluctant to consult a physician. In other cases false negative test results may delay necessary treatment. Further exploration of the use, sensitivity, specificity, benefits and harms of specific tests is warranted.

External anal sphincter defects in patients with fecal incontinence: comparison of endoanal MR imaging and endoanal US

PURPOSE

To prospectively compare in a multicenter study the agreement between endoanal magnetic resonance (MR) imaging and endoanal ultrasonography (US) in depicting external anal sphincter (EAS) defects in patients with fecal incontinence.

MATERIALS AND METHODS

The study was approved by the medical ethics committee of all participating centers. A total of 237 consenting patients (214 women, 23 men; mean age, 58.6 years +/- 13 [standard deviation]) with fecal incontinence were examined from 13 different hospitals by using endoanal MR imaging and endoanal US. Patients with an anterior EAS defect depicted on endoanal MR images and/or endoanal US scans underwent anal sphincter repair. Surgical findings were used as the reference standard in the determination of anterior EAS defects. The Cohen kappa statistic and McNemar test were used to calculate agreement and differences between diagnostic techniques.

RESULTS

Agreement between endoanal MR imaging and endoanal US was fair for the depiction of sphincter defects (kappa = 0.24 [95% confidence interval: 0.12, 0.36]). At surgery, EAS defects were found in 31 (86%) of 36 patients. There was no significant difference between MR imaging and US in the depiction of sphincter defects (P = .23). Sensitivity and positive predictive value were 81% and 89%, respectively, for endoanal MR imaging and 90% and 85%, respectively, for endoanal US.

CONCLUSION

In the selection of patients for anal sphincter repair, both endoanal MR imaging and endoanal US are sensitive tools for preoperative assessment, and both techniques can be used to depict surgically repairable anterior EAS defects.

Clinical presentation of fecal incontinence and anorectal function: what is the relationship?

OBJECTIVES

Fecal incontinence is classified into various types: passive, urge, and combined. Its clinical presentation is thought to be related to the underlying physiological or anatomical abnormality. The aim of the present study was to evaluate the associations between the frequency of clinical symptoms and anatomic and functional characteristics of the anorectum of patients with severe fecal incontinence.

METHODS

Associations were explored in a consecutive series of 162 patients (91% women, mean age 59 [SD +/- 12] yr) with a mean Vaizey incontinence score of 18 (SD +/- 3).

RESULTS

Urge incontinence was reported as "daily" by 55%, "often" by 27%, and "sometimes" by 7% of all patients. No significant associations were observed between the frequency of urge incontinence and either manometric data, anal mucosal sensitivity testing, or defects of internal anal sphincter (IAS) or external anal sphincter (EAS). A significant relation was observed between the frequency of urge incontinence and maximal tolerable volume (P= 0.03) and atrophy of the EAS (P= 0.05). Passive incontinence was reported as "daily" by 14%, "often" by 30%, and "sometimes" by 14% of all patients. Resting and maximal squeeze pressure were both associated (P < 0.001) with the frequency of passive incontinence. No relationship could be detected between clinical presentation and rectal sensation, anal mucosal sensitivity, defects, or atrophy of IAS or EAS.

CONCLUSION

Most patients reported combined incontinence (59%) and underlying pathophysiologic abnormalities were identified. The hypothesized associations between urge and passive incontinence and functional and anatomical impairment of the anorectum are less clear-cut than previously assumed. Patients presenting with fecal incontinence should undergo physiologic investigation.

MRI in evaluating atrophy of the external anal sphincter in patients with fecal incontinence

OBJECTIVE

External anal sphincter atrophy seen at endoanal MRI may predict poor outcome of surgical anal sphincter repair for an external anal sphincter defect. The purposes of this study were to compare external phased-array MRI to endoanal MRI for depicting external anal sphincter atrophy in patients with fecal incontinence and to evaluate observer reproducibility in detecting external anal sphincter atrophy with these techniques.

SUBJECTS AND METHODS

Thirty patients with fecal incontinence (23 women, seven men; mean age, 58.7 years; age range, 37-78 years) underwent both endoanal and external phased-array MRI. Images were evaluated for external anal sphincter atrophy by three radiologists. Measures of differences and agreement between both MRI techniques and of interobserver and intraobserver agreement of both techniques were calculated.

RESULTS

The MRI techniques did not significantly differ in their ability to depict external anal sphincter atrophy (p = 0.63) with good agreement (kappa = 0.72). Interobserver agreement was moderate (kappa = 0.53-0.56) for endoanal MRI and moderate to good (kappa = 0.55-0.8) for external phased-array MRI. Intraobserver agreement was moderate to very good (kappa = 0.57-0.86) for endoanal MRI and fair to very good (kappa = 0.31-0.86) for external phased-array MRI.

CONCLUSION

External phased-array MRI is comparable to endoanal MRI in depicting external anal sphincter atrophy and, thereby, in selecting patients for anal sphincter repair. Because results among interpreters varied considerably depending on the experience level, both techniques can be recommended in the diagnostic workup of fecal incontinence only if sufficient experience is available.

Functional changes after physiotherapy in fecal incontinence

BACKGROUND

Physiotherapy is a common treatment option in patients with fecal incontinence. Although physiotherapy may result in relief of symptoms, to what extent improvement is associated with changes in anorectal function is still unclear.

AIM

The aim of the present study was to investigate prospectively how anorectal function changes with physiotherapy and whether these changes are related to changes in fecal incontinence score.

METHODS

Consenting consecutive patients (n=266) with fecal incontinence (91% women; mean age, 59 years) underwent anorectal manometry, anal and rectal mucosal sensitivity measurements, and rectal capacity measurement at baseline and after nine sessions of standardized pelvic floor physiotherapy. These findings were compared with changes in Vaizey incontinence score.

RESULTS

On follow-up 3 months after physiotherapy, squeeze pressure (p=0.028), as well as urge sensation threshold (p=0.046) and maximum tolerable volume (p=0.018), had increased significantly. The extent of improvement was not related to age, duration of fecal incontinence, menopause, and endosonography findings. All other anorectal functions did not change. An improvement in the Vaizey score was moderately correlated with an increase in incremental squeeze pressure (r=0.14, p=0.04) and a decrease in anal mucosal sensitivity threshold (r=0.20, p=0.01).

CONCLUSIONS

Physiotherapy improves squeeze pressure, urge sensation, and maximum tolerable volume. However, improved anorectal function does not always result in a decrease in fecal incontinence complaints.

Electrical stimulation and pelvic floor muscle training with biofeedback in patients with fecal incontinence: a cohort study of 281 patients

PURPOSE

Pelvic floor rehabilitation is an appealing treatment for patients with fecal incontinence but reported results vary. This study was designed to assess the outcome of pelvic floor rehabilitation in a large series of consecutive patients with fecal incontinence caused by different etiologies.

METHODS

A total of 281 patients (252 females) were included. Data about medical history, anal manometry, rectal capacity measurement, and endoanal sonography were collected. Subgroups of patients were defined by anal sphincter complex integrity, and nature and possible underlying causes of fecal incontinence. Subsequently patients were referred for pelvic floor rehabilitation, comprising nine sessions of electric stimulation and pelvic floor muscle training with biofeedback. Pelvic floor rehabilitation outcome was documented with Vaizey score, anal manometry, and rectal capacity measurement findings.

RESULTS

Vaizey score improved from baseline in 143 of 239 patients (60 percent), remained unchanged in 56 patients (23 percent), and deteriorated in 40 patients (17 percent). Mean Vaizey score reduced with 3.2 points (P < 0.001). A Vaizey score reduction of >or= 50 percent was observed in 32 patients (13 percent). Mean squeeze pressure (+5.1 mmHg; P = 0.04) and maximal tolerated volume (+11 ml; P = 0.01) improved from baseline. Resting pressure (P = 0.22), sensory threshold (P = 0.52), and urge sensation (P = 0.06) remained unchanged. Subgroup analyses did not show substantial differences in effects of pelvic floor rehabilitation between subgroups.

CONCLUSIONS

Pelvic floor rehabilitation leads overall to a modest improvement in severity of fecal incontinence, squeeze pressure, and maximal tolerated volume. Only in a few patients, a substantial improvement of the baseline Vaizey score was observed. Further studies are needed to identify patients who most likely will benefit from pelvic floor rehabilitation.

The effects of creatine supplementation on selected factors of tennis specific training

BACKGROUND

Creatine supplementation is popular among tennis players but it is not clear whether it actually enhances tennis performance.

OBJECTIVES

To examine the effects of creatine supplementation on tennis specific performance indices.

METHODS

In a randomised, double blind design, 36 competitive male tennis players (24 creatine, mean (SD) age, 22.5 (4.9) years; 12 placebo, 22.8 (4.8) years) were tested at baseline, after six days of creatine loading, and after a maintenance phase of four weeks (14 creatine, 10 placebo). Serving velocity (10 serves), forehand and backhand velocity (three series of 5x8 strokes), arm and leg strength (bench press and leg press), and intermittent running speed (three series of five 20 metre sprints) were measured.

RESULTS

Compared with placebo, neither six days nor five weeks of creatine supplementation had a significant effect on serving velocity (creatine: +2 km/h; placebo: +2 km/h, p = 0.90); forehand velocity (creatine: +4 km/h; placebo: +4 km/h, p = 0.80), or backhand velocity (creatine: +3 km/h; placebo: +1 km/h, p = 0.38). There was also no significant effect of creatine supplementation on repetitive sprint power after 5, 10, and 20 metres, (creatine 20 m: -0.03 m/s; placebo 20 m: +0.01 m/s, p = 0.18), or in the strength of the upper and lower extremities.

CONCLUSIONS

Creatine supplementation is not effective in improving selected factors of tennis specific performance and should not be recommended to tennis players.

Relationship between external anal sphincter atrophy at endoanal magnetic resonance imaging and clinical, functional, and anatomic characteristics in patients with fecal incontinence

PURPOSE

External anal sphincter atrophy at endoanal magnetic resonance imaging has been associated with poor outcome of anal sphincter repair. We studied the relationship between external anal sphincter atrophy on endoanal magnetic resonance imaging and clinical, functional, and anatomic characteristics in patients with fecal incontinence.

METHODS

In 200 patients (mean Vaizey score, 18 (+/-2.9 standard deviation)) magnetic resonance images were evaluated for external anal sphincter atrophy (none, mild, or severe) by radiologists blinded to anorectal functional test results and details from medical history. Subgroups of patients with and without atrophy were compared for medical history, anal manometry, pudendal nerve latency testing, anal sensitivity testing, external anal sphincter thickness, and external anal sphincter defects. Whenever significant differences were detected, we tested for differences between patients with mild and severe atrophy.

RESULTS

External anal sphincter atrophy was demonstrated in 123 patients (62 percent): graded as mild in 79 (40 percent), and severe in 44 patients (22 percent). Patients with atrophy were more often female (P < 0.001) and older (P = 0.003). They had a lower maximal squeeze (P = 0.01) and squeeze increment pressure (P < 0.001). Patients with severe atrophy had a lower maximal squeeze (P = 0.003) and squeeze increment pressure (P < 0.001) than patients with mild atrophy. These effects were not attenuated by potential confounding variables. Patients with atrophy could not be identified a priori by other characteristics.

CONCLUSIONS

External anal sphincter atrophy at endoanal magnetic resonance imaging was depicted in 62 percent of patients, varying from mild to severe. Because increasing levels of atrophy were associated with impaired squeeze function, further studies are needed to evaluate whether grading atrophy is clinically valuable in selecting patients for anal sphincter repair.

Patients' perception of tests in the assessment of faecal incontinence

The objective of this study was to evaluate patient perception of endoanal MRI compared with defecography and anorectal functional testing in the workup of patients with faecal incontinence. Consenting consecutive patients underwent a standard testing protocol consisting of endoanal MRI, defecography and anorectal function combination. Patient experience was evaluated with a self-administered questionnaire, addressing anxiety, embarrassment, pain and discomfort, each measured on a 1 (none) to 5 (extreme) point-scale. Patients were also asked to rank the three tests from least to most inconvenient. Statistical analysis was performed with parametric tests. Data from 211 patients (23 men; mean age 59 years (SD+/-12)) were available. MRI had the lowest average score for embarrassment and discomfort (1.6) and defecography the highest (1.9 and 2.0, respectively) (p<0.0001, tested with general linear model for related samples). The average pain score was lowest for MRI (1.4) and highest for the anorectal function combination (1.7) (p<0.0001). Level of anxiety was highest for MRI (1.6 versus 1.4; p = 0.03). MRI was scored as least inconvenient by 69% of patients. Endoanal MRI was scored as least inconvenient. However, the differences in patient burden between the three diagnostic tests were small and absolute values were low for all tests. Patient perception will not be a key feature in determining an optimal diagnostic strategy in faecal incontinence.

Selecting an outcome measure for evaluating treatment in fecal incontinence

PURPOSE

Various outcome measures exist to evaluate treatment in fecal incontinence, including descriptive, severity (fecal incontinence scoring systems), and impact (quality-of-life questionnaires) and diagnostic measures. We studied associations between changes after treatment for a number of outcome measures and compared them to patients' subjective perception of relief.

METHODS

We analyzed data of 66 patients (92 percent female; mean age, 62 years) (Vaizey score, Wexner score, two impact scales, utility, resting pressure, and maximal incremental squeeze pressure) at baseline and after physiotherapy. In a standardized interview by phone, we asked patients to compare their situation before and after treatment. Correlations between changes in outcome measures were calculated. These changes were compared with patients' subjective perception.

RESULTS

There was a high correlation between the changes in the Vaizey and the Wexner scores (r = 0.94, P < 0.01). Changes in Vaizey and Wexner scores correlated moderately with changes in maximum incremental squeeze pressure (r = -0.29, -0.30, both P < 0.05). Changes in utility and resting pressure were not correlated with changes in any of the other measurements (all r values between -0.086 and 0.18). Average severity scores (Vaizey and Wexner) were 1 point lower for patients who rated their situation as worse or equal (62 percent), 4 points lower for patients who reported their situation to be better (21 percent), and 9 points lower in patients who rated their situation much better (17 percent) (P < .05).

CONCLUSION

Severity measures are best related to patients' subjective perception of relief.