INNOVATION From creation to implementation

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1 INNOVATION From creation to implementation VRA Annual Congress 0 Thursday November st and Friday November nd, 0 34th volume 0 05 PROGRAMME THURSDAY Nederlands tijdschrift voor Revalidatiegeneeskunde Congress Reader ö Congress Programme Overview ö Keynote Speakers ö Workshops & Minisymposia ö Free Papers ö Poster Presentations

2 Index Editorial 4 Programme 7 Organisation 8 Keynote Speakers S.H. Berdenis van Berlekom MBA 9 Professor T. van der Weijden MD PhD 0 Professor F.C.T. van der Helm PhD Professor J. Harlaar PhD 3 Professor B.R. Bloem MD PhD 5 b. Minisymposium Rehabilitation and virtual environments: a love affair or just a one night stand? 7 c. Minisymposium SCI: innovation in sitting, standing and walking 8 d. Workshop Problems and pitfalls in the vocational training of specialists are there to be solved 3 e. Minisymposium Evaluation, prediction and treatment of walking ability in children with spina bifida 3 f. Minisymposium It s my life! Innovation of care for young adults with childhood onset disabilities 33 g. Workshop Rehabilitation medicine: rehab is fun! 34 b. Workshop Effective exercises in rehabilitation medicine: how does it work? 35 c. Minisymposium From innovation to implementation in paediatric rehabilitation: playfulness and flow 36 d. Workshop Changes in educational program VRA for residents in PM&R 37 e. Minisymposium Physician Assistants in rehabilitation: from innovation to implementation 38 f. Workshop Clinical assessment of walking energy cost and fitness in children and adolescents with cerebral palsy or other motor impairments: application in pediatric rehabilitation 39 3b. Minisymposium Rehabilitation robotics: a promise for the near future? 40 3c. Minisymposium RCT s and alternative study designs in rehabilitation medicine; from design to implementation and all the bumps on the way 4 3d. Minisymposium Wheeled mobility: an ergonomics perspective 4 3e. Workshop of IFMS in a medical staff of rehabilitation physicians 43 3f. Minisymposium Lifespan expectations for individuals with cerebral palsy 44 Free Papers Thursday afternoon Parallel Session 45 Friday morning Parallel Session 5 Friday afternoon Parallel Session 3 59 Poster presentations Thursday 66 Friday 80 Nederlands Tijdschrift voor Revalidatiegeneeskunde (NTR) The Netherlands journal of Physical and Rehabilitation Medicine Het NTR is een mededelingen- en informatie periodiek van de Nederlandse Vereniging van Revalidatieartsen (VRA). De redactie wordt gevormd door Drs. Vera Baadjou Drs. Gerlof Balk Dr. Hans Bussmann Drs. Ben Drentje Hans Groen Dr. Lily Heijnen Drs. Esther Jacobs Dr. Ron Meijer Prof. dr. Rob Smeets Dr. Anne Visser-Meily Heidi Wals Hoofdredacteur Drs. Ben Drentje Redactieadres Redactiesecretariaat t.a.v. Heidi Wals Nederlandse Vereniging voor Revalidatieartsen (VRA) Postbus GR Utrecht Tel: (030) Uitgever, advertenties en abonnementen dchg medische communicatie Hendrik Figeeweg 3G-0 03 BJ Haarlem Tel. (03) Opmaak dchg medische communicatie, Haarlem Abonnement Jaarabonnement 80. Schriftelijke opzegging ten minste 4 weken voor het eind van de termijn. Het NTR verschijnt zesmaal per jaar. Inzending kopij Per met attachments. Complete tekst met eventuele afbeeldingen of tabellen in de tekst aanleveren. Teksten in Word (niet in pdf). Daarnaast tevens figuren, foto s of andere afbeeldingen, ook los van de tekst aanleveren als jpg of tiff. Richtlijnen voor auteurs Deze richtlijnen zijn te downloaden op Verschijning Februari, april, juni, augustus, oktober en december. Niets uit deze uitgave mag worden overgenomen zonder toestemming van de uitgever of de hoofdredacteur. De uitgever is niet aansprakelijk voor de inhoud van deze uitgave. 34e jaargang nummer 5 ISSN colofon 3

3 Editorial Innovation: from creation to implementation The theme of the International Annual Congress of the Netherlands Society of Rehabilitation Medicine 0 emphasizes the outmost importance for our profession not to stand still but to look for new avenues to face the several current and future challenges. For example, the expected increase of the aging population, the higher prevalence of co-morbidity and the consequences of advanced medical technology will result in a tremendous growth of patients with disability and restrictions in participation. Furthermore, a scarcity of health care workers is foreseen, which will make it impossible to take care of all these demands. Even more important, we seem to have reached the limits of the budget for health care and disability management. So we will have to disappoint many of our patients, unless we are able to come up with new concepts how to attract and educate new colleagues, find innovative solutions to enhance collaboration with other health care professionals, increase the effectiveness and efficiency of our interventions by incorporating knowledge from other medical specialists and other fields like technology such as IT and Virtual Reality. We must realise that today s problems cannot be solved with the same way of thinking that caused those "Innovation distinguishes between a leader and a follower" Steve Jobs problems. Innovation leads to change and we need to explore new clinical paths and broaden the borders of our specialty without loosing focus on the essence of our profession. The healthcare changes constantly and it offers us the possibility to actively contribute to this change and to be a co-designer of new methods. Let s face that challenge. For our Annual Congress the scientific committee succeeded in putting together a very exciting program with five excellent and renowned keynote speakers who shared their points of view on the opportunities, challenges and pitfalls of innovation. Besides, the highest number of symposia/workshops (9) ever, including 3 sessions with in total 4 excellent free paper presentations were scheduled. This issue of NTR reflects the high quality of the last congress of our Society, and invites us to boost our energy to create and innovate! Prof. Rob Smeets MD PhD, Chair Scientific Committee Dr. Juan Martina, MD, Chairman of the VRA 4

4 Programme VRA ANNUAL CONGRESS 0 Thursday November st Registration of the participants Opening congress The art of possibility S.H. Berdenis van Berlekom MBA Challenges in knowledge transfer Professor T. van der Weijden MD PhD.0.35 Poster presentations Visiting posters and commercial exhibition Lunch Parallel session a. Free Papers b. Mini-symposium: Rehabilitation and virtual environments: a love affair or just a one night stand? c. Mini-symposium: SCI: innovation in sitting, standing and walking d. Workshop: Problems and pitfalls in the vocational training of specialists are there to be solved e. Mini-symposium: Evaluation, prediction and treatment of walking ability in children with Spina Bifida f. Mini-symposium: It s my life. Innovation of care for young adults with childhood onset disabilities g. Workshop: Rehabilitation Medicine: Rehab is fun! Tea break and visiting commercial exhibition General Assembly VRA Free time Dinner and live-music PROGRAMME OVERVIEW Friday November nd Parallel session a. Free Papers b. Workshop: Effective Exercises in Rehabilitation Medicine: How does it work? c. Mini-symposium: From innovation to implementation in pediatric rehabilitation: playfulness and flow d. Workshop: Changes in Educational program VRA for residents in PM&R. e. Mini-symposium: Physician Assistants in rehabilitation: from innovation to implementation f. Workshop: Clinical assessment of walking energy cost and fitness in children and adolescents with cerebral palsy or other motor impairments: Application in pediatric rehabilitation Coffee break and visiting commercial exhibition.5.45 Force and position feedback mechanisms in neuromuscular control Professor F.C.T. van der Helm PhD.45.0 Poster presentations Visiting posters and commercial exhibition Lunch Parallel session 3 3a. Free Papers 3b. Mini-symposium: Rehabilitation Robotics: a promise for the near future? 3c. Mini-symposium: RCT s and alternative study designs in Rehabilitation Medicine; From design to implementation and all the bumps on the way 3d. Mini-symposium: Wheeled mobility: an ergonomics perspective 3e. Workshop: of IFMS in a medical staff of rehabilitation physicians 3f. Mini-symposium: Lifespan expectations for individuals with cerebral palsy Tea break and visiting commercial exhibition Awarding: best presentation and best poster PhD Award Rehabilitation Medicine Clinical Movement Analysis in Rehabilitation Medicine: the road to implementation Professor J. Harlaar PhD Healthcare new style: a different role for healthcare professionals and patients Professor B.R. Bloem MD PhD 7.00 Closing of the VRA Annual Congress PROGRAMME OVERVIEW 7

5 Organisation Organizing Society Netherlands Society of Physical and Rehabilitation Medicine Scientific Committee Netherlands Society of Physical and Rehabilitation Medicine Prof. R.J.E.M Smeets MD PhD M.J. Andela MD W.X.M. Faber MD J.F.M. Fleuren MD PhD I.J.M. de Groot MD PhD J.H. de Groot MSc PhD V. de Groot MD PhD S.I.G. van Haaster-Houwing, MSc (VRA bureau) J. van Meeteren MD PhD A. Mert MD PhD G.M. Ribbers MD PhD M.E. Roebroeck PhD J. Stolwijk-Swüste MD PhD A.H. Vrieling MD PhD Postal address Postbus GR Utrecht The Netherlands T +3 (0) Congress venue NH Conference Centre Leeuwenhorst Langelaan 3 XT Noordwijkerhout The Netherlands T +3 (0) Congress registration and acquisition sponsoring T +3 (0) T +3 (0) F +3 (0) Accreditation Accreditation has been granted for at the Netherlands Society of Physical and Rehabilitation Medicine and the European Accreditation Council for Continuing Medical Education (EACCME). 8

6 Keynote Speakers Keynote Speaker S.H. Berdenis van Berlekom The art of possibility While professionals in rehabilitation medicine are busy implementing the current best practice, they always have to be aware of signals indicating that a next practice is at hand. Innovators have a nose for this next trend, but do our organisations and their rehabilitation specialists have a nose for innovators? In his presentation, Steven van Berlekom will state that innovation is performing the art of possibility, a positive attitude towards ideas eventually changing the rules of the game (or not). He will reflect on a variety of topics, such as the difference between solving a problem and accomplishing an ambition, the manageability of the weather and the importance of passing. He will wander through questions as: How can we ensure improvements and innovations in the increasingly production-based environment of a rehabilitation centre? What organisational and cultural conditions invite professionals to become innovators? What kind of leaders and, as important, followers do we need to build an innovational environment? Which part can patients play in the search of the next practice? And last but not least: Are rehabilitation specialists equipped for performing the art of possibilities and if not, what can be done to support them? Curriculum Vitae Steven Berdenis van Berlekom (959) is member of the executive board of De Hoogstraat Revalidatie in Utrecht. His focus in the board is on quality and safety, innovation and scientific research. Since he became a physiotherapist in 983, Steven van Berlekom has been working in the field of rehabilitation medicine. In the eighties mainly as paediatric physiotherapist, in the nineties as a manager of rehabilitation teams at Sophia Revalidatie and later on at De Hoogstraat. In this period he earned a Masters of Business Administration Degree (MBA) from Henley Business School - Brunel University. In 003 Steven van Berlekom became as Manager Center of Excellence the mr. Fixit (de regelneef) of Professor Eline Lindeman, establishing and developing the Center of Excellence for Rehabilitation Medicine Utrecht. Here his experience as a professional met his organisational skills in topics as quality improvement, implementation and innovation. Due to an excellent team the Center of Excellence became a frontrunner in research and innovation in rehabilitation in the Netherlands. Steven van Berlekom was involved in well-known projects as the development and dissemination of the USER, the project Gezin in Zicht for paediatric rehabilitation teams, the development of the Beslishulp Beroerte in association with the WCN and - still running - two national projects for the implementation of the guidelines for Stroke and Cerebral Palsy. S.H. Berdenis van Berlekom MBA Steven van Berlekom joined the executive board of the Hoogstraat in 009. He is member of the advisory committee for research, innovation and quality (BOIK) of Revalidatie Nederland, vice-chairman of the programme-commission for the innovation-programme for rehabilitation at ZonMw, member of the advisory committee for quality at NVZ and member of the editorial board of Revalidatie Magazine. 9

7 Keynote Speakers Keynote Speaker Prof. T. van der Weijden Challenges in knowledge transfer Curriculum Vitae Professor T. van der Weijden MD PhD Research evidence on the effectiveness of medical interventions is published in large quantities every year. This does not automatically lead to improvements in patient care. Unwarranted interdoctor variation that has been documented since the 940 s, continues to persist in many health care settings. Systematic implementation efforts are needed to achieve and sustain high quality of care. Clinical practice guidelines are seen as a strategy of first choice in this field. The development of guidelines is a challenge; evidence-based information regarding effectiveness, efficiency, patient preferences, and safety has to be appraised, and subsequently related to national or local experiences on best practices to assure feasibility, timeliness and equity. Research is therefore needed on the preferred methods for development of multidisciplinary guidelines and quality of care indicators. Dissemination of guidelines does not lead to significant improvements in quality of care. Physicians may experience a conflict between the adherence to guidelines (with population-based Trudy van der Weijden received her medical degree in 989 and made a choice for fulltime research early in her career. She certified as epidemiologist. In 997 she defended her thesis Implementation of the Cholesterol clinical practice guideline in general practice for which she received the CaRe Award 997, the dissertation award of the Netherlands School of Primary Care. In 005, she was appointed as Program Leader in the research school for public health and primary care (CAPHRI) of Maastricht University, and in 00 as professor in Implementation of Clinical Practice Guidelines at the department of General Practice. She is leading the CAPHRI research program 'Implementation of evidence'. In 00 Trudy van der Weijden was awarded with a ZonMW Parel for the IMPALA project Shared Decision Making in lifestyle counseling. In 0 she chaired the International Conference on Shared Decision Making in Maastricht. She has (co-)authored over 0 international scientific papers in peer reviewed international journals, which include the highest impact medical journals such as British Medical Journal and Journal American Medical Association. She is visiting senior fellow at Nijmegen IQ Scientific Institute for Quality of Health Care, working with Gert Westert, and at the Cardiff Department of Primary Care and Public Health, working with Glyn Elwyn, UK. She is visiting professor at Hoge School Zuyd Heerlen, working for the Platform Quality of Life with Sandra Beurskens. recommendations) and patient-centred work (applying the guideline to a unique patient). Health care should be delivered according to accepted professional guidelines, with specific benchmarks for the quality indicators. However, health care should also meet objective and subjective needs of individual patients. 0

8 Keynote Speakers Keynote Speaker Prof. F.C.T. van der Helm Force and position feedback mechanisms in neuromuscular control Curriculum Vitae Professor Frans C.T. van der Helm PhD The simultaneously modulation of the strength of the force and position feedback loops determines the postural control of the human limbs. Force feedback originates from the Golgi tendon organs, and position feedback from the muscle spindles. Position tasks require a high stiffness of the human limb ( resist ), whereas force tasks require a low stiffness ( give way ). Using closed-loop system identification mechanisms in combination with force perturbations, the quantitative contribution of the various feedback loops can be determined. In force tasks, the stiffness becomes lower than in passive conditions showing that the reflexive feedback is actively giving way. Remarkedly, experimental results show a switch of the sign of position and force feedback gains between position and force tasks. A theoretical model was developed which can explain the symptoms of dystonia, like preferred position and high resistance against displacement. The model assumes a-symmetric feedback gains between flexors and extensors, and the lack of positive force feedback gains settings. Experiments with CRPS patients with dystonia showed that they Frans C.T. van der Helm is professor in Biomechatronics and Bio-robotics, Delft University of Technology, and also adjunctprofessor at the University of Twente, LUMC, Northwestern University (Chicago) and Case Western Reserve University (Cleveland). He has a MSc in Human Movement Science (985), and a PhD in Mechanical Engineering (99). He was member of the board of the International Society of Biomechanics ( ), and participates in the board of the Technical Group of Computer Simulation (TGCS) and the International Shoulder Group (ISG). He is one of programme leaders in the Medical Delta, the collaboration between Leiden Unversity Medical Center (LUMC), Erasmus Medical Center Rotterdam and TU Delft. He is Principal Investigator in the TREND research consortium, investigating Complex Regional Pain Syndrome as a neurological disorder, the NeuroSIPE (System Identification and Parameter Estimation in Neurophysiological systems) program and H-Haptics (Human centered Haptics) program, sponsored by the Dutch National Science Foundation. In 0 he received an ERC grant for a research project 4D EEG, improving temporal and spatial resolution of EEG source localization. In 0 he received the Simon Stevin Meester prize, the most prestigious award for research in the technical sciences in the Netherlands. He has published over 50 papers in international journals on topics as biomechanics of the upper and lower extremity, neuromuscular control, eye biomechanics, pelvic floor biomechanics, human motion control, posture stability, etc. could significantly less modulate their force feedback strength. It is concluded that Golgi tendon feedback has a similar important role for the stiffnes behaviour of the human limbs as muscle spindles, and they should be simultaneously quantified in order to understand neuromuscular control.

9 Keynote Speakers Keynote Speaker Prof. J. Harlaar Clinical movement analysis in rehabilitation medicine: the road to implementation Curriculum Vitae Professor Jaap Harlaar PhD Laboratory for Clinical Movement Analysis dept. Rehabilitation Medicine, VU University Medical Centre, Amsterdam MOVE Research Institute Amsterdam Human movement analysis is the scientific analytical method to reduce human motion to the mechanical behaviour of the (neuro-)musculoskeletal system. Whether or not application of such methods is useful in the clinical practise of rehabilitation medicine, requires a close interaction of application designers and physiatrists. It is obvious that the complexity of the human movement system in action, cannot be understood from observation and physical examination alone. However, simply measuring all information that can be acquired, is not automatically meaningful. The road behind: over the last 0 years the introduction of clinical movement analysis in the Netherlands has been governed by this interaction and has evaluated into an unique concept. Adapted technologies for clinical feasible solutions were developed and a network of clinical gait labs and multidisciplinary courses is now established. Jaap Harlaar (956) is biomedical engineer and professor in clinical movement analysis. He is heading the laboratory of clinical movement analysis at the Department of Rehabilitation Medicine at the VU University Medical Center. He is also co-heading the musculoskeletal biomechanics research group of the MOVE research institute Amsterdam. He is also lecturer at the faculty of human science of VU University Amsterdam. Jaap was trained at Twente University as an electrical engineer and specialized in measurement and signal processing of EMG during movement. At VUmc he designed and build instrumentation for clinical movement analysis in the context of rehabilitation medicine, receiving a PhD on this topic in 998. In his work Jaap highly values close collaboration with clinicians to establish innovations that must lead to meaningful applications. His current research focuses on the application of new technologies, i.e. computational biomechanics, Virtual Reality and inertial sensing, with an emphasis on orthotics. Jaap is co-founder of SMALLL, the Dutch-Flemish society of movement analysis laboratories. Furthermore Jaap serves ISPO Netherlands as chairman and is president of ESMAC (European Society for Movement Analysis in Adults and Children). The road ahead: short term developments will include even closer national collaborations involving datasharing, and the conception of guidelines for sensible clinical use. Technological developments will contribute to cost effectiveness, while computational biomechanical modelling will support the physiatrist in informed decision making. The challenge of this road ahead is not to get lost in technological opportunities, but to stay critically focused on the need to provide better care for our patients. This also requires the committment of the clinical community to the role of diagnostics in clinical practise of rehabilitation medicine. 3

10 Keynote Speakers Keynote Speaker Prof. B.R. Bloem Healthcare new style: a different role for health care professionals and patients Professor B.R. Bloem MD PhD The world around us is changing. Healthcare is no exception to this phenomenon. The role of both health care professionals and that of patients will change due to social changes such as individualism, globalization and technology. In my presentation I will address these new roles. Healthcare professionals need to develop from omnipotent Gods into a coach or a guide, who supports the patient in making the right decisions. Moreover, healthcare professionals have to specialize on a limited number of disorders and integrated care should be provided during the entire disease process of patients. The new role of the healthcare professionals has resulted in the development of ParkinsonNet. In my presentation I will elaborate on the creation of ParkinsonNet, the current state of affairs, and on some important developments for the near future. I will also discuss the important role, played by the rehabilitation specialists within the ParkinsonNet. Patients will change from passive objects into active subjects, who make a significant contribution to maintaining both their own good health and in the Curriculum Vitae Bas Bloem is a consultant neurologist at the Department of Neurology, Radboud University Nijmegen Medical Centre, the Netherlands. He received his MD degree (with honour) at Leiden University Medical Centre in 993. In 994, he obtained his PhD degree in Leiden, based on a thesis entitled Postural reflexes in Parkinson s disease. He was trained as a neurologist between 994 and 000, also at Leiden University Medical Centre. He received additional training as a movement disorders specialist during fellowships at The Parkinson's Institute, Sunneyvale, California (with Dr. J.W. Langston), and at the Institute of Neurology, Queen Square, London (with Prof. N.P. Quinn and Prof. J.C. Rothwell). In 00, he founded and became Medical Director of the Parkinson Centre Nijmegen (ParC), which was recognised from 005 onwards as centre of excellence for Parkinson s disease. Together with Dr. Marten Munneke, he also developed ParkinsonNet, an innovative healthcare concept that now consists of 64 professional networks for Parkinson patients covering all of the Netherlands (www.parkinsonnet.nl). In September 008, he was appointed as Professor of Neurology, with movement disorders as special area of interest. He is currently President of the International Society for Gait and Postural Research, and is on the editorial board for several national and international journals. Since 009, he is member of the European Section Executive Committee of the Movement Disorder Society. In 009, he also joined the board of ZonMw (The Netherlands Organisation for Health Research and Development). He currently has two main research interests: cerebral compensatory mechanisms, especially in the field of gait & balance; and healthcare innovation, aiming to develop and scientifically evaluate patient-centred collaborative care. For this latter purpose, Prof. Bloem co-founded MijnZorgnet (together with Prof. Jan Kremer), a service provider that delivers web-based communities for both patients and health professionals. Prof. Bloem has published over 350 publications, including more than 60 peer-reviewed international papers. recovery from diseases. Modern ICT solutions can support these new roles, but they can never be an aim in themselves. At the end of my presentation I will briefly address the question whether and how patients with a neurodegenerative disease like Parkinson in close cooperation with health care professionals can make use of such modern ICT applications. 5

11 Parallel Session b: Minisymposium Rehabilitation and virtual environments: a love affair or just a one night stand? Chair: A. Mert MD PhD W. Bles PhD, W.J. Renger MSc, M. Roerdink PhD, M.P. Schijven MD PhD, W. Wertheim MD Rehabilitation and virtual environments: a love affair or just a one night stand? In the last 4,5 years more than 000 sessions on the Computer Assisted Rehabilitation ENvironment at the Military Rehabilitation Center in Doorn have been performed. The success rate from the patient s perspective is very high, but adherence to several gaming and virtual reality principles is necessary. Often this means that the therapist has to fade into the background. A method has been developed of developing a rehabilitation game. This method that has been applied to the Body Posture game. This game has won the Best Serious Game 0 award of the Dutch Game awards. Principles and intensity of therapy that have worked well in our setting will be presented. These might be used as a starting point for future research and shaping of therapy. Also pitfalls in this type of research will be discussed. Lastly, how to use this type of assistive technology as an analysis tool will be shown. Simulation and serious gaming: seriously?! The application of digital games as training modality for medical professionals is on the rise. Often referred to as serious games, they form a category of training tools that provide a challenging simulated environment. They may be of use to train medical professionals, resulting in reduced healthcare cost while enhancing patient safety. Learning through challenging games occurs faster than imposed learning, with results more securely mapped in the brain, i.e. leading to better retention and enhancing deep and sustained learning. Acceptance of serious gaming, however, is a process that requires intensive collaboration with game designers, a change of mindset in health care educators and robust validation of the embedding of such technology in teaching healthcare professionals. This talk provides you with an overview of the current state-of-the-art in serious gaming for training health care professionals. From simulation to transformation: game design principles and its application in healthcare Simulation has been around for a long time and is used in many contexts to train professionals in understanding complex processes, decision making or performing complex motorskills. Games are relatively new in entering other contexts than entertainment, so called serious games. In this presentation we will look at the similarities and differences between games and simulation. What are the advantages of using or making games compared to simulations? A vital difference between games and simulations is their relationship to the real. Simulations aim at a : relationship with reality while using virtual presence. Games aim at :x relationship, hence the term transformation. This puts more importance on the collaboration between subject matter expert and designer, but if done right leads to a very different user experience for the user/patient/client. Using a number of examples of serious games in the context of healthcare, a number of critical lessons learned will be presented covering the design process and collaboration between medical experts and designers. Simulator and game induced sickness The use of serious gaming and simulators in health care holds a potential problem that needs to be addressed, since ignoring it will compromise the potential usefulness of these techniques. With increasing screen sizes, better graphics, the use head mounted displays and of motion platforms a special form of motion sickness, simulator sickness, can arise. This can lead to nausea, decreased performance and to aversion to these therapy forms. In rehabilitation practices where patients have decreased sensory functioning and suboptimal integration of sensory input (e.g. after a stroke), this can be a compounding problem. Overcoming and preventing simulator sickness is possible, but adherence to well known principles in the field of simulation is necessary. In this presentation the causes of simulator sickness are addressed, also how to prevent and overcome it. 7

12 Parallel Session Moving from the red carpet to a treadmill with visual context to enhance the task-specificity of intensive, repetitive gait training General recommendations for effective rehabilitation indicate that we should start as early as possible with high-intensity, repetitive and task-specific practice with feedback on performance. For gait rehabilitation, treadmill training represents a practice form that largely complies with these evidence-based ingredients. However, the task-specificity aspect of treadmill training can be disputed because it places no demands on precise foot placement, which is critical for safe ambulation in ever changing environments. After all, most falls occur due to inaccurate foot placement relative to environmental context (e.g., obstacles, uneven terrain), resulting in trips, slips and misplaced steps. A well-suited metaphor for treadmill walking is a red carpet: the regular, flat walking surface lacks fall hazards, placing minimal demands on foot placement precision. In this presentation, I will discuss the development of an innovative rehabilitation treadmill with projected visual context, placing high demands on foot positioning and thereby enhancing the task-specificity of treadmill training. Virtual Reality In Rehabilitation, how to get it operational for daily use. In recent years a lot of new technology entered healthcare institutions. One of these new technologies concerns a virtual reality instrument to enhance rehabilitation programs in a gaming environment. Since a few years the military rehabilitation center in the Netherlands is working with a VR-instrument called CAREN (computer assisted rehabilitation environment). CAREN is a high-end virtual reality tool providing diagnostic and treatment features. Embedding these virtual reality instruments in a medical rehabilitation environment requires quite some management skills. The treatment with this novel tool had to be aligned with the existing treatment protocols in neurological and orthopedic rehabilitation. Beside that we have to create commitment and acceptance of this tool by our therapists. In my presentation I will focus on how to create a platform in a healthcare organization to realize a startup with this new technlogy tool and I will report on our experiences with doing so. Programma Chair: A. Mert MD PhD. Rehabilitation and virtual environments: a love affair or just a one night stand? A. Mert MD PhD. Simulation and serious gaming: seriously?! M.P. Schijven MD PhD 3. From simulation to transformation: game design principles and its application in healthcare W.J. Renger MSc 4. Simulator and game induced sickness W. Bles PhD 5. Moving from the red carpet to a treadmill with visual context to enhance the task-specificity of intensive, repetitive gait training M. Roerdink PhD 6. Virtual Reality In Rehabilitation, how to get it operational for daily use. W. Wertheim MD c: Minisymposium SCI: innovation in sitting, standing and walking Chair: J.M. Stolwijk-Swüste MD PhD C. Smit MD, S. van Langeveld PT PhD, H. van de Meent MD PhD, H.A.F.M. Rijken PT, B. Fleerkotte PT, prof. T.W.J. Janssen PhD In this mini-symposium innovations in sitting, standing and walking in spinal cord injury will be presented. Pressure ulcers still are among the most prevalent and serious complications in people with a spinal cord injury (SCI). Electrical Stimulation-induced muscle activation of the gluteal and hamstring muscles induced significant acute reductions in interface pressure of the ischial tuberosities in SCI. Pressure relief movements improved (sub)cutaneous oxygenation and mean blood flow, while ES-induced contractions increased peak BF but not oxygenation. ES-induced contractions might be a promising additional method to reduce risk of pressure ulcers in SCI. 8

13 Parallel Session In a special project in 0, persons with tetraplegia C5 and C6 admitted to rehabilitation center De Hoogstraat were given the opportunity to explore the use of an ipad. Soon it became clear that the use of an ipad can contribute to the independence of persons with tetraplegia in communication, mobility, and self-care activities. The rehabilitation technology department and a software company developed applications and devices for the ipad and Smartphone to serve as an environmental control unit in the rehabilitation center and at home. Compared to conventional systems for environmental control at one s home the ipad is easier in use and price affordable. Traumatic spinal cord injury is a serious disorder in which early prediction of ambulation is important to counsel patients and to plan rehabilitation. A reliable, validated prediction rule to assess a patient s chances of walking independently after such injury was developed. This prediction rule, including age and four neurological tests, can give an early prognosis of an individual s ability to walk after traumatic spinal cord injury, which can be used to set rehabilitation goals and might improve the ability to stratify patients in interventional trials. Experiences from the past that led to the purchase of Lokomat and implementation of robot-assisted treadmill training with the Lokomat. A study focussing on the gait training of chronic SCI subjects with LOPES with Assisted-As-Needed support of the hip flexion ( and thereby step height) during swing. of the study and experiences of the subjects will be presented. The results of the first Dutch study into the effects of robot-assisted treadmill training (RATT) using the Lokomat will be discussed. In a randomized controlled trial with patients with stroke and a non-randomized trial with patients with incomplete spinal injury it was shown that RATT resulted in improvements in walking ability, but that results on group level were not clearly different from conventional gait training. A large variability in progression among patients was clear, and it remained unclear how this variability could be explained. Many questions about, for example, optimal training parameters, specific effects for different groups of patients, individual responses, and the costeffectiveness of robot-assisted treadmill training need to be answered. This can only be done in a multicenter study and in this mini-symposium the setup of such a collaborative effort will be discussed. Programme Chair: J.M. Stolwijk-Swüste MD PhD. Effect of electrostimulation of gluteal and hamstring muscles on sitting pressure, blood flow and oxygenation C. Smit MD. Implementing the use of an ipad as a multifunctional tool to gain independence in functional activities S. van Langeveld PT PhD 3. To walk or not to walk: a prediction rule for walking after SCI H. van de Meent MD PhD 4. Experiences in implementation of robot assisted treadmill training with the Lokomat H.A.F.M. Rijken PT 5. Experiences with robot assisted treadmill training with the LOPES B. Fleerkotte PT 6. Effects of robot assisted treadmill walking: where to walk to from here? Prof. T.W.J. Janssen PhD 7. Discussion of robot assisted treadmill training research in the future J.M. Stolwijk-Swüste MD PhD 9

14 Parallel Session d: Workshop Problems and pitfalls in the vocational training of specialists are there to be solved Chair: H. Hacking MD A. van Kuijk MD PhD, C. den Rooyen MSc On behalf of the Concilium VRA Medical education must be multidimensional and impart competence beyond Medical Expert to effectively be responsible to society and meet the needs of the patients in the th century. In 009 the KNMG adopted the framework for medical education called the CANMEDS framework for physician competence. The CANMEDS framework consists of 7 roles each identified by a set of competencies. Competencies are a complex set of behaviours built on the components of knowledge, skills, attitudes, and competence as personal ability. In 0 this framework has been integrated into standards of training ( Beter ) as well as in legislation (kaderbesluit CCMS). In clinical practice, however, Implementation can be hindered by resistance to change amongst both program directors, faculty staff, and residents. Frequently mentioned underlying concepts of opposition are the conceptual concern that standardized competencies may never be able to capture important aspects of the medical profession, faculty overload, lack of competence, lack of resources, or simple lack of interest. These different concepts ask for different implementation strategies. Successful implementation of the CANMEDS roles and the educational programme BETER in to teaching practice requires an opposition-tailored strategy involving intra- and interprofessional cooperation. In this highly interactive workshop we try to help program directors and faculty staff by providing Programme. Hub Hacking. Resistance to change: the puzzle Corry den Rooyen 3. Change-management: an example Annette van Kuijk 4. The puzzle & change management: do-it-your-self Corry den Rooyen & Annette van Kuijk 5. The puzzle & change management: lessons learned Hub Hacking 6. Manage educational change: Plan-do-check act Annette van Kuijk & Corry den Rooyen 7. Evaluation and closing Hub Hacking Maximum 30 participants a framework to analyse resistance to change and group dynamics. Participants will be challenged to analyse their own group of colleagues (either staff or residents). The more you understand people's needs, the better you will be able to manage educational change. Subsequently, we will provide a framework to plan, implement, and manage educational change in your own organization. Including an introduction in quality instruments, especially what and how to use these in small groups. 3

15 Parallel Session e: Minisymposium Evaluation, prediction and treatment of walking ability in children with spina bifida Presentation of the first multidisciplinary guideline Chair: B. Ivanyi MD PhD H.J.G. van den Berg-Emons PhD, J.F. de Groot PhD, M.J. Nederhand MD PhD, M.A.G.C. Schoenmakers PhD, J.A. van der Sluijs MD PhD Substantial progress in the treatment of walking ability in children with spina bifida (SB) has been reached by developments in orthesiology and its evaluation using computerized gait-analysis techniques, developments in neurosurgery and orthopedic surgery techniques, and specific training programs. Between 80 and 90% of children with lumbosacral SB become community ambulators during childhood. Nevertheless they remain at risk of a sedentary life, and to make walking possible they need a combination of active lifestyle, physiotherapy, orthotic management and surgical treatment. An optimal tuning of such a multidisciplinary treatment is essential, but to date multidisciplinary guidelines, which when implemented properly have shown to improve the quality of patient care, were missing. The first multidisciplinary evidence based guideline on evaluation, prediction and treatment of walking ability in children with SB is being established in the Netherlands. At the minisymposium the main aspects of the guideline will be presented by the authors. The main topics concern the outcome measures and prognostic factors of walking ability in children with SB and the recommended conservative and surgical treatment to enhance their walking ability. The conclusions and recommendations for best practice will be discussed and illustrated with clinical cases, also to solicit inputs from the audience. Speakers B. Ivanyi MD PhD, Department of Rehabilitation Medicine, Academic Medical Center, University of Amsterdam, the Netherlands H.J.G. van den Berg-Emons PhD, Department of Rehabilitation Medicine and Physical Therapy, Erasmus MC Rotterdam, the Netherlands J.F. de Groot PhD, Researchgroup Lifestyle and Health, HU University of Applied Sciences, Utrecht, the Netherlands M.J. Nederhand MD PhD, Roessingh Centre for Rehabilitation, Enschede, the Netherlands M.A.G.C. Schoenmakers PhD, Pediatric Physical Therapy and Exercise Physiology, University Medical Center, Utrecht, the Netherlands J.A. van der Sluijs MD PhD, Department of orthopedics, VU medical centre, Amsterdam, the Netherlands 3

16 Parallel Session f: Minisymposium It s my life! Innovation of care for young adults with childhood onset disabilities Chair: M.E. Roebroeck PhD W.M.A. van der Slot MD, M.S.G. Floothuis OT, E. Kruijver, C.G.B. Maathuis MD PhD, A. Grootoonk, S.R. Hilberink MSc On behalf of TransitieNet, national network to innovate transition and lifespan care In their transition to adulthood, young people with childhood onset disabilities may experience problems to manage their own life and take responsibility for their health. Since 007 Dutch rehabilitation centers cooperate in the national network TransitieNet to innovate care for young people (6-5 years). The centers implement young adult teams and ageappropriate interventions, aiming to improve the young people s autonomy in several life areas. So far, eight interventions focusing on different topics are developed for young people aged 6-5 years. Also interventions for youth and parents are available. We evaluate the feasibility and effectiveness of the interventions in multi-center studies. In this minisymposium clinicians from several rehabilitation centers will share their experiences with young adult teams and age-appropriate interventions addressing several life areas. We will particularly focus on the goals and methods of a young adult team, and on interventions to improve work participation, emerging romantic relationships and sexuality and skills for growing up (Groei-wijzer, for youth and their parents). Couples of presenters will share their experiences with developing an intervention and implementing it in clinical practice. They will address the following interventions: TraJect: At Work?! - an intervention to improve work participation of young adults with disabilities. Key principles are the convergence of rehabilitation and vocational services in one program and its just-intime availability, when the young person is looking for a job. Friendships, romantic relationships and sexuality - a group program to enhance the young adult s self-confidence and social skills. Exchanging experiences about intimacy and sexuality with agemates appeared to be highly valued by young people participating in this intervention. The Dutch version of Skills for Growing Up (Groeiwijzer), an intervention for youth with disabilities and their parents to encourage a child s development towards independence and autonomy. Implementing the Groei-wijzer seemed to increase the focus on autonomy and participation within rehabilitation care. With the use of practical examples and discussion on feasibility and preliminary effectiveness of the interventions we encourage interaction with participants of the symposium. Programme Chair: M.E. Roebroeck PhD, Erasmus MC. Goals and methods of a young adult team Wilma van der Slot MD, Rijndam Rehabilitation center. Intervention: friendships, romantic relationships and sexuality Egbert Kruijver, Sophia Rehabilitation Sander Hilberink MSc, Erasmus MC 3. TraJect: At Work?! - an intervention to improve work participation Monique Floothuis OT, Erasmus MC Marij Roebroeck PhD, Erasmus MC 4. Skills for Growing Up, the Dutch version: Groei-wijzer Karel Maathuis MD PhD, UMC Groningen Anneke Grootoonk, Centre for Rehabilitation, Beatrixoord 33

17 Parallel Session g: Workshop Rehabiltation Medicine: Rehab is fun! Chair: G.M. Rommers MD PhD M. Tepper MD, R. Dahmen MD, W.G.M. Bakx MD, Prof. F. Nollet MD PhD Only for medical students Rehabilitation medicine is all about function and participation. In this workshop we present patient cases with a variety of diagnoses well known to rehabilitation medicine. We present cases about stroke, spinal cord, amputation and orthotics devices to speed up the mobilisation process. To learn about cognitive limitations in everyday life and how to deal with it. Share the expertise and challenges ahead together with experienced staff to learn what rehabilitation medicine is all about! We will highlight the pleasure of everyday practise and what to learn from it for medical students. Information about clerkships and training posts will be available and specialist registrars tell you all about: rehab is fun! 34

18 Parallel Session b: Workshop Effective exercises in rehabilitation medicine: how does it work? Chair: P.C.T. van Aanholt MD R. Dekker MD PhD, F. Hettinga PhD On behalf of the Werkgroep VRA Bewegen en Sport (WVBS, National project group VRA physical activity and sports) It is well known that an active lifestyle is important for a healthy life. A lot of diseases are cured or at least have a less significant impact by an active lifestyle. The intention of the workshop is to promote the need of an active lifestyle for everybody and more specific for our patients and for people with a disability. We want to advocate the need of expertise of Exercise Physiology for Rehabilitation Physicians. We also show why knowledge of Exercise Physiology is of great importance to make the right Rehabilitation Program and to give an adequate advise for an active lifestyle. We show that the aim of the treatment should guide the selection of type of training program, which is specific for each individual. Programme. Opening Peter van Aanholt. An active lifestyle is important for everybody including patients and people with a disability Rienk Dekker 3. The knowledge of exercise physiology is neccesary in rehabilitation medicine Floor Hettinga 4. Active workshop Members of WVBS 5. Evaluation active workshop and it s implications in the rehabilitation program Peter van Aanholt We will have an active workshop. All participants will have to exercise physical activities with a different energy level. That is why it is advised to wear sportswear. 35

19 Parallel Session c: Minisymposium From innovation to implementation in paediatric rehabilitation: playfulness and flow Chair: Prof. A.C.H. Geurts MD PhD Prof. M.W.G. Nijhuis-van der Sanden PhD, A. Houwink PT PhD, P.B.M. Aarts OT PhD, Y.A. Geerdink OT MSc, J.C. van Munster MD Time on task is the most important predictor for the effectiveness of exercise training. Therefore for children, both a playful presentation and a generation of a positive flow are crucial. This minisymposium presents two state of the art, playful training interventions for children with writing disabilities ( Juf-in-a-Box ) and children with unilateral spastic cerebral palsy ( the Pirate concept ). Juf-in-a-Box Between 0 to 33% of children in primary education have problems with handwriting, which is one of the most common reasons for primary school children to be referred to paediatric physical or occupational therapy. Handwriting problems can be related to motor disorders e.g. DCD), or to cognitive and/or behavioural disorders (e.g. ADHD or Autism Spectrum Disorders). In addition, an inappropriate didactical approach is also a possible cause of handwriting problems. In the KNGF Evidence Statement Motor Handwriting Problems in Children, evidence is presented that the amount of training is essential for the development of quality and speed in handwriting Programme Chair: Prof. A.C.H. Geurts MD PhD. Theoretical background of motor writing disorders in children Prof. M.W.G. Nijhuis-van der Sanden PhD. Development and preliminary results of Juf-in-a-Box A. Houwink PT PhD 3. The current state of the implementation of the Pirate concept (LIPIC) P.B.M. Aarts OT PhD 4. Assessing individual change while implementing a CIMT concept: opportunities and barriers Y.A. Geerdink OT MSc 5. The role of the rehabilitation physician in the implementation of an intervention J.C. van Munster MD (Overvelde et al., 0; To increase the amount of practice, Juf-in-a-Box was developed. Juf-in-a-Box, a serious computer game on an interactive tablet, provides writing exercises with increasingly difficult levels presented so that motor skill learning is facilitated. The series of exercises are presented in a playful and educational way using challenging feedback. The effectiveness of the Juf has recently been tested in a first pilot study. In the first part of this mini-symposium, Ria Nijhuis-Van der Sanden will present the theoretical background and Annemieke Houwink will present the development and first results of Juf-in-a-Box. The Pirate concept The appreciation of an intervention in paediatric rehabilitation is often related to the provision of family-centred services, which are focused on improvement of a child s daily-life activities. Furthermore, playfulness and flow are important for children to enjoy the intervention and stay motivated. These are key aspects of the evidencebased intervention: modified constraint-induced movement therapy in the Pirate group. After extensive studies on the effects of the Pirate concept, a project has now started to implement this intervention in other rehabilitation centres in the Netherlands (Landelijke Implementatie Piraten Concept; LIPIC). In the second part of this minisymposium, Pauline Aarts will present the current state of the Pirate concept and LIPIC. Another important aspect of nation-wide implementation is to use one standard measurement protocol in order to evaluate all interventions and to form one database. These outcome measures should be reliable and valid, and useable for both diagnostic and evaluative purposes. Composing such an assessment battery is challenging, and the choices made and the proposal to set up a collective database for LIPIC are discussed by Yvonne Geerdink. Finally, Judith van Munster will discuss the role of the rehabilitation physician in selecting children for an appropriate upper-limb intervention such as the Pirate concept. 36

20 Parallel Session Identifying the main problems by examination and assessment are needed to determine the focus of an intervention, i.e. on upper-limb function, capacity, motor planning or neurocognitive problems such as developmental disregard. References. Overvelde A, Van Bommel-Rutgers I, Bosga-Stork I, Van Cauteren M, Halfwerk B, Smits-Engelsman B, Nijhuis-Van der Sanden MWG. KNGF: Evidence Statement Motorische schrijfproblemen bij kinderen. Suppl Ned Tijdschr Fysiother. 0;():-65; https://www.kngfrichtlijnen.nl/657/ Evidence-Statements.htm. Overvelde A, Van Bommel-Rutgers I, Bosga-Stork I, Van Cauteren M, Halfwerk B, Smits-Engelsman B, Nijhuis-Van der Sanden MWG.KNGF Evidence Statement Motor handwriting problems in children (Flowchart and Summary). https://www.kngfrichtlijnen.nl/654/kngf-guidelines- in- English.htm d: Workshop Changes in educational program VRA for residents in PM&R Chair: M. Tepper MD R. Dahmen MD, H. Arwert MD, M. van Beugen MD, L. Kruisheer MD, D. Jägers MD On behalf of the Educational Board VRA Educational programme BETER describes the competencies of a Medical Specialist in Physical and Rehabilitation Medicine according to the CANMEDS. In the current educational programme of the VRA most courses are dedicated to specific themes or diagnoses. In 04 a new four year course will be introduced; focusing on the themes Communication and Management and Clinical Reasoning. Each year will have its own subjects related to these themes as the course intensity and complexity increases with each passing year. Education in smaller groups is more effective and beneficial to the attitude of active learning. In the near future e-learning will play a more prominent role. In an interactive workshop we will introduce the VRA 04 educational programme. A guest speaker will introduce the concept of e-learning and there will be room to exchange experiences. The consequences for the role of course coordinator and organizing committee will also be discussed. Participants Course coordinators, trainers, members of VRA Concilium and VRA Kerngroep. Learning goals Information about changes in educational programme VRA 04 Knowledge about active learning and e-learning. 37

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