PURPOSE:Individuals with spinal cord injury, cauda equina syndrome or spina bifida often face challenges in maintaining a healthy lifestyle. A coordinated lifestyle care pathway beginning in the rehabilitation center and continuing into primary care may support the conditions needed for sustainable lifestyle behavior. This study aimed to identify determinants to inform the development and implementation of a lifestyle care pathway. METHODS:We conducted semi-structured interviews with 19 healthcare professionals and 24 individuals with spinal cord disorders. Separate topic guides were developed for each group to explore experiences, needs and views to identify determinants for implementing lifestyle care across the rehabilitation continuum and a transmural pathway. Transcripts were analyzed thematically. RESULTS:Determinants spanned three main phases of the pathway. In rehabilitation: embedding integrated lifestyle care within treatment, defining professional responsibilities, coordinating lifestyle care through collaborative, patient-centered practices. In the transition phase: building networks between rehabilitation and primary care, integrating lifestyle support into transition processes, securing sustainable financial structures. Post-rehabilitation: increasing knowledge on condition-specific lifestyle needs, promoting a coaching attitude among professionals, strengthening collaboration and community support. CONCLUSIONS:The findings emphasize that successful delivery of lifestyle care requires coordinated, well-aligned efforts among professionals and settings throughout the entire care trajectory.

OBJECTIVE:This randomised controlled trial evaluated the efficacy of the Tailored Injury Prevention in Adapted Sports (TIPAS) intervention on sports-related health problems in athletes participating in adaptive sports with physical impairments. METHODS:We randomly assigned 60 athletes participating in adaptive sports with physical impairments to an intervention group and 47 to a control group. The intervention group received direct, automated, predetermined preventive and management measures tailored to their weekly reported health problems, physical impairments and sports. The primary outcome was injury and illness prevalence over 40 weeks. Secondary outcomes were incidence, weekly cumulative severity score, weekly time loss, and total burden. A multinomial mixed methods analysis was performed to identify an intervention effect over time. RESULTS:The athletes (53 women, 54 men; age±45 years) reported 449 health problems (162 illnesses, 287 injuries) during the study period. The overall prevalence of health problems was 44% in the intervention group and 46% in the control group. Over time, no significant main intervention effect was found (illnesses OR: 1.02; 95% CI: 0.52 to 1.99; and injuries OR: 1.01; 95% CI: 0.55 to 1.86). However, a significant positive time×group interaction effect (p<0.001) indicated a reduction in injury prevalence in the intervention group over time, though not for illnesses. The rates versus severity analysis showed a significantly lower illness severity in the intervention group relative to the control group. CONCLUSION:The TIPAS intervention provides a non-significant decrease in the overall prevalence of sport-related injuries and illnesses and may reduce the severity of sport-related illnesses throughout a Dutch sports season. This tailored online preventive strategy provides an accessible programme to consider in adapted sports suited to athletes' physical impairments, sports participation and current health status. Trial registration number: ICTRP register: NL-OMON24078.

PURPOSE:A lifestyle front office (LFO) in the hospital is a not yet existing, novel concept that can refer patients under treatment in the hospital to community-based lifestyle interventions (CBLI). The aim of this study was to identify implementation barriers and facilitators regarding the implementation of an LFO in the hospital from the perspective of CBLI-professionals and to develop evidence-based implementation strategies to reduce these identified barriers. METHODS:We conducted semi-structured interviews until data saturation, with 23 lifestyle professionals working in the community. A semi-structured topic guide was used, inquiring about (1) community-based lifestyle interventions; (2) their views about referral from the LFO; and (3) their preferences, needs and recommendations for collaboration with the LFO in the hospital. The online interviews lasted on average 46 minutes, were audio-recorded and transcribed verbatim. A thematic content analysis was conducted. Found barriers and facilitators regarding the LFO where mapped using the consolidated framework for implementation research (CFIR) whereafter evidence based strategies were developed using the CFIR-Expert Recommendations for Implementing Change Strategy Matching Tool V.1.0 (CFIR-ERIC). RESULTS:Barriers and facilitators were divided into two main themes: 1) barriers and facilitators related to the referral from LFO to CBLI (i.e. financial, cultural, geographical, quality) and 2) barriers and facilitators related to the collaboration between LFO and CBLI (i.e. referral, communication platform and partnership). Thirty-seven implementation strategies concerning 15 barriers were developed and clustered into six overarching strategies: identify referral options, determine qualifications lifestyle professionals, develop support tools, build networks, facilitate learning collaboratives, and optimize workflow. CONCLUSIONS:In this study, barriers and facilitators for the development of the LFO were found and matching implementation strategies were developed. Practical improvements, like identifying specific referral options or develop support tools, can be implemented immediately. The implementation of other strategies, like connecting care pathways in basic services, primary, secondary and tertiary care, will take more time and effort to come to full potential. Future research should evaluate all implemented strategies.

Background/aim The participation of individuals with physical impairment in sports has numerous benefits, yet there is also the risk of sustaining sport-related injuries or illnesses. Therefore, prevention programmes of these problems are needed to ensure that individuals can maintain a healthy, active lifestyle. Currently, very few prevention interventions are accessible for these athletes. Therefore, the article aims to describe the development process of the Tailored Injury Prevention in Adapted Sports intervention, an online tailored injury and illness prevention intervention for athletes with a physical impairment.Methods The development was guided by the Knowledge Transfer Scheme (KTS).Results In the first step, a cohort study and a qualitative study were conducted to define the problem statement. In the second step, a systematic review was performed in order to learn from theory. Steps 3 and 4 involved an iterative process involving collaboration with diverse expert groups. This included defining athletes’ needs and creating a health problem blueprint, after which the intervention content was created. To ensure accuracy and completeness, a feedback loop was incorporated. In the final phase of this step, we refined the language used within the intervention together with athletes. Finally, an effect and process evaluation will take place in the last step of the KTS.Conclusions Through a five-step approach of the KTS, we developed an online injury and illness prevention intervention for athletes with a physical impairment. This intervention provides direct, timely feedback based on their current health status. Furthermore, it takes the sport and the physical impairment of the athletes into account with regard to the given prevention advices.

CONTEXT:Participation in sports is associated with a risk of sports-related health problems. For athletes with an impairment, sports-related health problems further burden an already restricted lifestyle, underlining the importance of prevention strategies in para-sports. OBJECTIVE:To provide a comprehensive overview with quality assessment of the literature on sports-related health problems, their etiology, and available preventive measures in para-sports following the steps of the Sequence of Prevention. DATA SOURCES:A literature search (in PubMed, Embase, SPORTDiscus, CINAHL and the Cochrane Library) was performed up to December 8, 2021, in collaboration with a medical information specialist. STUDY SELECTION:The search yielded 3006 articles, of which 64 met all inclusion criteria. STUDY DESIGN:Systematic review with quality assessment. LEVEL OF EVIDENCE:Level 3. DATA EXTRACTION:Two independent researchers carried out the screening process and quality assessment. One researcher extracted data, and the Sequence of Prevention categorized evidence. RESULTS:A total of 64 studies were included, of which 61 reported on the magnitude and risk factors of sports-related health problems, while only 3 reported on the effectiveness of preventive measures. Of these, 30 studies were of high quality. Most studies (84%) included elite-level athletes. The reported injury incidence varied widely between sports (0-91 per 1000 athlete days) and impairment categories (1-50 per 1000 athlete days). The same applies to illness incidence with regard to different sports (3-49 per 1000 athlete days) and impairment categories (6-14 per 1000 athlete days). CONCLUSION:This review shows the current vast range of reported sport-related health problems in para-sports. There is limited evidence concerning the severity of these sports-related health problems and inconclusive evidence on the risk factors. Lastly, the evidence regarding the development and effectiveness of preventive measures for para-athletes is sparse.

Use of the term ‘alcohol industry’ plays an important role in discussions of alcohol and public health. In this paper, we examine how the term is currently used and explore the merits of alternative conceptualisations.We start by examining current ways of referring to ‘alcohol industry’ in public health and then explore the potential for organisational theory, political science, and sociology to provide alcohol research with more inclusive and nuanced conceptualizations.We identify, and critique, three conceptualisations based on purely economic understandings of industry: literal, market, and supply-chain understandings. We then examine three alternative conceptualizations based on systemic understandings of industry: organizational, social-network, and common-interest understandings. In examining these alternatives, we also identify the extent to which they open up new ways of approaching the levels at which industry influence is understood to operate in alcohol and public health research and policy.Each of the six understandings of ‘industry’ can play a role in research but their utility depends on the question being asked and the breadth and depth of the analysis being undertaken. However, for those intending to engage with a broader disciplinary base, approaches grounded in the systemic understandings of ‘industry’ are better positioned to study the complex nexus of relationships that contribute to alcohol industry influence.

Samenvatting Inleiding De helft van de volwassen Nederlanders heeft matig tot ernstig overgewicht. De gecombineerde leefstijlinterventie begeleidt mensen met overgewicht naar een gezonde leefstijl. Naast fysieke contactmomenten kunnen digitale coachingsmiddelen ingezet worden om cliënten op afstand te begeleiden. In de praktijk blijkt dat digitale toepassingen nog niet ten volle worden benut. Om het gebruik te stimuleren is inzicht nodig in de ervaringen en ondersteuningsbehoeften van leefstijlcoaches ten aanzien van de inzet van digitale technologie. Methode Met één vragenlijst en twee focusgroepgesprekken zijn data verzameld over het gebruik, de wensen en ondersteuningsbehoeften rond het inzetten van digitale coachingsmiddelen bij leefstijlcoaches. De vragenlijsten zijn descriptief geanalyseerd en de focusgroepgesprekken zijn thematisch geanalyseerd. Resultaten Uit de vragenlijstresultaten ( N = 79) en de focusgroepgesprekken ( N = 10) bleek dat leefstijlcoaches vooral ervaring hebben opgedaan met videobellen, applicaties en online informatie. Ze gaven aan dat digitale coaching de zelfredzaamheid van hun cliënten ondersteunt. Online groepsbegeleiding wordt als minder effectief ervaren dan fysieke groepssessies, omdat er weinig interactie tussen cliënten plaatsvindt. Ook ervaren leefstijlcoaches praktische barrières bij het gebruik. Ze hebben behoefte aan uitwisseling van ervaringen met collega’s, scholing en instructies over de manier waarop digitale coachingsmiddelen ingezet kunnen worden. Conclusie Leefstijlcoaches achten digitale coachingsmiddelen van toegevoegde waarde bij de individuele begeleiding van hun cliënten. Het wegnemen van praktische barrières en het faciliteren van uitwisseling en scholing kunnen een ruimere inzet van digitale coachingsmiddelen stimuleren.

Objectives: Currently, the knowledge about the epidemiology of sport-related health problems of athletes with a physical impairment is limited. Therefore, this study aims to describe the prevalence, incidence and severity of sport-related health problems of athletes with a physical impairment in the Netherlands over a one sport season. Design: Prospective cohort study. Methods: Athletes (n = 99) with a physical impairment participated in this study. After completing a baseline questionnaire, athletes started a 40-week health monitoring period, during which they completed the Dutch translation of the OSTRC Questionnaire on Health Problems every week. Based on the reported information, injury and illness prevalence, incidence, weekly cumulative severity score, weekly time loss from sport and the total burden were calculated. Results: A total of 368 health problems were reported by 95 athletes. These health problems consisted of 258 injuries and 110 illnesses. The average weekly prevalence of health problems was 48.0 %; for injuries 34.6 %, and illnesses 13.4 %. Differences were found when considering injury severity, with the highest severity scores for athletes with a limb deficiency. Furthermore, recreational athletes reported the highest injury severity scores, followed by athletes who competed nationally and athletes who competed internationally. Conclusions: Data from this study show a high average weekly prevalence of health problems, and differences amongst various impairment categories and sport levels when considering the severity of injuries. These results add to the knowledge regarding sport-related health problem epidemiology in this population, indicating that impairment category and sport level should be taken into account when developing injury prevention strategies.

Introduction:In the Netherlands, half of the adult population is overweight. Combined Lifestyle Interventions guide overweight clients towards a healthy lifestyle. In addition to the face-to face sessions with clients, lifestyle professionals can use digital coaching tools to guide their clients remotely. In practice it appears that the digital applications are not fully used. To stimulate the use of digital technology, insight is needed into the experiences and support needs of lifestyle professionals. Method:Data about the use, wishes and support needs regarding the use of digital coaching tools among lifestyle professionals were collected by a questionnaire and two focus groups. The results of the questionnaires were analyzed descriptively and the focus groups were analyzed thematically. Results:Seventy-nine lifestyle professionals completed the questionnaire. Ten lifestyle professionals participated in a focus group. Both methods showed that professionals have gained experience with video communication, apps and online information. Lifestyle professionals mention that these digital coaching tools support the self-reliance of clients. Online group sessions are perceived as less effective than face-to-face group sessions, because of the lack of interaction between clients. Lifestyle professionals also experience practical barriers in using digital coaching tools. To stimulate the use of digital coaching tools, they need an exchange of experience with colleagues, training and instruction on how to use these tools. Conclusion:Lifestyle professionals consider digital coaching tools to be an added value to individual coaching. They see opportunities for wider use in the future when practical barriers are overcome, and exchange of experience and training are facilitated.

Abstract Purpose The main purpose of this explorative study was to examine implementation strategies of workplace health promoting interventions for employees of a large education institution. The corresponding objectives were to identify facilitators and barriers for implementation, to define needs and wishes of employees regarding health promotion and to develop suitable interventions and implementation strategies. The health promoting interventions and strategies were gathered using an innovative participatory approach. Methods We used a collaborative participatory action research (PAR) approach among delegates of teachers, managers and HR professionals with three groups (5-6 delegates) representing three divisions of the organization. In four 3-hour co-creation sessions each group of delegates discussed health promoting intervention strategies including implementation facilitators and barriers, wishes and needs of their colleagues and implementation strategies. The sessions were facilitated and guided by researchers and data were collected in written anonymous reports. The researchers thematically analyzed the data and presented the collected data in a final session. In the final session, representatives of the three delegate groups shared the data and discussed common suitable health promoting intervention strategies. Results The co-creation sessions resulted in a variation of facilitators and barriers on multiple levels of implementation. We identified common facilitators at the individual (e.g. individualized approach), team (e.g. social inclusiveness) and organizational level (e.g. wide health promotion initiatives). Conversely, common barriers were identified at the individual (e.g. lack of time), team (e.g. lack of manager support) and organizational level (e.g. hampered digital accessibility). Main topics derived from the wishes and needs include a facilitating (healthy) work environment (e.g. healthy food choices) and social meeting options (e.g. group physical activities). These wishes and needs were accompanied with facilitating prerequisites (e.g. flexibility and autonomy). Lastly, the co-creation sessions provided suitable intervention avenues including an in-house health promotion center backed by an accessible digital environment (intranet). Conclusions This participatory approach provided tailored workplace health promoting interventions and offered implementation strategies targeting education professionals. These implementation strategies will be pilot-tested in phases across multiple divisions within the education institution. Support/Funding Source The study was internally funded by the Inholland University of Applied Sciences.

Background A healthy lifestyle is indispensable for the prevention of noncommunicable diseases. However, lifestyle medicine is hampered by time constraints and competing priorities of treating physicians. A dedicated lifestyle front office (LFO) in secondary/tertiary care may provide an important contribution to optimize patient-centred lifestyle care and connect to lifestyle initiatives from the community. The LOFIT study aims to gain insight into the (cost-)effectiveness of the LFO. Methods Two parallel pragmatic randomized controlled trials will be conducted for (cardio)vascular disorders (i.e. (at risk of) (cardio)vascular disease, diabetes) and musculoskeletal disorders (i.e. osteoarthritis, hip or knee prosthesis). Patients from three outpatient clinics in the Netherlands will be invited to participate in the study. Inclusion criteria are body mass index (BMI) ≥25 (kg/m 2 ) and/or smoking. Participants will be randomly allocated to either the intervention group or a usual care control group. In total, we aim to include 552 patients, 276 in each trial divided over both treatment arms. Patients allocated to the intervention group will participate in a face-to-face motivational interviewing (MI) coaching session with a so-called lifestyle broker. The patient will be supported and guided towards suitable community-based lifestyle initiatives. A network communication platform will be used to communicate between the lifestyle broker, patient, referred community-based lifestyle initiative and/or other relevant stakeholders (e.g. general practitioner). The primary outcome measure is the adapted Fuster-BEWAT, a composite health risk and lifestyle score consisting of resting systolic and diastolic blood pressure, objectively measured physical activity and sitting time, BMI, fruit and vegetable consumption and smoking behaviour. Secondary outcomes include cardiometabolic markers, anthropometrics, health behaviours, psychological factors, patient-reported outcome measures (PROMs), cost-effectiveness measures and a mixed-method process evaluation. Data collection will be conducted at baseline, 3, 6, 9 and 12 months follow-up. Discussion This study will gain insight into the (cost-)effectiveness of a novel care model in which patients under treatment in secondary or tertiary care are referred to community-based lifestyle initiatives to change their lifestyle. Trial registration ISRCTN ISRCTN13046877 . Registered 21 April 2022.

Purpose (1) To estimate the proportion of Dutch wheelchair users with spinal cord injury (SCI) who meet different SCI exercise guidelines; (2) to evaluate which demographic and lesion characteristics are associated with meeting these guidelines; (3) whether meeting these guidelines is associated with physical fitness and health. Materials and methods Based on the PASIPD questionnaire items, participants were allocated to meeting two SCI aerobic exercise guidelines, which differ in exercise load. Differences in personal, lesion, fitness, and health characteristics between groups were tested with a one-way ANOVA. Multiple regression analyses were performed to evaluate if meeting guidelines was associated with better fitness and health. Statistical significance was accepted at p < 0.05. Results Of the 358 included participants, 63.1% met at least one aerobic exercise guideline. Being female, older age, having tetraplegia, and lower educational level were associated with a lower likelihood to meet the aerobic exercise guidelines. Meeting aerobic exercise guidelines showed a positive association with all respiratory and exercise capacity parameters. Limited associations were found between meeting exercise guidelines and health. Conclusions Meeting exercise guidelines was associated with better respiratory functions and exercise capacity with additional fitness and some body composition benefits in higher exercise activity levels.

Heart rate (HR) is an important and commonly measured physiological parameter in wearables. HR is often measured at the wrist with the photoplethysmography (PPG) technique, which determines HR based on blood volume changes, and is therefore influenced by blood pressure. In individuals with spinal cord injury (SCI), blood pressure control is often altered and could therefore influence HR accuracy measured by the PPG technique. The objective of this study is to investigate the HR accuracy measured with the PPG technique with a Fitbit Charge 2 (Fitbit Inc) in wheelchair users with SCI, how the activity intensity affects the HR accuracy, and whether this HR accuracy is affected by lesion level. The HR of participants with (38/48, 79%) and without (10/48, 21%) SCI was measured during 11 wheelchair activities and a 30-minute strength exercise block. In addition, a 5-minute seated rest period was measured in people with SCI. HR was measured with a Fitbit Charge 2, which was compared with the HR measured by a Polar H7 HR monitor used as a reference device. Participants were grouped into 4 groups—the no SCI group and based on lesion level into the T1 (cervical) group. Mean absolute percentage error (MAPE) and concordance correlation coefficient were determined for each group for each activity type, that is, rest, wheelchair activities, and strength exercise. With an overall MAPEall lesions of 12.99%, the accuracy fell below the standard acceptable MAPE of –10% to +10% with a moderate agreement (concordance correlation coefficient=0.577). The HR accuracy of Fitbit Charge 2 seems to be reduced in those with cervical lesion level in all activities (MAPEno SCI=8.09%; MAPE=11.16%; MAPET1−T5=10.5%; and MAPE>T1=20.43%). The accuracy of the Fitbit Charge 2 decreased with increasing intensity in all lesions (MAPErest=6.5%, MAPEactivity=12.97%, and MAPEstrength=14.2%). HR measured with the PPG technique showed lower accuracy in people with SCI than in those without SCI. The accuracy was just above the acceptable level in people with paraplegia, whereas in people with tetraplegia, a worse accuracy was found. The accuracy seemed to worsen with increasing intensities. Therefore, high-intensity HR data, especially in people with cervical lesions, should be used with caution.

Combined lifestyle interventions (CLI) are focused on guiding clients with weight-related health risks into a healthy lifestyle. CLIs are most often delivered through face-to-face sessions with limited use of eHealth technologies. To integrate eHealth into existing CLIs, it is important to identify how behavior change techniques are being used by health professionals in the online and offline treatment of overweight clients. Therefore, we conducted online semi-structured interviews with providers of online and offline lifestyle interventions. Data were analyzed using an inductive thematic approach. Thirty-eight professionals with (n = 23) and without (n = 15) eHealth experience were interviewed. Professionals indicate that goal setting and action planning, providing feedback and monitoring, facilitating social support, and shaping knowledge are of high value to improve physical activity and eating behaviors. These findings suggest that it may be beneficial to use monitoring devices combined with video consultations to provide just-in-time feedback based on the client's actual performance. In addition, it can be useful to incorporate specific social support functions allowing CLI clients to interact with each other. Lastly, our results indicate that online modules can be used to enhance knowledge about health consequences of unhealthy behavior in clients with weight-related health risks.

PURPOSE:The aim of this study was to determine changes in physical activity, nutrition, sleep behaviour and body composition in wheelchair users with a chronic disability after 12 weeks of using the WHEELS mHealth application (app). METHODS:A 12-week pre-post intervention study was performed, starting with a 1-week control period. Physical activity and sleep behaviour were continuously measured with a Fitbit charge 3. Self-reported nutritional intake, body mass and waist circumference were collected. Pre-post outcomes were compared with a paired-sample t-test or Wilcoxon signed-rank test. Fitbit data were analysed with a mixed model or a panel linear model. Effect sizes were determined and significance was accepted at p < .05. RESULTS:Thirty participants completed the study. No significant changes in physical activity (+1.5 √steps) and sleep quality (-9.7 sleep minutes; -1.2% sleep efficiency) were found. Significant reduction in energy (-1022 kJ, d = 0.71), protein (-8.3 g, d = 0.61) and fat (-13.1 g, d = 0.87) intake, body mass (-2.2 kg, d = 0.61) and waist circumference (-3.3 cm, d = 0.80) were found. CONCLUSION:Positive changes were found in nutritional behaviour and body composition, but not in physical activity and sleep quality. The WHEELS app seems to partly support healthy lifestyle behaviour.Implications for RehabilitationHealthy lifestyle promotion is crucial, especially for wheelchair users as they tend to show poorer lifestyle behaviour despite an increased risk of obesity and comorbidity.The WHEELS lifestyle app seems to be a valuable tool to support healthy nutrition choices and weight loss and to improve body satisfaction, mental health and vitality.

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.

Background Participation is sport is associated with a risk of sports injuries and illnesses. For athletes with an impairment, sports related health issues pose further burden upon an already restricted lifestyle. This underlines the importance of injury prevention in adapted sports. Objective To provide an overview of the current evidence regarding injuries and their prevention in adapted sports. Design A systematic review with quality assessment. Setting Peer-reviewed literature on sports injuries in adapted sports. Participants Individuals with a physical impairment that affects motor function, and who are active in sports or physical activity. Assessment of Risk Factors This study was conducted in accordance with the ‘Preferred Reporting Items for Systematic Reviews and Meta-Analyses’ (PRISMA) guidelines. Main Outcome Measurements Literature and evidence was categorised by the sequence of prevention; i.e. (1) problem magnitude; (2) aetiology of injury; (3) development of preventive measures; and (4) evaluation of effectiveness. Results 52 studies were included. A total of 5 studies reported on the first step of the sequence of prevention (problem magnitude) only. 28 studies reported information on both the first and second step, 15 studies on only the second step and only 4 studies on the third and fourth step of the sequence. Most studies included participants of an elite level (82.7%). There is a wide range of injury and illness incidence between various sports (2.2 - 90.9 per 1000 athlete days) and impairment categories (0.6 - 50.0 per 1000 athlete days). Conclusions Current evidence regarding injuries in adapted sports is mostly limited to elite level athletes. The evidence regarding the development of preventive measures and their effectiveness is limited in this target group. More knowledge is needed of the aetiology and risk factors of various adapted sports, physical impairments and level of performance to develop future prevention strategies for this population.

Objective To evaluate the experience of clients and clinicians in working with a tool to help set goals that are personally meaningful to rehabilitation clients. Design We have applied the tool in the outpatient rehabilitation setting. Clients' and clinicians' experiences in working with the tool were evaluated in individual, semi-structured interviews and focus group interviews, respectively. Thematic analysis was used to analyze the data. Setting A university medical center and a rehabilitation center. Subjects Clients with a first-time stroke (n = 8) or multiple sclerosis (n = 10), and clinicians (n = 38). Intervention The tool to help set meaningful goals consisted of a session (i) to explore the client's fundamental beliefs, goals and attitudes and (ii) to identify a meaningful overall rehabilitation goal. The results of that session were used by the multidisciplinary rehabilitation team (iii) to help the client to set specific rehabilitation goals that served to achieve the meaningful overall rehabilitation goal. Results Both clients and clinicians reported that the tool helped to set a meaningful overall rehabilitation goal and specific goals that became meaningful as they served to achieve the overall goal. This contributed to clients' intrinsic rehabilitation motivation. In some clients, the meaningfulness of the rehabilitation goals facilitated the process of behavior change. Both clients and clinicians made suggestions on how the tool could be further improved. Conclusion In the opinion of both clients and clinicians, the tool does indeed result in goal setting that is personally meaningful. Further development, implementation and evaluation of the tool is warranted.

Context: Goal-setting is a key characteristic of modern rehabilitation. However, goals need to be meaningful and of importance to the client. Axioms: Both theories and empirical evidence support the importance of a hierarchy of goals: one or more overall goals that clients find personally meaningful and specific goals that are related to the overall goals. We posit that the client's fundamental beliefs, goals and attitudes ("global meaning") need to be explored before setting any rehabilitation goal. A chaplain or other person with similar skills can be involved in doing so in an open-ended way. The client's fundamental beliefs, goals and attitudes serve as a point of departure for setting rehabilitation goals. Setting goals: We set out a three-stage process to set goals: (1) exploring the client's global meaning (i.e. fundamental beliefs, goals and attitudes), (2) deriving a meaningful overall rehabilitation goal from the client's global meaning and (3) setting specific rehabilitation goals that serve to achieve the meaningful overall rehabilitation goal. Conclusion: This is an extension of current practice in many rehabilitation teams, which may help counter the drive toward exclusively functional goals based around independence.

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.