Patients with multimorbidity and functional impairments will be recruited through three regional outpatient centers and assigned in a 1:1 ratio to either standard care or the InATheGer intervention. The intervention will take place over 14 weeks and comprise 20 therapy days. A trained care manager, called the “InA-Manager,” will coordinate multimodal sessions integrating medical, therapeutic and psychosocial support.

Assessments will occur at baseline before randomization and at 18 and 31 weeks after baseline. The primary outcome is improvement in mobility and functional independence at 18 weeks, measured with an adapted Functional Independence Measure. Secondary outcomes will include changes in quality of life assessed with the EQ-5D-5L, medication use, healthcare utilization and costs.

The study will combine a randomized clinical comparison with qualitative process evaluation and economic analysis. The process component is intended to examine implementation and contextual factors affecting delivery of the model, while the economic component will assess costs and resource use. The design therefore addresses three distinct questions: whether participant outcomes differ between the intervention and standard-care groups, how the program is implemented in practice, and what it costs.

The researchers plan to analyze whether any clinical benefits, if observed, are accompanied by favorable economic performance. A qualitative process evaluation will also explore organizational and contextual conditions that may influence the intervention’s operation. The trial focuses on a population for whom coordinated outpatient care may be especially important.

The study is intended to address that coordination problem through a model that combines different forms of support and assigns an identifiable care manager to organize the program. If InATheGer proves clinically effective and cost-effective, the researchers say the results could inform policy decisions and the development or scaling of coordinated interprofessional outpatient services. Because the article is a protocol, those benefits and wider implementation remain contingent on future trial findings.

The study is prospectively registered in the German Clinical Trials Register as DRKS00036229, with registration recorded on 8 April 2025.

Subject of Research: A randomized trial protocol evaluating interprofessional outpatient care for older adults with multimorbidity and functional impairments.

Article Title: A randomized controlled trial, process and economic evaluation, comparing multimodal care intervention to standard care for older adults in Mecklenburg-Western Pomerania, Germany: study protocol of the intensified interprofessional outpatient therapy for geriatric patients (InATheGer) model

Article References: Dini, L., Ordonez-Cruickshank, A., Koppelow, M., Wollny, A., Richter, L., Daubmann, A., Suling, A., Pardey, N., Stapelfeldt, P. M., Meinhold, S., Kloth, A., Sarganas, G., van Munster, M., Zutz, S., Dannenberg, M., & Odonkor, S. N. N. T. (2026). A randomized controlled trial, process and economic evaluation, comparing multimodal care intervention to standard care for older adults in Mecklenburg-Western Pomerania, Germany: study protocol of the intensified interprofessional outpatient therapy for geriatric patients (InATheGer) model. BMC Geriatrics. https://doi.org/10.1186/s12877-026-08363-0

Image Credits: AI Generated

DOI: 10.1186/s12877-026-08363-0

Keywords: geriatric care, multimorbidity, interprofessional care, randomized controlled trial, functional independence, mobility, quality of life, healthcare utilization, economic evaluation, outpatient care, randomized, controlled

The research, published in Frontiers in Neurology by a team at Paracelsus Medical University and the Christian Doppler University Hospital, tackles a stubborn gap in routine care. Post-stroke spasticity affects between roughly 4 and 42.6 percent of stroke survivors depending on when they are assessed, and patients with severe initial arm weakness are at particularly high risk, with up to 46 percent developing spastic hypertonia within the first year. Left untreated, abnormal muscle tone can lead to contractures, pain syndromes, skin breakdown and lasting losses in independence. Despite effective therapies being available, studies from France and elsewhere have documented widespread underuse of botulinum toxin, especially among older, multimorbid patients whose competing medical problems can obscure the functional toll of rigid, clenched muscles.

The Salzburg team, led by Melanie Rudelstorfer and Richard Friedrich Radlberger, reasoned that the missing link might not be treatment capacity but detection. Physicians spend limited time at the bedside, while nurses, physiotherapists and occupational therapists observe patients continuously during washing, dressing and mobilization. If these professionals could reliably flag candidates for specialist evaluation, the referral pipeline to botulinum toxin therapy might finally match the true prevalence of the disorder.

To test that idea, the researchers conducted a prospective, two-phase, single-center study of 124 patients treated across neurology and geriatric wards, two neurological rehabilitation units and a long-term care facility between April and October 2025. The participants had a median age of 72 years, ranging from 20 to 94, and just under half were men. Stroke was the most common admission diagnosis, accounting for 33.1 percent of cases, followed by traumatic causes such as fractures, traumatic brain injury and paraplegia at 30.6 percent, with a mixed group of infections, internal medicine conditions and multiple sclerosis making up most of the remainder.

In the first phase, the researchers deployed an existing instrument called the Spastic Movement Disorder Decision Tree, or SMD-DT. This algorithmic tool combines the Modified Ashworth Scale for grading muscle tone, the Medical Research Council scale for muscle strength, and the Spasticity-Associated Arm Pain Scale into a structured pathway for judging whether a patient’s spasticity is clinically relevant and might warrant treatment. Nurses, physiotherapists and occupational therapists each applied the decision tree independently, blinded to one another’s results, and their judgments were compared against the assessment of an experienced neurologist, who served as the reference standard.

The results revealed a striking dependence on context and professional background. On a neurological rehabilitation unit, where staff regularly manage complex spasticity cases, agreement with the neurologist was excellent: physiotherapists and nurses each achieved a Cohen’s kappa of 1.00, meaning perfect agreement, while occupational therapists reached 0.79. But on a geriatric ward, where referrals for botulinum toxin were infrequent and staff had less neurological exposure, the decision tree faltered. Occupational therapists still managed substantial agreement at kappa 0.65 and physiotherapists reached 0.46, but nurses dropped to 0.28, a level classified as fair and not statistically significant in that sample. All professional groups showed a sensitivity of 0.67 in the geriatric setting, meaning a third of true cases slipped past them.

That failure proved instructive. Rather than abandoning nurse-led screening, the researchers convened an interprofessional meeting between nursing staff and a botulinum toxin-experienced neurologist to understand why the scales-based tool did not translate to everyday nursing workflows. Out of that consensus came the Salzburg Nursing Questionnaire, or SNQ, a radically simplified instrument built around three practical questions drawn from the caregiver’s perspective: Does the nurse need physical strength to overcome the patient’s tense posture during personal care, for example at the genital area, armpits or during catheter changes? Is pain perceived during mobilization, such as dressing or hygiene? And are there skin injuries like macerations or ulcerations caused by the tense posture, for instance on palms, elbows or armpits? A single yes triggers a referral recommendation, and the questionnaire is designed to be completed after morning care, requiring no formal rating scales at all.

The second phase put the SNQ through its paces in independent cohorts to avoid training effects. On a second neurological rehabilitation unit with 28 patients, the questionnaire achieved a kappa of 0.61 against the physician’s referral recommendation, with a sensitivity of 1.00, meaning every true case was caught, and a specificity of 0.96, with only one false positive. The more dramatic result came from an independent long-term care facility specializing in multiple sclerosis and vegetative state patients, where the SNQ achieved both sensitivity and specificity of 1.00 relative to the neurologist’s recommendation for botulinum toxin treatment. In other words, three yes-or-no questions answered by nurses during routine care matched the judgment of a spasticity expert without missing a single candidate.

The authors are careful to frame these numbers within the study’s limitations. It was a single-center investigation with modest sample sizes, producing wide confidence intervals, and the reference standard rested on the clinical judgment of one neurologist rather than fully operationalized criteria, since no objective benchmark exists for botulinum toxin indication. The SMD-DT also focuses primarily on the upper limbs, potentially overlooking patients whose spasticity affects only the legs, a blind spot the SNQ avoids because it applies regardless of body region. The SNQ itself has not yet undergone formal psychometric validation, and the authors emphasize that assessments of construct validity, test-retest reliability and external validation in further cohorts remain pending before widespread implementation.

Even so, the study carries a message that resonates well beyond Salzburg: screening instruments are not one-size-fits-alls, and their diagnostic performance is inseparable from who applies them and where. Algorithm-based tools built on formal scales may excel in therapy-oriented disciplines like physiotherapy and occupational therapy, particularly in rehabilitation settings, whereas simplified, function-oriented checklists are better matched to the realities of nursing workflows outside specialized neurology. A differentiated, profession-specific screening strategy, the authors argue, could finally close the notorious gap between how common spasticity is and how rarely it is treated, transforming bedside observations made while washing and dressing a patient into timely referrals for a therapy that can relieve pain, ease caregiving and preserve independence. An English translation of the questionnaire is provided for international readers, though the original German version was used in the study and the translation has not been formally validated.

Subject of Research: Interprofessional screening tools for detecting candidates for botulinum toxin therapy in spastic movement disorders

Article Title: Improving detection of candidates for botulinum toxin therapy in spasticity: an interprofessional screening approach

Article References: Rudelstorfer, M., Mayr-Pirker, B., Trinka, E., Iglseder, B., & Radlberger, R. F. (2026). Improving detection of candidates for botulinum toxin therapy in spasticity: an interprofessional screening approach. Frontiers in Neurology, 17, Article 1939701. https://doi.org/10.3389/fneur.2026.1939701

Image Credits: AI Generated

DOI: 10.3389/fneur.2026.1939701

Keywords: botulinum toxin, spasticity, post-stroke spasticity, nursing questionnaire, screening, neurorehabilitation, diagnostic accuracy, interprofessional care, geriatrics, movement disorders, referral, Salzburg Nursing Questionnaire

The research team, led by Citra Windani Mambang Sari of the Doctoral Program in Medical Science and the Department of Community Health Nursing at Universitas Padjadjaran, used a sequential model-development design. Rather than testing a finished intervention, the study focused on the crucial early stages of building one: synthesising existing concepts, drafting the model and its supporting modules, submitting them to multidisciplinary expert scrutiny, refining the materials and finally checking whether the intended users could actually read and use them. This staged approach reflects a growing recognition in implementation science that interventions fail in the field far more often because of weak design and validation than because of poor ideas.

The intellectual architecture of the model draws on several complementary frameworks. The researchers integrated the Functional Consequences framework, which foregrounds how diabetes and its treatments interact with age-related changes in function; King’s Goal Attainment Theory, which frames care as a negotiated process in which nurse and patient jointly set and pursue goals; and Meiqari and colleagues’ continuity-of-care framework, which maps the informational, management and relational dimensions of seamless care. These theoretical anchors were combined with unpublished formative project findings, focus group discussions with community nurses, and systematic review evidence on continuity-of-care strategies for older adults with diabetes across Asia. The result is a model grounded simultaneously in theory, local practice experience and the best available regional evidence.

What emerged from this synthesis is a comprehensive care package in which the community nurse acts as the coordinating hub. Under the model, the nurse orchestrates physician-led structured diabetes education, shared goal setting with the patient, interprofessional home visits carried out by community nurses working alongside nutritionists and pharmacists, telephone follow-up with patients, multidisciplinary case conferences, family follow-up, and dedicated education sessions for patients and their families. Each element targets a known weak point in fragmented primary care: education that ends at the clinic door, home environments that health professionals never see, families left without guidance, and specialists and generalists who never compare notes.

Validation was handled with quantitative precision. Twelve purposively selected multidisciplinary experts — spanning community and primary care nursing, programme leadership, academia, medicine, pharmacy and geriatric diabetes care, each meeting predefined eligibility criteria — rated the model book and two accompanying modules on a four-point scale. The researchers quantified agreement using the item-level content validity index, calculated as the proportion of experts rating an item 3 or 4, and the scale-level content validity index average, with an acceptability threshold set in advance at 0.90 or above. The results were striking: because no expert rated any item below 3, every item-level index reached 1.00, and the scale-level average was 1.00 for all three instruments. Mean item scores stood at 3.86 for the model book, 3.82 for the older-adult and family module, and 3.90 for the health-worker module.

A perfect validity score is rare in instrument development, and its significance deserves careful reading. It indicates unanimous expert endorsement that the model’s content is relevant, clear and appropriate for its purpose — not that the model has been proven to work. The authors are explicit on this point, noting that the findings support progression to pilot and feasibility testing but do not establish implementation feasibility or clinical effectiveness. That distinction matters for readers weighing the study’s implications: content validation is a gate through which promising interventions must pass, but it is the first gate, not the last.

The team also tested whether the materials would be usable by the people expected to rely on them. Twenty-two intended users — twelve health workers and ten older adults with diabetes — completed structured readability and practicality appraisals, with items scored as a percentage of the maximum possible. The health-worker module scored 90.52 percent and the older-adult and family module scored 97.13 percent; both fell within the appraisal instrument’s defined category of very practical, which requires scores above 81.25 percent. For a module designed to be read and acted upon by older patients and their families, a practicality score approaching 97 percent is a notable signal that the materials communicate in language and formats that real users can navigate.

Expert scrutiny was not merely confirmatory; it shaped the model. Feedback from the panel informed refinements across a wide range of content areas, including the scope of primary care activities, the implementation flow of the model, the delineation of interprofessional roles, the involvement of family members, telehealth monitoring, emergency action guidance, nutrition, medication management, foot care and stress-management content. This iterative refinement loop — draft, rate, revise — is precisely what content validation is designed to achieve, converting the collective judgement of a multidisciplinary panel into concrete improvements before any patient encounters the intervention in routine care.

The study’s context gives it broader resonance. Indonesia’s population is ageing rapidly, and community health centres are the frontline for chronic disease management for millions of older people. Diabetes care in later life demands coordination across time and across professions, yet the components that deliver it — education, follow-up, home visiting, referral, family engagement and interprofessional communication — often operate in silos. A model that positions the community nurse as the connective tissue, supported by explicit modules for both health workers and families, offers a structurally plausible answer to a systems problem rather than a purely clinical one. The two-day training curriculum and twelve-week intervention pathway documented in the study’s supplementary materials suggest the team has already thought through how the model would be operationalised on the ground.

The researchers are careful to frame what comes next. The readability and practicality scores represent preliminary user appraisal among a sampled group of intended users and do not establish practicality in routine care. Future studies, the authors write, should assess caregiver usability, feasibility, fidelity, acceptability, workforce and resource requirements, and the model’s effects on self-management, glycaemic outcomes as measured by markers such as HbA1c, and functional well-being. Ethics approval for the work was granted by the Health Research Ethics Committee of Universitas Padjadjaran, and the publication was supported by Universitas Padjadjaran through the Indonesian Endowment Fund for Education under the EQUITY Program, with the funder playing no role in study design or reporting. If subsequent pilot and feasibility studies bear out the promise suggested by the unanimous expert endorsement and near-perfect practicality scores, Indonesia may gain a replicable template for nurse-led chronic care coordination — one built not on imported assumptions but on the realities of its own primary care system and the lived circumstances of its older patients and their families.

Subject of Research: Nurse-led continuity of care model development and content validation for older adults with type 2 diabetes in Indonesian primary care

Article Title: Development and content validation of a nurse-led continuity of care model for older adults with type 2 diabetes in Indonesian primary care

Article References: Sari, C. W. M., Haroen, H., Juniarti, N., Amalia, L., & Pardosi, J. F. (2026). Development and content validation of a nurse-led continuity of care model for older adults with type 2 diabetes in Indonesian primary care. BMC Nursing. https://doi.org/10.1186/s12912-026-05432-y

Image Credits: AI Generated

DOI: 10.1186/s12912-026-05432-y

Keywords: continuity of care, community nursing, older adults, type 2 diabetes, primary care, model development, content validity, self-management, Indonesia, interprofessional care, family engagement, nurse-led care