Chronic upper extremity pain and co-occurring symptoms in a general population

OBJECTIVE

To estimate the prevalence of self reported chronic upper extremity pain associated with physical impairment in a general population, and its co-occurrence with chronic upper extremity numbness or tingling and chronic pain at other locations.

METHODS

A general health questionnaire was mailed to 3,000 persons (age 25-74 years) who were randomly selected from a general population register.

RESULTS

The response rate was 83%. The prevalence of chronic upper extremity pain associated with physical impairment was 20.8% (95% confidence interval [95% CI] 19.2-22.5), and that of co-occurring numbness or tingling was 6.7% (95% CI 5.7-7.7). Among the responders with chronic upper extremity pain associated with physical impairment, 84% reported more than 1 painful area.

CONCLUSION

Chronic upper extremity pain associated with physical impairment and co-occurring chronic upper extremity numbness or tingling were common in the general population. The presence of more than 1 location for pain in the upper extremity as well as in other parts of the body was frequent.

The disabilities of the arm, shoulder and hand (DASH) outcome questionnaire: longitudinal construct validity and measuring self-rated health change after surgery

BACKGROUND

The disabilities of the arm, shoulder and hand (DASH) questionnaire is a self-administered region-specific outcome instrument developed as a measure of self-rated upper-extremity disability and symptoms. The DASH consists mainly of a 30-item disability/symptom scale, scored 0 (no disability) to 100. The main purpose of this study was to assess the longitudinal construct validity of the DASH among patients undergoing surgery. The second purpose was to quantify self-rated treatment effectiveness after surgery.

METHODS

The longitudinal construct validity of the DASH was evaluated in 109 patients having surgical treatment for a variety of upper-extremity conditions, by assessing preoperative-to-postoperative (6-21 months) change in DASH score and calculating the effect size and standardized response mean. The magnitude of score change was also analyzed in relation to patients' responses to an item regarding self-perceived change in the status of the arm after surgery. Performance of the DASH as a measure of treatment effectiveness was assessed after surgery for subacromial impingement and carpal tunnel syndrome by calculating the effect size and standardized response mean.

RESULTS

Among the 109 patients, the mean (SD) DASH score preoperatively was 35 (22) and postoperatively 24 (23) and the mean score change was 15 (13). The effect size was 0.7 and the standardized response mean 1.2.The mean change (95% confidence interval) in DASH score for the patients reporting the status of the arm as "much better" or "much worse" after surgery was 19 (15-23) and for those reporting it as "somewhat better" or "somewhat worse" was 10 (7-14) (p = 0.01). In measuring effectiveness of arthroscopic acromioplasty the effect size was 0.9 and standardized response mean 0.5; for carpal tunnel surgery the effect size was 0.7 and standardized response mean 1.0.

CONCLUSION

The DASH can detect and differentiate small and large changes of disability over time after surgery in patients with upper-extremity musculoskeletal disorders. A 10-point difference in mean DASH score may be considered as a minimal important change. The DASH can show treatment effectiveness after surgery for subacromial impingement and carpal tunnel syndrome. The effect size and standardized response mean may yield substantially differing results.

Breast cancer patients' experiences of lymphoedema

The aim of this study was to explore employed women's experiences of light or moderate arm lymphoedema following breast cancer treatment in order to gain a deeper understanding of this phenomenon. Twelve women took part in a semistructured interview. A qualitative method with a phenomenological approach was applied to analyse data. In order to integrate the experiences in the everyday life of the women, a critical incident method was used. The findings indicate that there are many different practical and psychosocial problems related to arm lymphoedema. Three main themes were common to all the women. These themes were: (i) Attitudes from people in their surroundings, including reactions to the problem from other people and reactions from the women on the attitudes of other people. (ii) Discovery and understanding of oedema as a chronic disease and its treatment. (iii) Coping, including both problem-focused and emotion-focused strategies. The problems integrated in daily life were of low frequency but of considerable importance to the women. In conclusion, it is of great importance that health care professionals should be aware of and have knowledge about these problems. The women's needs for expressing their experiences of arm lymphoedema may be encouraged at the time of discovery and then regularly as long as the women seek care. Efforts may be made to strengthen the women's coping skills, eventually in a multidisciplinary approach. The interaction skills of health care professionals are probably of great importance in strengthening the resources of the women leading to a positive outcome.

Performance of health-status scales when used selectively or within multi-scale questionnaire

BACKGROUND

Little work has been done to investigate the suggestion that the use of selected scales from a multi-scale health-status questionnaire would compromise reliability and validity. The aim of this study was to compare the performance of three scales selected from the SF-36 generic health questionnaire when administered in isolation or within the entire SF-36 to patients with musculoskeletal disorders.

METHODS

Two groups of patients referred to an orthopedic department completed a mailed questionnaire within 4 weeks prior to and a second questionnaire during their visit. The first group completed three SF-36 scales related to physical health (physical functioning, bodily pain, and general health perceptions) on one occasion and all eight SF-36 scales on the other occasion. The second group completed the entire SF-36 on two occasions. Results for patients who reported unchanged health status and had complete scores were analyzed; 80 patients in the first and 62 patients in the second group.

RESULTS

The Cronbach alpha reliability and intraclass correlation coefficients exceeded 0.7 for all three scales for both groups. For the first group the mean difference between the scores was 0.4 point for physical functioning, 2.5 points for bodily pain, and 0.5 point for general health perceptions, which did not differ significantly from the corresponding differences for the second group (0.1, 1.9 and 1 point, respectively).

CONCLUSION

The use of selected scales from a multi-scale health-status questionnaire seems to yield similar results compared to their use within the entire questionnaire.

Six- and 24-month follow-up of pool exercise therapy and education for patients with fibromyalgia

OBJECTIVE

To follow patients with fibromyalgia six and 24 months after they finished a six-month treatment programme. The programme comprised pool exercise therapy, adjusted to the patients' limitations, and education based on their health problems.

METHODS

Twenty-six patients were examined six and 24 months after the completion of the treatment programme with the Fibromyalgia Impact Questionnaire (FIQ), SF-36, the 6-minute walk test, and the Grippit measure. The values obtained at the follow-up examinations were compared with the baseline and post-treatment values.

RESULTS

As compared with baseline, symptom severity (FIQ, SF-36), physical function (FIQ, SF-36, 6-minute walk test) and quality of life (SF-36) still showed improvements six months after the completion of treatment (p <0.05). Pain (FIQ, SF-36), fatigue (FIQ, SF-36), walking ability, and social function (SF-36) still showed improvements 2 years after the completion of the programme as compared with the baseline values (p < 0.05). No significant changes were found for these variables, when the values obtained at the two follow-up examinations were compared with those of the post-treatment examination.

CONCLUSIONS

Improvements in symptom severity, physical function and social function were still found six and 24 months after the completed treatment programme.

The effect of McKenzie therapy as compared with that of intensive strengthening training for the treatment of patients with subacute or chronic low back pain: A randomized controlled trial

STUDY DESIGN

A randomized controlled comparative trial with an 8-month follow-up period was conducted.

OBJECTIVE

To compare the effect of the McKenzie treatment method with that of intensive dynamic strengthening training in patients with subacute or chronic low back pain.

SUMMARY OF BACKGROUND DATA

Randomized studies indicate that the efficacy of the McKenzie method in the treatment of patients with acute or subacute low back pain is debatable. Currently, no randomized studies examining the effects of this method for patients with chronic low back pain have been published.

METHODS

For this study, 260 consecutive patients with low back pain and at least 8 weeks duration of symptoms (85% of the patients had more than 3 months duration of symptoms) were randomized into two groups: Group A was treated with the McKenzie method (n = 132), and Group B was treated with intensive dynamic strengthening training (n = 128). The treatment period for both groups was 8 weeks at an outpatient clinic, followed by 2 months of self-training at home. Treatment results were recorded at the end of the treatment period at the clinic, then 2 and 8 months after. In both groups, 30% of the patients were lost to follow-up evaluation. An intention-to-treat analysis of the main effect variables, disability, and pain was performed for all the patients included in the study. A supplementary analysis of the 180 patients who completed the full treatment program also was undertaken.

RESULTS

Intention-to-treat analysis showed a tendency toward a difference in reduction of disability in favor of the McKenzie group at the 2-month follow-up assessment (P = 0.04), but no differences at the end of treatment and at the 8-month follow-up evaluation. No differences in reduction of pain were observed at any time between the groups. The supplementary analysis of the patients who had completed the full intervention showed a tendency toward a difference in favor of the McKenzie method in reduction of pain at the end of treatment (P = 0.02). This difference reached statistical significance at the 2-month follow-up assessment (P = 0.01), but no difference was found after 8 months. The supplementary analysis showed no differences between the groups with regard to reduction of disability.

CONCLUSION

The McKenzie method and intensive dynamic strengthening training seem to be equally effective in the treatment of patients with subacute or chronic low back pain.

Clinical tests on impairment level related to low back pain: a study of test reliability

The objectives of the study were, in a working population, to standardize and evaluate a set of clinical tests on impairment level related to the low back with reference to intra- and inter-rater reliability. The study was undertaken in two steps. In step 1, 15 tests were examined for inter-rater reliability by three pairs of physiotherapists and for intra-rater reliability by one physiotherapist. Intra-rater reliability was acceptable (kappa > 0.40) for 14 of the 15 tests. Inter-rater reliability was acceptable for 7 of the 15 tests. In step 2, the tests, indicating a non-acceptable inter-rater reliability (kappa < 0.40) were further standardized and retested by two of the physiotherapists. This further standardization procedure resulted in an acceptable inter-rater reliability for all of these tests. Clinical tests of a working population should preferably be performed by the same rater. However, when tests are performed by different raters, it is suggested that test procedures should be regularly standardized, and in pain provocation tests, the magnitude of the applied pressure should be checked regularly and compared with co-raters, in order to improve inter-rater reliability.

Early planning of care and rehabilitation after amputation for vascular disease by means of Katz Index of Activities of Daily Living

The aim of the study was to investigate whether the Swedish version of the Katz Index of ADL (Activities of Daily Living), on days 5-7 after amputation for vascular disease, had predictive value regarding length of hospital stay, discharge to the patient's own home or death within 1 month. Patients who had recently undergone primary unilateral trans-tibial amputation, living in their own homes before the amputation, were included. Fifty-two patients with a median age of 78 years (60-92) were assessed with the Katz Index of ADL. Results revealed that of the 10 (20%) patients discharged to their own homes within 1 month, only 2 belonged to grades A-C, that is, were independent in the majority of functions in personal ADL. Within 6 months 62% were discharged to their own homes. Eighty-four percent of the patients in grades D-G, i.e. most dependent on others, were still at the hospital or dead 1 month post-operatively. All the patients who belonged to grades A-F survived the first month post-operatively. The Katz Index of ADL had predictive value regarding early outcome in terms of length of hospital stay, discharge to the patient's own home or death within 1 month, and positive predictive value regarding survival the first month post-operatively.

Validity of the Body Awareness Scale-Health (BAS-H)

Quality of movement assessment using the Body Awareness Scale-Health (BAS-H) was validated against the following self-rating tests: Nottingham Health Profile (NHP); Arthritis Self-Efficacy Scale (ASES); Psychological General Well-Being (PGWB); Sense of Coherence (SoC); Sivic Psychosomatism test (SPS); Symptom Check List 90-R (SCL 90-R); and Visual Analogue Scale for pain intensity (VAS-pain). In total, 75 persons were included, divided into three groups: psychiatric outpatients (n = 25), chronic pain patients (n = 25) and healthy controls (n = 25). The highest significant correlations were obtained between the BAS-H total index and the sub-indices of grounding/stability to the centre line, centering/breathing and flow on the one hand, and the NHP, the ASES, and the PGWB on the other, with r ranging from 0.36 to 0.73. Multiple regression analysis revealed the NHP to explain 50% and ASES a further 5% of the variance in the BAS-H total index. Significant differences for both the BAS-H total index and the sub-indices were obtained between the two patient groups and the healthy controls. It is concluded that the construct validity of the BAS-H was found to be in accordance with theoretical expectations.

Factors associated with the development of arm lymphedema following breast cancer treatment: a match pair case-control study

We examined factors that may influence the development of arm lymphedema following breast cancer treatment including the specific mode of therapy, patient occupation and life style. Medical record data and a questionnaire were used to collect information after surgery concerning such issues as wound seroma, infection, adjuvant treatment, vessel string (phlebitis), body mass index, smoking habits and stress. Occupational workload was assessed after surgery whereas housework, exercise, hobbies and body weight were assessed both before and after surgery. Seventy-one breast cancer treated women with arm lymphedema lasting more than 6 months but less than 2 years were matched to women similarly treated for breast cancer but without arm lymphedema (controls). The matching factors included axillary node status, time after axillary dissection, and age. In the lymphedema group, there was a higher body mass index at time of surgery (p=0.03) as well at time of study (p=0.04). No differences were found in occupational workload (n=38) or housework, but the lymphedema group reduced their spare time activities including exercise after surgery compared with the controls (p<0.01). In conclusion, women treated for breast cancer with axillary node dissection with or without adjuvant radiotherapy could maintain their level of physical activity and occupational workload after treatment without an added risk of developing arm lymphedema. On the other hand, a higher BMI before and after operation increases the lymphedema risk.

Evaluation of an external device measuring knee joint rotation: an in vivo study with simultaneous Roentgen stereometric analysis

An external device ("rottometer") specially designed to measure knee joint rotation was developed and evaluated with respect to its validity. Simultaneous measurements were made with the rottometer and Roentgen stereometric analysis (RSA) in five patients with implanted tantalum markers in the tibia and femur. Measurements of internal and external rotation were made at 90 degrees and 60 degrees of knee flexion using 3, 6 and 9 N m torques. The coefficients of determination (r2) between the results obtained with the rottometer and RSA were around 0.9 for the total rotation. The rottometer consistently overestimated the rotation by about 100% and this systematic error was most constant at 90 degrees flexion for the different torques. The magnitude of this error from soft tissue deformation as well as the rotatory movements in the hip, foot and ankle joints must be considered when using external devices to measure knee rotation in clinical studies. The most accurate registrations were found in 90 degrees flexion with 9 N m force (r2 = 0.94).

Assessment of work postures and movements using a video-based observation method and direct technical measurements

The aim was to study postures and movements during repetitive work using video-based observations and direct technical measurements (inclinometers and goniometers). A total of 21 healthy women from a poultry processing plant volunteered. Neck flexion > 20 degrees was registered during 92% of the recorded time with the observation method, while the corresponding value measured with the inclinometer was 65%. Different reference positions and different measured variables apparently contributed to the differences between the methods. Mean wrist position was measured to be 0 degrees in flexion-extension and 19 degrees in ulnar deviation. Differences between the methods in the registered hand positions were small. The number of repetitive movements/minute and mean power frequency (MPF) of the electrogoniometer data was significantly related, showing both variables to be relevant measures of repetitiveness. In conclusion, the observation method and the technical measurements supplemented each other well. A reduction in class categories was suggested for future observation methods.

Antimicrobial susceptibility patterns of enterococci in intensive care units in Sweden evaluated by different MIC breakpoint systems

Three hundred and twenty-two (322) clinical isolates were collected from patients admitted to intensive care units (ICUs) at eight Swedish hospitals between December 1996 and December 1998. Of the isolates, 244 (76%) were Enterococcus faecalis, 74 (23%) were Enterococcus faecium and four (1%) were other Enterococcus spp. MICs of ampicillin, imipenem, meropenem, piperacillin/tazobactam, ciprofloxacin, trovafloxacin, clinafloxacin, gentamicin, streptomycin, vancomycin, teicoplanin, quinupristin/dalfopristin, linezolid and evernimicin were determined by Etest. Susceptible and resistant isolates were defined according to the species-related MIC breakpoints of the British Society for Antimicrobial Chemotherapy (BSAC), the National Committee for Clinical Laboratory Standards (NCCLS) and the Swedish Reference Group for Antibiotics (SRGA). Tentative breakpoints were applied for new/experimental antibiotics. Multidrug resistance among enterococci in ICUs is not uncommon in Sweden, particularly among E. faecium, and includes ampicillin resistance and concomitant resistance to fluoroquinolones. Almost 20% of E. faecalis isolates showed high-level resistance to gentamicin and concomitant resistance to fluoroquinolones. Vancomycin-resistant enterococci were only found sporadically. Among the new antimicrobial agents, linezolid and evernimicin showed the best activity against all enterococcal isolates. There was good concordance between the BSAC, NCCLS and SRGA breakpoints in detecting resistance. When applying the SRGA breakpoints for susceptibility, isolates were more frequently interpreted as intermediate. This might indicate earlier detection of emerging resistance using the SRGA breakpoint when the native population is considered susceptible, but with the risk that isolates belonging to the native susceptible population will be incorrectly interpreted as intermediate.

No significant differences between intervention programmes on neck, shoulder and low back pain: a prospective randomized study among home-care personnel

The effects of two different prevention programmes on: (1) reported neck, shoulder and back pain, (2) perceived physical exertion at work and perceived work-related psychosocial factors, were evaluated by questionnaires after 12 and 18 months. Female nursing aides and assistant nurses (n = 282) working in the home-care services, were randomly assigned to one of three groups for: (1) individually designed physical training programme, (2) work-place stress management, (3) control group. Results revealed no significant differences between the three groups. However, improvements in low back pain were registered within both intervention groups for up to 18 months. Perceived physical exertion at work was reduced in the physical training group. Improvements in neck and shoulder pain did not differ within the three groups. Dissatisfaction with work-related, psychosocial factors was generally increased in all groups. As the aetiology of neck, shoulder and back disorders is multifactorial, a combination of the two intervention programmes might be preferable and should be further studied.

Long-term outcome of meniscectomy: symptoms, function, and performance tests in patients with or without radiographic osteoarthritis compared to matched controls

OBJECTIVE

To describe the long-term influence of meniscectomy on pain, functional limitations, and muscular performance. To assess the effects of radiographic osteoarthritis (OA), gender and age on these outcomes in patients with meniscectomy.

DESIGN

159 subjects (35 women), mean age 53 years, were examined 19 (17-22) years after open meniscectomy. Self-reported symptoms and function were assessed, performance tests were carried out and radiographs were taken. Sixty-eight age- and gender-matched controls were examined likewise. The data was analysed in two steps. First, subjects with meniscectomy were compared to the controls, and subgroup analyses were carried out with regard to radiographic OA, gender and age. Second, similar comparisons were carried out within the meniscectomized group.

RESULTS

Meniscectomized subjects reported significantly (P< 0.001) more symptoms and functional limitations than did controls. This was also true when operated subjects without OA were compared to controls without OA. Within the meniscectomized group, severe radiographic OA (joint space narrowing grade 2 or more) and female gender, but not older age, was associated with more symptoms and functional limitations. Meniscectomy was associated with worse muscular performance. Female gender and older age were associated with worse muscular performance in the study group.

CONCLUSIONS

Meniscectomy is associated with long-term symptoms and functional limitations, especially in women. Patients who had developed severe radiographic OA experienced more symptoms and functional limitations. Age did not influence self-reported outcomes, however older age was associated with worse muscular performance.

Motivation as a predictor of changes in quality of life and working ability in multidisciplinary rehabilitation. A two-year follow-up of a prospective controlled study in patients with prolonged musculoskeletal disorders

PURPOSE

To evaluate the two year outcome of multidisciplinary rehabilitation for patients with prolonged musculoskeletal disorders (MSDs), in terms of health-related quality of life (HRQL) and working ability. In addition, predictors of outcome were examined.

METHODS

The rehabilitation group and the matched control group comprised 122 and 114 patients respectively. Baseline data were compared with two year follow-up data within and between the groups. The variables that were measured were: HRQL (Nottingham Health Profile), motivation, body awareness, pain, pain-related medicine consumption, psychosomatic symptoms, working environment and working ability.

RESULTS

Variables which improved significantly for the rehabilitation group compared with the control group were: HRQL (p = 0.049), emotional reactions (p = 0.043), pain related to movements (p = 0.028) and need for pain-related medicines (p = 0.009). Multivariate regression analysis including all patients revealed that motivation was a predictor of change in HRQL (p = 0.001) and working ability (p < 0.001).

CONCLUSION

The rehabilitation programme appeared to improve HRQL to a greater extent than ordinary treatment available within primary care. The patient's level of motivation could be an important predictor of outcome.

Pool exercise combined with an education program for patients with fibromyalgia syndrome. A prospective, randomized study

OBJECTIVE

To evaluate the effects of 6 months of pool exercise combined with a 6 session education program for patients with fibromyalgia syndrome (FM).

METHODS

The study population comprised 58 patients, randomized to a treatment or a control group. Patients were instructed to match the pool exercises to their threshold of pain and fatigue. The education focused on strategies for coping with symptoms and encouragement of physical activity. The primary outcome measurements were the total score of the Fibromyalgia Impact Questionnaire (FIQ) and the 6 min walk test, recorded at study start and after 6 mo. Several other tests and instruments assessing functional limitations, severity of symptoms, disabilities, and quality of life were also applied.

RESULTS

Significant differences between the treatment group and the control group were found for the FIQ total score (p = 0.017) and the 6 min walk test (p < 0.0001). Significant differences were also found for physical function, grip strength, pain severity, social functioning, psychological distress, and quality of life.

CONCLUSION

The results suggest that a 6 month program of exercises in a temperate pool combined with education will improve the consequences of FM.

Muscle sizes and moment arms of rotator cuff muscles determined by magnetic resonance imaging

Biomechanical models which require information on, e.g., joint torque and muscle force are useful in the estimation of when and how mechanical overload of the musculoskeletal system may lead to disorders. The aim was to study the reliability and validity of magnetic resonance imaging (MRI) to quantify muscle sizes and moment arms by MRI and to test selected anthropometric measures as predictors of muscle sizes and moment arms. A total of 20 healthy Scandinavian women (age 22-58 years) participated in an MRI scanning of their dominant shoulder. With a PC-based program the reliability and the validity of the MRI measurements was estimated to be high, and mean anatomical cross-sectional areas (ACSA) and muscle lengths were measured to be 4.0, 9.8 and 12.1 cm(2) and 12.0, 12.6 and 12.8 cm for m. supraspinatus, m. infraspinatus and m. subscapularis, respectively. Volumes were calculated to be 48.8, 125.1 and 153.6 cm(3). Moment arms were measured with the upper arm in a neutral position and in a functional position of 34 degrees abduction for m. supraspinatus only, and were 2.4 and 2.6 cm. Physiological cross-sectional area (PCSA) and its fiber force component were estimated from dissected fiber length and pennation angle. MRI volume and PCSA were 1.4-1.7 times higher than dissection data, primarily because of age differences. No external anthropometric measures were found to be predictors of volumes or moment arms.

Comparison of muscle sizes and moment arms of two rotator cuff muscles measured by ultrasonography and magnetic resonance imaging

OBJECTIVE

The purpose was to investigate ultrasound (US) and anthropometry (AN) as valid alternatives to magnetic resonance imaging (MRI) regarding muscle size characteristics of two rotator cuff muscles.

METHODS

Eight healthy females (age 27-54 yrs.) went through MRI and US scannings and AN measurements, where muscle thickness, cross-section area (CSA), moment arm, muscle length and width were measured on supraspinatus and infraspinatus muscle.

RESULTS

The agreement between the methods was very satisfactory for CSA, and satisfactory for muscle thickness, moment arm, muscle length and width, with a mean difference below 2 mm in thickness and below 5 mm in muscle length and width. Volume could be estimated satisfactory in supraspinatus muscle, but not in infraspinatus muscle, where volume had to be calculated from thickness, length and width. As a significant relation was found in the MRI measurements between thickness and CSA, thickness measurements may replace CSA in inaccessible muscles.

CONCLUSIONS

US was a valid method in measuring CSA, muscle thickness and moment arm. Combined with anthropometric measures of muscle length and width, volume can be calculated, which is important when defining the physiological cross-sectional area and muscle function. Further development and validation of the method is needed, however.

Health-related quality of life in primary Sjögren's syndrome, rheumatoid arthritis and fibromyalgia compared to normal population data using SF-36

OBJECTIVE

To investigate the health-related quality of life in women with primary Sjogren's syndrome (prim SS) and compare with normative data and the health-related quality of life in women with rheumatoid arthritis (RA) and women with fibromyalgia.

METHODS

A questionnaire including the MOS Short-Form 36 (SF-36) was completed by 42 prim SS women, 59 RA women, and 44 women with fibromyalgia.

RESULTS

All three patient groups experienced a decreased quality of life level ranging from 5 to 65 % in all SF-36 scales compared to normative data. Differences between groups were seen in 7 of the 8 scales (p< or = 0.004). The prim SS patients experienced a higher quality of life level with regard to physical function than the women with RA and fibromyalgia, whereas in the psychological dimensions the quality of life level was comparable to that of the two other groups.

CONCLUSION

The health-related quality of life was significantly decreased as compared to norms in prim SS women and comparable to the levels of women with RA and fibromyalgia.

A study of the usage of a decision-support system for infective endocarditis

The objective of this study was to examine a design for a World Wide Web-based decision-support system in use by clinically active physicians. A prototype implementation of the design concerned management of infective endocarditis patient cases. The design was based on an integration of hypertext and rule-based knowledge. In the study sessions, physicians in the field of internal medicine worked on managing authentic patient cases in a laboratory setting. Data was collected from interviews with the physicians using video recordings and stimulated recall technique. The qualitative data was analysed according to the constant comparative method in order to develop a model of the physicians' usage of the system. The resulting model describes perceived contributions and criteria for usefulness of the system. The ways the physicians used the system showed that it was able to provide patient-specific support for confirming clinical decisions, for higher-level patient management, and for preparing for and initiating expert consultations. Users also stated that new medical knowledge could be gained as a side effect of using the system.