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Naughton N, Algar L. Linking commonly used hand therapy outcome measures to individual areas of the International Classification of Functioning: A systematic review. J Hand Ther 2020; 32:243-261. [PMID: 29433763 DOI: 10.1016/j.jht.2017.11.039] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2017] [Revised: 11/21/2017] [Accepted: 11/25/2017] [Indexed: 02/03/2023]
Abstract
STUDY DESIGN Systematic review. INTRODUCTION Identifying outcome measures that correspond to the International Classification of Functioning (ICF) provides insight into selecting appropriate outcome tools in hand therapy practice. PURPOSE OF THE STUDY The objective of this study is to systematically review patient-reported outcome measures commonly used in hand therapy to determine the extent to which the content represents the biopsychosocial view of the ICF. METHODS A comprehensive literature search was conducted. Studies that met inclusion criteria were identified, and outcome measures were extracted. The meaningful concept was determined for each item on the measure and linked to the most specific ICF category. Summary linkage calculations were completed. RESULTS Eleven patient-reported outcomes were identified from 43 included studies. Activity and participation had the highest content coverage followed by body functions. There was linking to personal factors and not defined-disability and mental health. Environmental factors were not represented in any of the included outcome measures. The core set representation of unique codes ranged from 8.55% to 18.80% (mean: 11.97%) for the Comprehensive ICF Core Set for Hand Conditions and from 30.43% to 47.83% (mean: 31.40%) for the Brief ICF Core Set for Hand Conditions. The percent representation of the Comprehensive ICF Core Set for Hand Conditions for unique disability ranged from 21.62% to 43.24% (mean: 20.33%) and from 62.50% to 87.50% (mean: 72.22%) for the Brief ICF Core Set for Hand Conditions. DISCUSSION None of the included measures represent all categories of the ICF Core Sets for Hand Conditions. CONCLUSION Utilizing the most recent refinement rules for the linking process, this study provides comparisons of measures along with clarity of content coverage for the most commonly used tools in the practice of hand therapy.
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Affiliation(s)
| | - Lori Algar
- Orthopaedic Specialty Group PC, Fairfield, CT, USA
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Adams J, Lowe W, Protheroe J, Lueddeke J, Armstrong R, Russell C, Nutbeam D, Ballinger C. Self-management of a musculoskeletal condition for people from harder to reach groups: a qualitative patient interview study. Disabil Rehabil 2019; 41:3034-3042. [PMID: 30369265 PMCID: PMC6913654 DOI: 10.1080/09638288.2018.1485182] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2017] [Revised: 06/01/2018] [Accepted: 06/03/2018] [Indexed: 10/31/2022]
Abstract
Background: This study recorded the functional health literacy levels of people with musculoskeletal (MSK) conditions from harder to reach groups and explored their experiences in engaging with health care professionals to self-manage their MSK condition.Methods: We recruited participants, identified by key health and social care contacts as likely to have lower health literacy levels, and used semi-structured interviews to collect data. Thematic analysis was used to identify the main key themes arising from the transcribed interviews.Results: Eighteen participants were identified and recruited from harder to reach community populations, 10 were scored as having inadequate functional health literacy on the Short Form Rapid Estimate of Adult Literacy Measure. Three themes were identified in relation to participants' experiences of MSK self-management approaches: engaging with health care services; interpreting the health care providers' message; and facilitating participation in MSK self-management.Conclusions: Our findings indicate that people with a MSK condition, from harder to reach groups, experience multi-morbidity, find health care systems complicated and hear from health care professionals that their MSK condition cannot be cured. People interpreted that a lack of cure meant that nothing could be done to help their MSK pain. Engaging with self-management strategies was not seen as a priority for our participants. Strategies to simplify health communication, more time to process health information and supportive social networks helped our participants to understand and manage their MSK health on a day-to-day basis. Implications for RehabilitationMSK conditions are long term and prevalent in the UK with substantial impact on people's daily life.Currently self-management strategies for MSK conditions are poorly communicated and many patients believe that nothing can be done to help their MSK pain.Good clinician communication that supports self-management is needed so that key messages can be effectively understood and used by patients with a range of literacy skills.Health services need to be even more accessible to help all individuals from a range of backgrounds better self-manage their MSK conditions.
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Affiliation(s)
- Jo Adams
- Faculty of Health Sciences, University of Southampton, Southampton, UK
| | - Wendy Lowe
- Faculty of Health Sciences, University of Southampton, Southampton, UK
- Centre Medical Education Barts and The London School of Medicine and Dentistry Queen Mary, University of London, London, UK
| | - Joanne Protheroe
- Research Institute for Primary Care & Health Sciences, Keele University, Keele, UK
| | - Jill Lueddeke
- Richard Taunton’s Sixth Form College, Southampton, UK
| | - Ray Armstrong
- University Hospital Southampton Foundation NHS Trust, Southampton, UK
| | - Cynthia Russell
- Faculty of Health Sciences, University of Southampton, Southampton, UK
| | - Don Nutbeam
- Faculty of Health Sciences, University of Southampton, Southampton, UK
- Sydney School of Public Health, University of Sydney Australia, Sydney, Australia
| | - Claire Ballinger
- Faculty of Health Sciences, University of Southampton, Southampton, UK
- Faculty of Medicine, University of Southampton, Southampton, UK
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Keene DJ, Costa ML, Tutton E, Hopewell S, Barber VS, Dutton SJ, Redmond AC, Willett K, Lamb SE. Progressive functional exercise versus best practice advice for adults aged 50 years or over after ankle fracture: protocol for a pilot randomised controlled trial in the UK - the Ankle Fracture Treatment: Enhancing Rehabilitation (AFTER) study. BMJ Open 2019; 9:e030877. [PMID: 31678945 PMCID: PMC6830709 DOI: 10.1136/bmjopen-2019-030877] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
INTRODUCTION Ankle fractures result in significant morbidity in adults, with prognosis worsening with increasing age. Previous trials have not found evidence supporting supervised physiotherapy sessions, but these studies have not focused on older adults or tailored the exercise interventions to the complex needs of this patient group. The Ankle Fracture Treatment: Enhancing Rehabilitation study is a pilot randomised controlled trial to assess feasibility of a later definitive trial comparing best-practice advice with progressive functional exercise for adults aged 50 years and over after ankle fracture.The main objectives are to assess: (i) patient engagement with the trial, measured by the participation rate of those eligible; (ii) establish whether the interventions are acceptable to participants and therapists, assessed by intervention adherence levels, participant interviews and a therapist focus group; (iii) participant retention in the trial, measured by the proportion of participants providing outcome data at 6 months; (iv) acceptability of measuring outcomes at 3 and 6 month follow-up. METHODS AND ANALYSIS A multicentre pilot randomised controlled trial with an embedded qualitative study. At least 48 patients aged 50 years and over with an ankle fracture requiring surgical management, or non-operative management by immobilisation for at least 4 weeks, will be recruited from a minimum of three National Health Service hospitals in the UK. Participants will be allocated 1:1 via a central web-based randomisation system to: (i) best-practice advice (one session of face-to-face self-management advice delivered by a physiotherapist and up to two optional additional sessions) or (ii) progressive functional exercise (up to six sessions of individual face-to-face physiotherapy). An embedded qualitative study will include one-to-one interviews with up to 20 participants and a therapist focus group. ETHICS AND DISSEMINATION Hampshire B Research Ethics Committee (18/SC/0281) gave approval on 2nd July 2018. TRIAL REGISTRATION NUMBER ISRCTN16612336.
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Affiliation(s)
- David J Keene
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Matthew L Costa
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Elizabeth Tutton
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Sally Hopewell
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- Centre for Statistics in Medicine, University of Oxford, Oxford, UK
| | - Vicki S Barber
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- Centre for Statistics in Medicine, University of Oxford, Oxford, UK
| | - Susan J Dutton
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- Centre for Statistics in Medicine, University of Oxford, Oxford, UK
| | - Anthony C Redmond
- Leeds Institute of Rheumatology and Musculoskeletal Medicine, University of Leeds, Leeds, UK
| | - Keith Willett
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Sarah E Lamb
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- Centre for Statistics in Medicine, University of Oxford, Oxford, UK
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Rydholm M, Wikström I, Hagel S, Jacobsson LTH, Turesson C. The relation between upper extremity joint involvement and grip force in early rheumatoid arthritis: a retrospective study. Rheumatol Int 2019; 39:2031-2041. [PMID: 31494739 DOI: 10.1007/s00296-019-04438-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Accepted: 08/29/2019] [Indexed: 11/30/2022]
Abstract
To investigate the relation between joint involvement in the upper extremities and grip force in patients with early rheumatoid arthritis (RA). An inception cohort of 225 patients with early RA was followed according to a structured protocol. The same rheumatologist assessed all patients for swollen joints and joint tenderness. Grip force was measured (Grippit; AB Detektor, Gothenburg, Sweden) at the same visit. Average grip force values for the dominant hand were expressed as % of expected, based on age- and sex-specific reference values from the literature. Associations between grip force and current synovitis or tenderness of individual joints, and other disease parameters measured at the same visit, were examined. Patients with current synovitis of the wrist joint or ≥ 1 metacarpophalangeal (MCP) joint of the dominant hand had a significantly lower grip force at inclusion, at 1 year and at 5 years. Proximal interphalangeal joint tenderness and MCP joint tenderness were consistently associated with reduced grip force. In multivariate analysis, extensive MCP joint synovitis was associated with lower grip force at inclusion (β - 2.8% per joint; 95% CI - 5.3 to - 0.4), and also at the 1-year follow-up. Patient reported pain scores and erythrocyte sedimentation rates had independent negative associations with grip force at all time points. In patients with early RA, extensive synovitis of the MCP joints was associated with reduced grip force, independently of other upper extremity joint involvement. Pain and inflammation have effects on hand function beyond those mediated by local synovitis.
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Affiliation(s)
- Maria Rydholm
- Rheumatology, Department of Clinical Sciences, Lund University, Malmö, Sweden.,Department of Rheumatology, Skåne University Hospital, Malmö, Sweden
| | - Ingegerd Wikström
- Rheumatology, Department of Clinical Sciences, Lund University, Malmö, Sweden.,Department of Rheumatology, Skåne University Hospital, Malmö, Sweden
| | - Sofia Hagel
- Department of Rheumatology, Skåne University Hospital, Lund, Sweden.,Rheumatology, Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Lennart T H Jacobsson
- Rheumatology, Department of Clinical Sciences, Lund University, Malmö, Sweden.,Department of Rheumatology and Inflammation Research, Sahlgrenska Academy at Gothenburg University, Gothenburg, Sweden
| | - Carl Turesson
- Rheumatology, Department of Clinical Sciences, Lund University, Malmö, Sweden. .,Department of Rheumatology, Skåne University Hospital, Malmö, Sweden.
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Lee H, Herbert RD, Lamb SE, Moseley AM, McAuley JH. Investigating causal mechanisms in randomised controlled trials. Trials 2019; 20:524. [PMID: 31443729 PMCID: PMC6708183 DOI: 10.1186/s13063-019-3593-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Accepted: 07/17/2019] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION In some randomised trials, the primary interest is in the mechanisms by which an intervention exerts its effects on health outcomes. That is, clinicians and policy-makers may be interested in how the intervention works (or why it does not work) through hypothesised causal mechanisms. In this article, we highlight the value of understanding causal mechanisms in randomised trials by applying causal mediation analysis to two randomised trials of complex interventions. MAIN BODY In the first example, we examine a potential mechanism by which an exercise programme for rheumatoid arthritis of the hand could improve hand function. In the second example, we explore why a rehabilitation programme for ankle fractures failed to improve lower-limb function through hypothesised mechanisms. We outline critical assumptions that are required for making valid causal inferences from these analyses, and provide results of sensitivity analyses that are used to assess the degree to which the estimated causal mediation effects could have been biased by residual confounding. CONCLUSION This paper demonstrates how the application of causal mediation analyses to randomised trials can identify the mechanisms by which complex interventions exert their effects. We discuss methodological issues and assumptions that should be considered when mediation analyses of randomised trials are used to inform clinical practice and policy decisions.
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Affiliation(s)
- Hopin Lee
- Centre for Statistics in Medicine, Rehabilitation Research in Oxford, Nuffield Department of Orthopaedics Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK. .,School of Medicine and Public Health, University of Newcastle, Newcastle, NSW, Australia.
| | - Robert D Herbert
- Neuroscience Research Australia (NeuRA), Sydney, NSW, Australia.,School of Medical Sciences, University of New South Wales, Sydney, NSW, Australia
| | - Sarah E Lamb
- Centre for Statistics in Medicine, Rehabilitation Research in Oxford, Nuffield Department of Orthopaedics Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Anne M Moseley
- Institute for Musculoskeletal Health, School of Public Health, University of Sydney, Sydney, NSW, Australia
| | - James H McAuley
- Neuroscience Research Australia (NeuRA), Sydney, NSW, Australia.,Prince of Wales Clinical School, University of New South Wales, Sydney, NSW, Australia
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Rydholm M, Wikström I, Hagel S, Jacobsson LTH, Turesson C. The Relation Between Disease Activity, Patient-Reported Outcomes, and Grip Force Over Time in Early Rheumatoid Arthritis. ACR Open Rheumatol 2019; 1:507-515. [PMID: 31777832 PMCID: PMC6857997 DOI: 10.1002/acr2.11062] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Accepted: 07/08/2019] [Indexed: 12/28/2022] Open
Abstract
Objective The objective of this study is to identify early predictors of future reduced grip force in patients with rheumatoid arthritis (RA) and to identify early predictors of grip force over time. Methods In a structured follow‐up of an inception cohort of patients with early RA, average grip force values of the dominant hand were evaluated and compared with the expected based on age‐ and sex‐specific reference values. Potential predictors of reduced grip force (less than 50% of expected) at 5 years were examined using logistic regression. Differences in percentage of expected grip force values over the study period and differences in change over time, by baseline disease parameters, were estimated using mixed linear‐effects models. Results Among 200 patients with early RA, 44% had reduced grip force 5 years after diagnosis. Baseline characteristics that predicted reduced grip force at 5 years included high scores for the Health Assessment Questionnaire Disability Index (odds ratio 1.54 per SD; 95% confidence interval 1.13‐2.11), high scores for pain and patient global assessment, and low grip force. C‐reactive protein levels, the erythrocyte sedimentation rate, the 28‐joint Disease Activity Score (DAS28), rheumatoid factor, anti–cyclic citrullinated peptide antibodies, joint counts, and synovitis of individual joints in the dominant upper extremity did not predict reduced grip force. Patients with baseline synovitis of the wrist or metacarpophalangeal joints or patients with a high DAS28 had lower estimated grip force at inclusion but also greater improvement of grip force over time. Conclusion Patient‐reported outcomes predicted reduced grip strength 5 years after diagnosis. This underlines the prognostic importance of disability in early RA. Joint counts and synovitis in individual joints may change rapidly in early RA and appear to be less predictive of long‐term hand function.
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Affiliation(s)
- Maria Rydholm
- Lund University and Skåne University Hospital, Malmö, Sweden
| | | | - Sofia Hagel
- Lund University and Skåne University Hospital, Lund, Sweden
| | - Lennart T H Jacobsson
- Sahlgrenska Academy at Gothenburg University, Gothenburg, Sweden, and Lund University, Malmö, Sweden
| | - Carl Turesson
- Lund University and Skåne University Hospital, Malmö, Sweden
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Ellegaard K, von Bülow C, Røpke A, Bartholdy C, Hansen IS, Rifbjerg-Madsen S, Henriksen M, Wæhrens EE. Hand exercise for women with rheumatoid arthritis and decreased hand function: an exploratory randomized controlled trial. Arthritis Res Ther 2019; 21:158. [PMID: 31242937 PMCID: PMC6595578 DOI: 10.1186/s13075-019-1924-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Accepted: 05/22/2019] [Indexed: 02/21/2023] Open
Abstract
BACKGROUND People with hand-related rheumatoid arthritis (RA) experience problems performing activities of daily living (ADL). Compensatory strategies to improve ADL ability have shown effective. Similarly, hand exercise has shown effect on pain, grip strength, and self-reported ability. A combination has shown positive effects based on self-report, but self-report and observation provide distinct information about ADL. The purpose of this study was to examine whether hand exercise as add on to compensatory intervention (CIP) will improve observed ADL ability in RA. METHODS Women (n = 55) with hand-related RA were randomized to CIPEXERCISE (intervention) or CIP only (control). CIP is focused on joint protection, assistive devices, and alternative ways of performing AD. The hand-exercise program addressed range of motion and muscle strength. Primary outcome was change in observed ADL motor ability measured by the Assessment of Motor and Process Skills (AMPS). Baseline measures were repeated after 8 weeks. RESULTS Improvements in ADL motor ability in CIPEXERCISE (mean change = 0.24 logits; 95% CI = 0.09 to 0.39) and CIPCONTROL (mean change =0.20 logits; 95% CI = 0.05 to 0.35) were statistically significant, with no differences between groups (mean difference = 0.04 logits; 95% CI = - 0.16 to 0.25). Thirteen (46.4%) participants in the CIPEXERCISE and 12 (44.4%) in the CIPCONTROL obtained clinically relevant improvements (≥ 0.30 logits) in ADL motor ability; this group difference was not significant (z = 0.15; p = 0.88). CONCLUSION Adding hand exercise to a compensatory intervention did not yield additional benefits in women with hand-related RA. The study was approved by the ethics committee 14th of April 2014 (H-3-2014-025) and registered at ClinicalTrials.gov 16th of May 2014 (NCT02140866).
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Affiliation(s)
- Karen Ellegaard
- The Parker Institute, Copenhagen University Hospital Bispebjerg and Frederiksberg, Nordre Fasanvej 57, DK-2000, Copenhagen F, Denmark.
| | - Cecilie von Bülow
- The Parker Institute, Copenhagen University Hospital Bispebjerg and Frederiksberg, Nordre Fasanvej 57, DK-2000, Copenhagen F, Denmark.,The Research Initiative for Activity Studies and Occupational Therapy, General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Alice Røpke
- Metropolitan University College, Institute for Occupational Therapy and Physiotherapy, Copenhagen, Denmark
| | - Cecilie Bartholdy
- The Parker Institute, Copenhagen University Hospital Bispebjerg and Frederiksberg, Nordre Fasanvej 57, DK-2000, Copenhagen F, Denmark.,Department of Physical and Occupational Therapy, Copenhagen University Hospital Bispebjerg and Frederiksberg, Copenhagen, Denmark
| | - Inge Skovby Hansen
- Department of Physical and Occupational Therapy, Copenhagen University Hospital Bispebjerg and Frederiksberg, Copenhagen, Denmark
| | - Signe Rifbjerg-Madsen
- The Parker Institute, Copenhagen University Hospital Bispebjerg and Frederiksberg, Nordre Fasanvej 57, DK-2000, Copenhagen F, Denmark
| | - Marius Henriksen
- The Parker Institute, Copenhagen University Hospital Bispebjerg and Frederiksberg, Nordre Fasanvej 57, DK-2000, Copenhagen F, Denmark.,Department of Physical and Occupational Therapy, Copenhagen University Hospital Bispebjerg and Frederiksberg, Copenhagen, Denmark
| | - Eva Ejlersen Wæhrens
- The Parker Institute, Copenhagen University Hospital Bispebjerg and Frederiksberg, Nordre Fasanvej 57, DK-2000, Copenhagen F, Denmark.,The Research Initiative for Activity Studies and Occupational Therapy, General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark
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Doko I, Bajić Ž, Dubravić A, Qorolli M, Grazio S. Hand grip endurance moderating the effect of grip force on functional ability and disease activity in rheumatoid arthritis patients: a cross-sectional study. Rheumatol Int 2019; 39:647-656. [PMID: 30747253 DOI: 10.1007/s00296-019-04250-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Accepted: 02/04/2019] [Indexed: 10/27/2022]
Abstract
To examine the effect of endurance on the relationship between grip force and measures of functional capacity and disease activity, we performed a cross-sectional study at the University Department of Rheumatology, Physical medicine and Rehabilitation from January 2017 to August 2018. Functional capacity of the hand was measured by ABILHAND-RA questionnaire and disease activity was assessed by the Disease Activity Score (DAS-28-CRP). All participants underwent dynamometric measurements of maximal grip force and hand grip endurance during repeated gripping. We analyzed the data from 34 RA patients at the median (IQR) age of 57 (51-61), 31 (91%) of them women, and 44 healthy participants at the age of 55 (50-59), 39 (89%) of them women. The moderating effect of endurance on the correlation between maximum grip force and the ABILHAND-RA score was not significant in healthy participants (b = 0.000, 95% CI - 0.005-0.004, p = 0.862), but it was in RA patients (b = 0.003, 95% CI 0.000-0.005, p = 0.027). In RA patients, the effect of maximum grip force on the ABILHAND-RA score increased with the increase in hand grip endurance. In RA patients, the interaction between endurance and grip force significantly explained the 15% more variance of the disease activity than main effects of these two measures, age, gender and body mass index alone. Hand grip endurance during repeated gripping affects the correlation between maximum grip force and the ABILHAND-RA score in a pattern that differs in RA patients and in the healthy population. In RA patients, hand grip endurance significantly moderates the correlation between maximum grip force and the DAS-28-CRP.
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Affiliation(s)
- Ines Doko
- University Department of Rheumatology, Physical and Rehabilitation Medicine, Clinical Hospital Centre Sestre milosrdnice, Vinogradska 29, HR-10.000, Zagreb, Croatia.
| | - Žarko Bajić
- Psychiatric Hospital "Sveti Ivan", Jankomir 11, HR-10.000, Zagreb, Croatia
| | - Amir Dubravić
- Ruđer Bošković Institute, Bijenička Cesta 54, HR-10.000, Zagreb, Croatia
| | - Merita Qorolli
- Clinic of Physical Medicine and Rehabilitation, University Clinical Centre of Kosova, Pristina, Kosovo
| | - Simeon Grazio
- University Department of Rheumatology, Physical and Rehabilitation Medicine, Clinical Hospital Centre Sestre milosrdnice, Vinogradska 29, HR-10.000, Zagreb, Croatia
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Erdinç Gündüz N, Erdem D, Kızıl R, Solmaz D, Önen F, Ellidokuz H, Gülbahar S. Is dry heat treatment (fluidotherapy) effective in improving hand function in patients with rheumatoid arthritis? A randomized controlled trial. Clin Rehabil 2018; 33:485-493. [PMID: 30450972 DOI: 10.1177/0269215518810778] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE: To evaluate the efficacy of dry heat treatment (fluidotherapy) in improving hand function in patients with rheumatoid arthritis. DESIGN: Prospective randomized controlled trial. SETTING: Departments of Physical Medicine and Rehabilitation and Rheumatology in a university hospital. SUBJECTS: Patients with rheumatoid arthritis. INTERVENTIONS: All patients were randomly divided into two groups. Group 1 underwent dry heat treatment (fluidotherapy) and Group 2 was a control group. Patients in both groups participated in a joint protection and exercise program. MAIN MEASURES: Primary outcome measures were Health Assessment Questionnaire and Duruoz Hand Index. Secondary outcome measures were pain and stiffness, Grip Ability Test, Disease Activity Score-28, and grip strength. These assessments were performed at the hospital at baseline, week 3, and week 12. RESULTS: A total of 93 participants were allocated to Group 1 ( n = 47) and Group 2 ( n = 46). The mean age of these groups was 54.19 ± 11.15 years and 53.00 ± 10.15 years, respectively ( P = 0.592). At baseline, there were no significant differences between the groups in any parameter except significantly poorer Health Assessment Questionnaire score in Group 1 ( P = 0.007). At week 3, there were no significant differences between the groups in any of the parameters ( P > 0.005). At week 12, Duruoz Hand Index scores were significantly better in Group 2 ( P = 0.039). CONCLUSION: Dry heat treatment (fluidotherapy) was not effective in improving hand function in patients with rheumatoid arthritis. Moreover, no positive effect on any other clinical parameters was observed.
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Affiliation(s)
- Nihan Erdinç Gündüz
- 1 Department of Physical Medicine and Rehabilitation, Faculty of Medicine, Dokuz Eylul University, Izmir, Turkey
| | - Didem Erdem
- 1 Department of Physical Medicine and Rehabilitation, Faculty of Medicine, Dokuz Eylul University, Izmir, Turkey
| | - Ramazan Kızıl
- 1 Department of Physical Medicine and Rehabilitation, Faculty of Medicine, Dokuz Eylul University, Izmir, Turkey
| | - Dilek Solmaz
- 2 Division of Rheumatology, Department of Internal Medicine, Faculty of Medicine, Dokuz Eylul University, Izmir, Turkey
| | - Fatoş Önen
- 2 Division of Rheumatology, Department of Internal Medicine, Faculty of Medicine, Dokuz Eylul University, Izmir, Turkey
| | - Hülya Ellidokuz
- 3 Department of Biostatistics and Medical Informatics, Faculty of Medicine, Dokuz Eylul University, Izmir, Turkey
| | - Selmin Gülbahar
- 1 Department of Physical Medicine and Rehabilitation, Faculty of Medicine, Dokuz Eylul University, Izmir, Turkey
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Williamson E, Ward L, Vadher K, Dutton SJ, Parker B, Petrou S, Hutchinson CE, Gagen R, Arden NK, Barker K, Boniface G, Bruce J, Collins G, Fairbank J, Fitch J, French DP, Garrett A, Gandhi V, Griffiths F, Hansen Z, Mallen C, Morris A, Lamb SE. Better Outcomes for Older people with Spinal Trouble (BOOST) Trial: a randomised controlled trial of a combined physical and psychological intervention for older adults with neurogenic claudication, a protocol. BMJ Open 2018; 8:e022205. [PMID: 30341124 PMCID: PMC6196848 DOI: 10.1136/bmjopen-2018-022205] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Revised: 08/21/2018] [Accepted: 08/30/2018] [Indexed: 12/23/2022] Open
Abstract
INTRODUCTION Neurogenic claudication due to spinal stenosis is common in older adults. The effectiveness of conservative interventions is not known. The aim of the study is to estimate the clinical and cost-effectiveness of a physiotherapist-delivered, combined physical and psychological intervention. METHODS AND ANALYSIS This is a pragmatic, multicentred, randomised controlled trial. Participants are randomised to a combined physical and psychological intervention (Better Outcomes for Older people with Spinal Trouble (BOOST) programme) or best practice advice (control). Community-dwelling adults, 65 years and over, with neurogenic claudication are identified from community and secondary care services. Recruitment is supplemented using a primary care-based cohort. Participants are registered prospectively and randomised in a 2:1 ratio (intervention:control) using a web-based service to ensure allocation concealment. The target sample size is a minimum of 402. The BOOST programme consists of an individual assessment and twelve 90 min classes, including education and discussion underpinned by cognitive behavioural techniques, exercises and walking circuit. During and after the classes, participants undertake home exercises and there are two support telephone calls to promote adherence with the exercises. Best practice advice is delivered in one to three individual sessions with a physiotherapist. The primary outcome is the Oswestry Disability Index at 12 months. Secondary outcomes include the 6 Minute Walk Test, Short Physical Performance Battery, Fear Avoidance Beliefs Questionnaire and Gait Self-Efficacy Scale. Outcomes are measured at 6 and 12 months by researchers who are masked to treatment allocation. The primary statistical analysis will be by 'intention to treat'. There is a parallel health economic evaluation and qualitative study. ETHICS AND DISSEMINATION Ethical approval was given on 3 March 2016 (National Research Ethics Committee number: 16/LO/0349). This protocol adheres to the Standard Protocol Items: Recommendations for Interventional Trials checklist. The results will be reported at conferences and in peer-reviewed publications using the Consolidated Standards of Reporting Trials guidelines. A plain English summary will be published on the BOOST website. TRIAL REGISTRATION NUMBER ISRCTN12698674; Pre-results.
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Affiliation(s)
- Esther Williamson
- Centre for Rehabilitation Research, Nuffield Department of Rhuematology, Orthopaedics and Musculskeletal Sciences, University of Oxford, Oxford, UK
| | - Lesley Ward
- Centre for Rehabilitation Research, Nuffield Department of Rhuematology, Orthopaedics and Musculskeletal Sciences, University of Oxford, Oxford, UK
| | - Karan Vadher
- Oxford Clinical Trials Research Unit, Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Susan J Dutton
- Oxford Clinical Trials Research Unit, Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Ben Parker
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Stavros Petrou
- Warwick Medical School, University of Warwick, Coventry, UK
| | | | - Richard Gagen
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Nigel K Arden
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Karen Barker
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- Oxford University Hospitals NHS Trust, Oxford, UK
| | - Graham Boniface
- Centre for Rehabilitation Research, Nuffield Department of Rhuematology, Orthopaedics and Musculskeletal Sciences, University of Oxford, Oxford, UK
| | - Julie Bruce
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Gary Collins
- Oxford Clinical Trials Research Unit, Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Jeremy Fairbank
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Judith Fitch
- Patient and Public Involvement Representative, Yorkshire, UK
| | - David P French
- Manchester Centre for Health Psychology, School of Health Sciences, University of Manchester, Manchester, UK
| | - Angela Garrett
- Centre for Rehabilitation Research, Nuffield Department of Rhuematology, Orthopaedics and Musculskeletal Sciences, University of Oxford, Oxford, UK
| | - Varsha Gandhi
- Centre for Rehabilitation Research, Nuffield Department of Rhuematology, Orthopaedics and Musculskeletal Sciences, University of Oxford, Oxford, UK
| | | | - Zara Hansen
- Centre for Rehabilitation Research, Nuffield Department of Rhuematology, Orthopaedics and Musculskeletal Sciences, University of Oxford, Oxford, UK
| | - Christian Mallen
- Arthritis Research UK Primary Care Centre, Institute for Primary Care and Health Sciences, Keele University, Keele, UK
| | - Alana Morris
- Centre for Rehabilitation Research, Nuffield Department of Rhuematology, Orthopaedics and Musculskeletal Sciences, University of Oxford, Oxford, UK
| | - Sarah E Lamb
- Centre for Rehabilitation Research, Nuffield Department of Rhuematology, Orthopaedics and Musculskeletal Sciences, University of Oxford, Oxford, UK
- Oxford Clinical Trials Research Unit, Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
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Björk M, Thyberg I, Valtersson E, Östlund G, Stenström B, Sverker A. Foot Barriers in Patients With Early Rheumatoid Arthritis: An Interview Study Among Swedish Women and Men. Arthritis Care Res (Hoboken) 2018; 70:1348-1354. [PMID: 29195001 DOI: 10.1002/acr.23486] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Accepted: 11/28/2017] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Foot impairments are related to reduced mobility and participation restrictions in daily activities in patients with established rheumatoid arthritis (RA). The new biologic medications are effective and reduce disease activity, but not disability to the same extent. Foot impairments are assumed to be related to participation restrictions also in patients with early RA, diagnosed after the introduction of biologic medications. Knowledge of foot impairments needs to be explored further after the introduction of biologic disease-modifying antirheumatic drugs (bDMARDs). The aim of this study was to explore the patients' perspective of foot impairments related to early RA. METHODS The sample included 59 patients (ages 20-63 years) who were interviewed about participation dilemmas in daily life using the critical incident technique. The interviews were audio-recorded and transcribed. Data related to foot impairments were extracted and analyzed thematically. A research partner validated the analysis. RESULTS Patients with early RA described a variety of participation restrictions related to foot impairments: foot hindrances in domestic life, foot impairments influencing work, leisure activities restricted by one's feet, struggling to be mobile, and foot impairments as an early sign of rheumatic disease. CONCLUSION There is a need to focus on foot impairments related to early RA, and for health care professionals to understand these signs. A suggestion for future research is to conduct a longitudinal followup of foot impairment related to medication, disease activity, and disability in patients diagnosed after the introduction of bDMARDs.
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Williams MA, Srikesavan C, Heine PJ, Bruce J, Brosseau L, Hoxey‐Thomas N, Lamb SE. Exercise for rheumatoid arthritis of the hand. Cochrane Database Syst Rev 2018; 7:CD003832. [PMID: 30063798 PMCID: PMC6513509 DOI: 10.1002/14651858.cd003832.pub3] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Rheumatoid arthritis is an inflammatory polyarthritis that frequently affects the hands and wrists. Hand exercises are prescribed to improve mobility and strength, and thereby hand function. OBJECTIVES To determine the benefits and harms of hand exercise in adults with rheumatoid arthritis. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library), MEDLINE, Embase, CINAHL, AMED, Physiotherapy Evidence Database (PEDro), OTseeker, Web of Science, ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP) up to July 2017. SELECTION CRITERIA We considered all randomised or quasi-randomised controlled trials that compared hand exercise with any non-exercise therapy. DATA COLLECTION AND ANALYSIS We used standard methodological procedures as outlined by the Cochrane Musculoskeletal Group. MAIN RESULTS We included seven studies involving 841 people (aged 20 to 94 years) in the review. Most studies used validated diagnostic criteria and involved home programmes.Very low-quality evidence (due to risk of bias and imprecision) from one study indicated uncertainty about whether exercise improves hand function in the short term (< 3 months). On a 0 to 80 points hand function test (higher scores mean better function), the exercise group (n = 11) scored 76.1 points and control group (n = 13) scored 75 points.Moderate-quality evidence (due to risk of bias) from one study indicated that exercise compared to usual care probably slightly improves hand function (mean difference (MD) 4.5, 95% confidence interval (CI) 1.58 to 7.42; n = 449) in the medium term (3 to 11 months) and in the long term (12 months or beyond) (MD 4.3, 95% CI 0.86 to 7.74; n = 438). The absolute change on a 0-to-100 hand function scale (higher scores mean better function) and number needed to treat for an additional beneficial outcome (NNTB) were 5% (95% CI 2% to 7%); 8 (95% CI 5 to 20) and 4% (95% CI 1% to 8%); 9 (95% CI 6 to 27), respectively. A 4% to 5% improvement indicates a minimal clinical benefit.Very low-quality evidence (due to risk of bias and imprecision) from two studies indicated uncertainty about whether exercise compared to no treatment improved pain (MD -27.98, 95% CI -48.93 to -7.03; n = 124) in the short term. The absolute change on a 0-to-100-millimetre scale (higher scores mean more pain) was -28% (95% CI -49% to -7%) and NNTB 2 (95% CI 2 to 11).Moderate-quality evidence (due to risk of bias) from one study indicated that there is probably little or no difference between exercise and usual care on pain in the medium (MD -2.8, 95% CI - 6.96 to 1.36; n = 445) and long term (MD -3.7, 95% CI -8.1 to 0.7; n = 437). On a 0-to-100 scale, the absolute changes were -3% (95% CI -7% to 2%) and -4% (95% CI -8% to 1%), respectively.Very low-quality evidence (due to risk of bias and imprecision) from three studies (n = 141) indicated uncertainty about whether exercise compared to no treatment improved grip strength in the short term. The standardised mean difference for the left hand was 0.44 (95% CI 0.11 to 0.78), re-expressed as 3.5 kg (95% CI 0.87 to 6.1); and for the right hand 0.46 (95% CI 0.13 to 0.8), re-expressed as 4 kg (95% CI 1.13 to 7).High-quality evidence from one study showed that exercise compared to usual care has little or no benefit on mean grip strength (in kg) of both hands in the medium term (MD 1.4, 95% CI -0.27 to 3.07; n = 400), relative change 11% (95% CI -2% to 13%); and in the long term (MD 1.2, 95% CI -0.62 to 3.02; n = 355), relative change 9% (95% CI -5% to 23%).Very low-quality evidence (due to risk of bias and imprecision) from two studies (n = 120) indicated uncertainty about whether exercise compared to no treatment improved pinch strength (in kg) in the short term. The MD and relative change for the left and right hands were 0.51 (95% CI 0.13 to 0.9) and 44% (95% CI 11% to 78%); and 0.82 (95% CI 0.43 to 1.21) and 68% (95% CI 36% to 101%).High-quality evidence from one study showed that exercise compared to usual care has little or no benefit on mean pinch strength of both hands in the medium (MD 0.3, 95% CI -0.14 to 0.74; n = 396) and long term (MD 0.4, 95% CI -0.08 to 0.88; n = 351). The relative changes were 8% (95% CI -4% to 19%) and 10% (95% CI -2% to 22%).No study evaluated the American College of Rheumatology 50 criteria.Moderate-quality evidence (due to risk of bias) from one study indicated that people who also received exercise with strategies for adherence were probably more adherent than those who received routine care alone in the medium term (risk ratio 1.31, 95% CI 1.15 to 1.48; n = 438) and NNTB 6 (95% CI 4 to 10). In the long term, the risk ratio was 1.09 (95% CI 0.93 to 1.28; n = 422).Moderate-quality evidence (due to risk of bias) from one study (n = 246) indicated no adverse events with exercising. The other six studies did not report adverse events. AUTHORS' CONCLUSIONS It is uncertain whether exercise improves hand function or pain in the short term. It probably slightly improves function but has little or no difference on pain in the medium and long term. It is uncertain whether exercise improves grip and pinch strength in the short term, and probably has little or no difference in the medium and long term. The ACR50 response is unknown. People who received exercise with adherence strategies were probably more adherent in the medium term than who did not receive exercise, but with little or no difference in the long term. Hand exercise probably does not lead to adverse events. Future research should consider hand and wrist function as their primary outcome, describe exercise following the TIDieR guidelines, and evaluate behavioural strategies.
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Affiliation(s)
- Mark A Williams
- Oxford Brookes UniversityDepartment of Sport and Health SciencesJack Straws LaneOxfordOxonUKOX3 0FL
| | - Cynthia Srikesavan
- University of OxfordNuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS)Windmill roadOxfordUKOX3 7LD
| | - Peter J Heine
- University of OxfordNuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS)Windmill roadOxfordUKOX3 7LD
| | - Julie Bruce
- University of WarwickWarwick Clinical Trials UnitGibbet Hill RdCoventryUKCV4 7AL
| | - Lucie Brosseau
- University of OttawaSchool of Rehabilitation Sciences, Faculty of Health Sciences451 Smyth RoadOttawaONCanadaK1H 8M5
| | - Nicolette Hoxey‐Thomas
- University of OxfordNuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS)Windmill roadOxfordUKOX3 7LD
| | - Sarah E Lamb
- University of OxfordNuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS)Windmill roadOxfordUKOX3 7LD
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Srikesavan C, Williamson E, Cranston T, Hunter J, Adams J, Lamb SE. An Online Hand Exercise Intervention for Adults With Rheumatoid Arthritis (mySARAH): Design, Development, and Usability Testing. J Med Internet Res 2018; 20:e10457. [PMID: 29950288 PMCID: PMC6041557 DOI: 10.2196/10457] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Revised: 04/16/2018] [Accepted: 04/24/2018] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND The Strengthening and Stretching for Rheumatoid Arthritis of the Hand (SARAH) program is a tailored, progressive 12-week exercise program for people with hand problems due to rheumatoid arthritis. The program was shown to be clinically and cost-effective in a large clinical trial and is recommended by the UK National Institute for Health and Care Excellence (NICE) guidelines for rheumatoid arthritis in adults. OBJECTIVE We have developed an online version of the SARAH program (mySARAH) to make the SARAH program widely accessible to people with rheumatoid arthritis. The purposes of this study were to develop mySARAH and to evaluate and address its usability issues. METHODS We developed mySARAH using a three-step process and gaining feedback from patient contributors. After initial development, mySARAH was tested in two iterative usability cycles in nine participants using a simplified think-aloud protocol and self-reported questionnaires. We also evaluated if participants executed the SARAH exercises correctly after watching the exercise videos included on the website. RESULTS A preliminary version of mySARAH consisting of six sessions over a 12-week period and delivered via text, exercise videos, images, exercise plan form, exercise calendar, and links to additional information on rheumatoid arthritis was developed. Five participants (1 male; 4 females; median age 64 years) and four participants (four females; median age 64.5 years) took part in the first and second usability testing cycles respectively. Usability issues identified from Cycle 1 such as having a navigation tutorial video and individualised feedback on pain levels were addressed prior to Cycle 2. The need for more instructions to complete the mySARAH patient forms was identified in Cycle 2 and was rectified. Self-reports from both cycles indicated that participants found the program useful and easy to use and were confident in performing the SARAH exercises themselves. Eight of the nine participants correctly demonstrated all the exercises. CONCLUSIONS mySARAH is the first online hand exercise intervention for people with rheumatoid arthritis. We actively involved target users in the development and usability evaluation and ensured mySARAH met their needs and preferences.
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Affiliation(s)
- Cynthia Srikesavan
- Rehabilitation Research in Oxford, Nuffield Department of Orthopedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
| | - Esther Williamson
- Rehabilitation Research in Oxford, Nuffield Department of Orthopedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
| | - Tim Cranston
- Oxford Clinical Trials Research Unit, Nuffield Department of Orthopedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Headington, Oxford, United Kingdom
| | - John Hunter
- Rehabilitation Research in Oxford, Nuffield Department of Orthopedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
| | - Jo Adams
- Centre for Innovation and Leadership in Health Sciences, Faculty of Health Sciences, University of Southampton, Southampton, United Kingdom
| | - Sarah E Lamb
- Rehabilitation Research in Oxford, Nuffield Department of Orthopedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
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Rydholm M, Book C, Wikström I, Jacobsson L, Turesson C. Course of Grip Force Impairment in Patients With Early Rheumatoid Arthritis Over the First Five Years After Diagnosis. Arthritis Care Res (Hoboken) 2018; 70:491-498. [PMID: 28692794 DOI: 10.1002/acr.23318] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Accepted: 07/06/2017] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Objective measures of function are important in rheumatoid arthritis (RA). The objective of this study was to investigate grip strength in patients with early RA. METHODS An inception cohort of 225 patients with early RA was followed in accordance with a structured protocol. Average and peak grip force values of the dominant hand (measured using a Grippit device [AB Detektor]) were evaluated and compared to expected age- and sex-specific reference values from the literature. Separate analyses were performed for those with limited self-reported disability (Health Assessment Questionnaire disability index [HAQ DI] score ≤0.5) and clinical remission (Disease Activity Score in 28 joints <2.6). RESULTS Baseline average grip force among RA patients was significantly lower than the corresponding expected value (mean 105N versus 266N; P < 0.001). Observed average and peak grip force values were significantly reduced compared to those expected in women as well as in men over time and at all time points. The average grip force improved significantly from inclusion to the 12-month visit (age-corrected mean change 34N [95% confidence interval 26-43]). At 5 years, the average grip force was still lower than that expected overall (mean 139N versus 244N; P < 0.001), and also among those with HAQ DI scores ≤0.5 and those in clinical remission. CONCLUSION Grip strength improved in early RA patients, particularly during the first year. However, it was still significantly impaired 5 years after diagnosis, even among those with limited self-reported disability and those in clinical remission. This suggests that further efforts to improve hand function are important in early RA.
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Affiliation(s)
- Maria Rydholm
- Lund University and Skåne University Hospital, Malmö, Sweden
| | | | | | - Lennart Jacobsson
- Lund University, Malmö, Sweden, and Sahlgrenska Academy at Gothenburg University, Gothenburg, Sweden
| | - Carl Turesson
- Lund University and Skåne University Hospital, Malmö, Sweden
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Srikesavan CS, Williamson E, Eldridge L, Heine P, Adams J, Cranston T, Lamb SE. A Web-Based Training Resource for Therapists to Deliver an Evidence-Based Exercise Program for Rheumatoid Arthritis of the Hand (iSARAH): Design, Development, and Usability Testing. J Med Internet Res 2017; 19:e411. [PMID: 29237581 PMCID: PMC5745347 DOI: 10.2196/jmir.8424] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Revised: 10/09/2017] [Accepted: 10/11/2017] [Indexed: 11/18/2022] Open
Abstract
Background The Strengthening and Stretching for Rheumatoid Arthritis of the Hand (SARAH) is a tailored, progressive exercise program for people having difficulties with wrist and hand function due to rheumatoid arthritis (RA). The program was evaluated in a large-scale clinical trial and was found to improve hand function, was safe to deliver, and was cost-effective. These findings led to the SARAH program being recommended in the UK National Institute for Health and Care Excellence guidelines for the management of adults with RA. To facilitate the uptake of this evidence-based program by clinicians, we proposed a Web-based training program for SARAH (iSARAH) to educate and train physiotherapists and occupational therapists on delivering the SARAH program in their practice. The overall iSARAH implementation project was guided by the 5 phases of the analysis, design, development, implementation, and evaluation (ADDIE) system design model. Objective The objective of our study was to conduct the first 3 phases of the model in the development of the iSARAH project. Methods Following publication of the trial, the SARAH program materials were made available to therapists to download from the trial website for use in clinical practice. A total of 35 therapists who downloaded these materials completed an online survey to provide feedback on practice trends in prescribing hand exercises for people with RA, perceived barriers and facilitators to using the SARAH program in clinical practice, and their preferences for the content and Web features of iSARAH. The development and design of iSARAH were further guided by a team of multidisciplinary health professionals (n=17) who took part in a half-day development meeting. We developed the preliminary version of iSARAH and tested it among therapists (n=10) to identify and rectify usability issues and to produce the final version. Results The major recommendations made by therapists and the multidisciplinary team were having a simple Web design and layout, clear exercise pictures and videos, and compatibility of iSARAH on various browsers and devices. We rectified all usability issues in the preliminary version to develop the final version of iSARAH, which included 4 short modules and additional sections on self-assessment, frequently asked questions, and a resource library. Conclusions The use of the ADDIE design model and engagement of end users in the development and evaluation phases have rendered iSARAH a convenient, easy-to-use, and effective Web-based learning resource for therapists on how to deliver the SARAH program. There is also huge potential for adapting iSARAH across different cultures and languages, thus opening more opportunities for wider uptake and application of the SARAH program into practice.
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Affiliation(s)
- Cynthia Swarnalatha Srikesavan
- Centre for Rehabilitation Research in Oxford, Botnar Research Centre, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
| | - Esther Williamson
- Centre for Rehabilitation Research in Oxford, Botnar Research Centre, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
| | - Lucy Eldridge
- Oxford Clinical Trials Research Unit, Botnar Research Centre, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
| | - Peter Heine
- Centre for Rehabilitation Research in Oxford, Botnar Research Centre, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
| | - Jo Adams
- Centre for Innovation and Leadership in Health Sciences, University of Southampton, Southampton, United Kingdom
| | - Tim Cranston
- Oxford Clinical Trials Research Unit, Botnar Research Centre, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
| | - Sarah E Lamb
- Centre for Rehabilitation Research in Oxford, Botnar Research Centre, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
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Kojima T, Ishikawa H, Tanaka S, Haga N, Nishida K, Yukioka M, Hashimoto J, Miyahara H, Niki Y, Kimura T, Oda H, Asai S, Funahashi K, Kojima M, Ishiguro N. Validation and reliability of the Timed Up and Go test for measuring objective functional impairment in patients with long-standing rheumatoid arthritis: a cross-sectional study. Int J Rheum Dis 2017; 21:1793-1800. [DOI: 10.1111/1756-185x.13237] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Toshihisa Kojima
- Department of Orthopedic Surgery; Nagoya University Hospital; Nagoya Japan
| | - Hajime Ishikawa
- Department of Rheumatology; Niigata Rheumatic Center; Niigata Japan
| | - Sakae Tanaka
- Department of Orthopaedic Surgery; Faculty of Medicine; The University of Tokyo Hospital; Tokyo Japan
| | - Nobuhiko Haga
- Department of Rehabilitation Medicine; The University of Tokyo Hospital; Tokyo Japan
| | - Keiichiro Nishida
- Department of Orthopedic Surgery; Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences; Okayama Japan
| | - Masao Yukioka
- Department of Orthopedic Surgery; Yukioka Hospital; Osaka Japan
| | - Jun Hashimoto
- Department of Rheumatology; National Hospital Organization Osaka Minami Medical Center; Kawachinagano Japan
| | - Hisaaki Miyahara
- Department of Orthopedic Surgery; National Hospital Organization Kyushu Medical Center; Fukuoka Japan
| | - Yasuo Niki
- Department of Orthopedic Surgery; Keio University School of Medicine; Tokyo Japan
| | - Tomoatsu Kimura
- Department of Orthopedic Surgery; Faculty of Medicine; University of Toyama; Toyama Japan
| | - Hiromi Oda
- Department of Orthopedic Surgery; Saitama Medical University; Morohongo, Moroyama Japan
| | - Shuji Asai
- Department of Orthopedic Surgery; Nagoya University Hospital; Nagoya Japan
| | - Koji Funahashi
- Department of Orthopedic Surgery; Kariya-Toyota General Hospital; Kariya Japan
| | - Masayo Kojima
- Department of Medical Education; Nagoya City University Graduate School of Medical Sciences; Nagoya Japan
| | - Naoki Ishiguro
- Department of Orthopedic Surgery; Nagoya University Hospital; Nagoya Japan
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Lee H, Lamb SE. Advancing Physical Therapist Interventions by Investigating Causal Mechanisms. Phys Ther 2017; 97:1119-1121. [PMID: 29121341 DOI: 10.1093/ptj/pzx095] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2017] [Accepted: 09/07/2017] [Indexed: 11/14/2022]
Affiliation(s)
- Hopin Lee
- H. Lee, PhD, Centre for Statistics in Medicine, Nuffield Department of Orthopaedics Rheumatology and Musculoskeletal Sciences, University of Oxford, Windmill Road, Headington, Oxford, UK OX3 7LD, and School of Medicine and Public Health, University of Newcastle, New South Wales, Australia
| | - Sarah E Lamb
- S.E. Lamb, MSc, MA, MCSP, Grad Dip Statistics, DPhil, Centre for Statistics in Medicine, Nuffield Department of Orthopaedics Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford
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Randomized feasibility trial of the Scleroderma Patient-centered Intervention Network hand exercise program (SPIN-HAND): Study protocol. JOURNAL OF SCLERODERMA AND RELATED DISORDERS 2017; 3:91-97. [DOI: 10.5301/jsrd.5000263] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Accepted: 10/16/2017] [Indexed: 11/20/2022]
Abstract
Background: Significant functional impairment of the hands is nearly universal in systemic sclerosis (SSc, scleroderma). Hand exercises may improve hand function, but developing, testing and disseminating rehabilitation interventions in SSc is challenging. The Scleroderma Patient-centered Intervention Network (SPIN) was established to address this issue and has developed an online hand exercise program to improve hand function for SSc patients (SPIN-HAND). The aim of the proposed feasibility trial is to evaluate the feasibility of conducting a full-scale randomized controlled trial (RCT) of the SPIN-HAND intervention. Design and methods: The SPIN-HAND feasibility trial will be conducted via the SPIN Cohort. The SPIN Cohort was developed as a framework for embedded pragmatic trials using the cohort multiple RCT design. In total, 40 English-speaking SPIN Cohort participants with at least mild hand function limitations (Cochin Hand Function Scale ≥3) and an indicated interest in using an online hand-exercise intervention will be randomized with a 1:1 ratio to be offered to use the SPIN-HAND program or usual care for 3 months. The primary aim is to evaluate the trial implementation processes, required resources and management, scientific aspects, and participant acceptability and usage of the SPIN-HAND program. Discussion: The SPIN-HAND exercise program is a self-help tool that may improve hand function in patients with SSc. The SPIN-HAND feasibility trial will ensure that trial methodology is robust, feasible, and consistent with trial participant expectations. The results will guide adjustments that need to be implemented before undertaking a full-scale RCT of the SPIN-HAND program. Trial registration: ClinicalTrials.gov Identifier: NCT03092024.
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Kojima T, Ishikawa H, Tanaka S, Haga N, Nishida K, Yukioka M, Hashimoto J, Miyahara H, Niki Y, Kimura T, Oda H, Asai S, Funahashi K, Kojima M, Ishiguro N. Characteristics of functional impairment in patients with long-standing rheumatoid arthritis based on range of motion of joints: Baseline data from a multicenter prospective observational cohort study to evaluate the effectiveness of joint surgery in the treat-to-target era. Mod Rheumatol 2017; 28:474-481. [PMID: 28741973 DOI: 10.1080/14397595.2017.1349593] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVE To explore the characteristics of functional impairment in patients with established rheumatoid arthritis (RA) based on the range of motion (ROM) of joints in a prospective observational study of RA patients undergoing joint surgery. METHODS We collected data on demographics, Health Assessment Questionnaire Disability Index (HAQ-DI), and the ROM of large joints including the shoulder, elbow, wrist, hip, knee, and ankle. Associations between the ROM of each joint and disability in the eight HAQ-DI categories were determined using receiver operating characteristic (ROC) and logistic regression analyses. ROM cut-off values of each joint for the absence of disability in each HAQ-DI category were determined using ROC curves. RESULTS A total of 460 patients were enrolled and analyzed in this study. Based on ROC analysis, the ROM of each joint was significantly associated with disability in each category. After adjusting for disease activity, age, and sex, shoulder abduction had the highest independent impact on disability in activity [cut-off: 139 degrees (OR: 5.26)], elbow flexion-extension in dressing [121 degrees (OR: 2.22)], wrist flexion-extension in reach [86 degrees (OR: 2.71)], hip flexion-extension in walking [126 degrees (OR: 3.42)], and knee flexion-extension in walking [134 degrees (OR: 2.97)]. CONCLUSIONS Limited ROM of multiple joints was significantly associated with functional impairment in patients with long-standing RA. Motion in daily activity involves multiple joints, and at least two joints were independently involved in disability.
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Affiliation(s)
- Toshihisa Kojima
- a Department of Orthopedic Surgery , Nagoya University Hospital , Nagoya , Japan
| | - Hajime Ishikawa
- b Department of Orthopedic Surgery , Niigata Rheumatic Center , Niigata , Japan
| | - Sakae Tanaka
- c Department of Orthopaedic Surgery, Faculty of Medicine , The University of Tokyo , Tokyo , Japan
| | - Nobuhiko Haga
- d Department of Rehabilitation Medicine , The University of Tokyo Hospital , Tokyo , Japan
| | - Keiichiro Nishida
- e Department of Human Morphology , Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences , Okayama , Japan
| | - Masao Yukioka
- f Department of Orthopedic Surgery , Yukioka Hospital , Osaka , Japan
| | - Jun Hashimoto
- g Department of Rheumatology , National Hospital Organization Osaka Minami Medical Centre , Kawachinagano , Japan
| | - Hisaaki Miyahara
- h Orthopedic Surgery , National Hospital Organization Kyushu Medical Centre , Fukuoka , Japan
| | - Yasuo Niki
- i Department of Orthopedic Surgery , Keio University School of Medicine , Tokyo , Japan
| | - Tomoatsu Kimura
- j Department of Orthopedic Surgery, Faculty of Medicine , University of Toyama , Toyama , Japan
| | - Hiromi Oda
- k Department of Orthopedic Surgery , Saitama Medical University , Moroyama , Japan
| | - Shuji Asai
- a Department of Orthopedic Surgery , Nagoya University Hospital , Nagoya , Japan
| | - Koji Funahashi
- a Department of Orthopedic Surgery , Nagoya University Hospital , Nagoya , Japan
| | - Masayo Kojima
- l Department of Medical Education , Nagoya City University Graduate School of Medical Sciences , Nagoya , Japan
| | - Naoki Ishiguro
- a Department of Orthopedic Surgery , Nagoya University Hospital , Nagoya , Japan
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Hopewell S, Keene DJ, Maia Schlüssel M, Dritsaki M, Dutton S, Carr A, Hamilton W, Hansen Z, Jaggi A, Littlewood C, Soutakbar H, Heine P, Cureton L, Barker K, Lamb SE. Clinical and cost-effectiveness of progressive exercise compared with best practice advice, with or without corticosteroid injection, for the treatment of rotator cuff disorders: protocol for a 2x2 factorial randomised controlled trial (the GRASP trial). BMJ Open 2017; 7:e018004. [PMID: 28716796 PMCID: PMC5683303 DOI: 10.1136/bmjopen-2017-018004] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
INTRODUCTION Shoulder pain is very common, with around 70% of cases due to disorders of the rotator cuff. Despite widespread provision of physiotherapy, there is uncertainty about which type of exercise and delivery mechanisms are associated with best outcomes. There is also uncertainty around the long-term benefits and harms of corticosteroid injection therapy, which is often used in addition to physiotherapy. The Getting it Right: Addressing Shoulder Pain trial will assess the clinical and cost-effectiveness of individually tailored, progressive exercise compared with best practice advice, with or without corticosteroid injection, in adults with a rotator cuff disorder. METHODS AND ANALYSIS We are conducting a large multicentre randomised controlled trial (2×2 factorial design). We will recruit adults ≥18 years with a new episode of shoulder pain attributable to a rotator cuff disorder as per British Elbow and Shoulder Society guidelines, not currently receiving physiotherapy or being considered for surgery, from at least eight UK National Health Service primary care-based musculoskeletal and related physiotherapy services. Participants (n=704) will be randomised (centralised computer-generated 1:1:1:1 allocation ratio) to one of four interventions: (1) progressive exercise (≤6 physiotherapy sessions); (2) best practice advice (one physiotherapy session); (3) corticosteroid injection then progressive exercise (≤6 sessions) or (4) corticosteroid injection then best practice advice (one session). The primary outcome is the mean difference in Shoulder Pain and Disability Index (SPADI) total score at 12 months. Secondary outcomes are: pain and function SPADI subdomains; health-related quality of life (Five-Level version of the EuroQol EQ-5D-5L); sleep disturbance; return to activity; global impression of change; health resource use; out-of-pocket expenses; work disability. A parallel within-trial economic evaluation will be conducted. The primary analysis will be intention to treat. ETHICS AND DISSEMINATION Research Ethics Committee approval (REC: 16/SC/0508) has been obtained. Results of the main trial and secondary outcomes will be submitted for publication in a peer-reviewed journal. TRIAL REGISTRATION NUMBER ISRCTN16539266; EudraCT number: 2016-002991-28.
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Affiliation(s)
- Sally Hopewell
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - David J Keene
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Michael Maia Schlüssel
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Melina Dritsaki
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Susan Dutton
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Andrew Carr
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | | | - Zara Hansen
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Anju Jaggi
- Royal National Orthopaedic Hospital NHS Trust, Stanmore, Middlesex, UK
| | | | - Hessam Soutakbar
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Peter Heine
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Lucy Cureton
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Karen Barker
- Oxford University Hospitals NHS Trust, Oxford, UK
| | - Sarah E Lamb
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
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72
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Hall AM, Copsey B, Williams M, Srikesavan C, Lamb SE. Mediating Effect of Changes in Hand Impairments on Hand Function in Patients With Rheumatoid Arthritis: Exploring the Mechanisms of an Effective Exercise Program. Arthritis Care Res (Hoboken) 2017; 69:982-988. [PMID: 27696750 DOI: 10.1002/acr.23093] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2016] [Revised: 08/15/2016] [Accepted: 09/13/2016] [Indexed: 11/12/2022]
Abstract
OBJECTIVE To determine whether the effect of the Strengthening and Stretching for Rheumatoid Arthritis of the Hand (SARAH) exercise program on hand function was mediated by changes in the proposed active ingredients: strength, dexterity, and/or range of motion. METHODS The SARAH intervention included exercises hypothesized to improve potential mediators of grip strength, pinch strength, wrist flexion, wrist extension, finger flexion, finger extension, thumb opposition, and dexterity, which would theoretically improve self-reported hand function. All variables were measured at baseline and at 4 and 12 months. Structural equation modeling was used to assess mediation on change in hand function via change in potential mediators. RESULTS Change in grip strength partially mediated change in hand function. Grip strength mediated 19.4% (95% confidence interval 0.9%, 37.8%) of the treatment effect. CONCLUSION Improvements in grip strength at 4 months are likely to mediate improved hand function at 12 months. The role of joint mobility exercises is less clear and is likely influenced by the choice of measurement tools for both mobility and function outcomes. More robust measurements of wrist and hand mobility for patients with rheumatoid arthritis may be necessary to determine the relationship between this variable and self-reported hand function. Using a large trial data set, we have demonstrated that techniques used to target grip strength are key active ingredients of the SARAH exercise program and mediate its effect.
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Affiliation(s)
- Amanda M Hall
- University of Oxford, England, UK, and Memorial University, Newfoundland, Canada
| | | | - Mark Williams
- University of Oxford and Oxford Brookes University, England, UK
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Ng JL, Kersh ME, Kilbreath S, Knothe Tate M. Establishing the Basis for Mechanobiology-Based Physical Therapy Protocols to Potentiate Cellular Healing and Tissue Regeneration. Front Physiol 2017; 8:303. [PMID: 28634452 PMCID: PMC5460618 DOI: 10.3389/fphys.2017.00303] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2016] [Accepted: 04/27/2017] [Indexed: 12/17/2022] Open
Abstract
Life is mechanobiological: mechanical stimuli play a pivotal role in the formation of structurally and functionally appropriate body templates through mechanobiologically-driven cellular and tissue re/modeling. The body responds to mechanical stimuli engendered through physical movement in an integrated fashion, internalizing and transferring forces from organ, through tissue and cellular length scales. In the context of rehabilitation and therapeutic outcomes, such mechanical stimuli are referred to as mechanotherapy. Physical therapists use mechanotherapy and mechanical interventions, e.g., exercise therapy and manual mobilizations, to restore function and treat disease and/or injury. While the effect of directed movement, such as in physical therapy, is well documented at the length scale of the body and its organs, a number of recent studies implicate its integral effect in modulating cellular behavior and subsequent tissue adaptation. Yet the link between movement biomechanics, physical therapy, and subsequent cellular and tissue mechanoadaptation is not well established in the literature. Here we review mechanoadaptation in the context of physical therapy, from organ to cell scale mechanotransduction and cell to organ scale extracellular matrix genesis and re/modeling. We suggest that physical therapy can be developed to harness the mechanosensitivity of cells and tissues, enabling prescriptive definition of physical and mechanical interventions to enhance tissue genesis, healing, and rehabilitation.
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Affiliation(s)
- Joanna L. Ng
- Graduate School of Biomedical Engineering, University of New South WalesSydney, NSW, Australia
| | - Mariana E. Kersh
- Department of Mechanical Science and Engineering, University of Illinois at Urbana-ChampaignChampaign, IL, United States
| | - Sharon Kilbreath
- Faculty of Health Sciences, University of SydneySydney, NSW, Australia
| | - M. Knothe Tate
- Graduate School of Biomedical Engineering, University of New South WalesSydney, NSW, Australia
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Prior Y, Sutton C, Cotterill S, Adams J, Camacho E, Arafin N, Firth J, O'Neill T, Hough Y, Jones W, Hammond A. The effects of arthritis gloves on people with Rheumatoid Arthritis or Inflammatory Arthritis with hand pain: a study protocol for a multi-centre randomised controlled trial (the A-GLOVES trial). BMC Musculoskelet Disord 2017; 18:224. [PMID: 28558734 PMCID: PMC5450242 DOI: 10.1186/s12891-017-1583-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Accepted: 05/15/2017] [Indexed: 12/03/2022] Open
Abstract
Background Arthritis gloves are regularly provided as part of the management of people with rheumatoid arthritis (RA) and undifferentiated (early) inflammatory arthritis (IA). Usually made of nylon and elastane (i.e. Lycra®), these arthritis gloves apply pressure with the aims of relieving hand pain, stiffness and improving hand function. However, a systematic review identified little evidence supporting their use. We therefore designed a trial to compare the effectiveness of the commonest type of arthritis glove provided in the United Kingdom (Isotoner gloves) (intervention) with placebo (control) gloves (i.e. larger arthritis gloves providing similar warmth to the intervention gloves but minimal pressure only) in people with these conditions. Methods Participants aged 18 years and over with RA or IA and persistent hand pain will be recruited from National Health Service Trusts in the United Kingdom. Following consent, participants will complete a questionnaire booklet, then be randomly allocated to receive intervention or placebo arthritis gloves. Within three weeks, they will be fitted with the allocated gloves by clinical specialist rheumatology occupational therapists. Twelve weeks (i.e. the primary endpoint) after completing the baseline questionnaire, participants will complete a second questionnaire, including the same measures plus additional questions to explore adherence, benefits and problems with glove-wear. A sub-sample of participants from each group will be interviewed at the end of their participation to explore their views of the gloves received. The clinical effectiveness and cost-effectiveness of the intervention, compared to placebo gloves, will be evaluated over 12 weeks. The primary outcome measure is hand pain during activity. Qualitative interviews will be thematically analysed. Discussion This study will evaluate the commonest type of arthritis glove (Isotoner) provided in the NHS (i.e. the intervention) compared to a placebo glove. The results will help occupational therapists, occupational therapy services and people with arthritis make informed choices as to the value of arthritis gloves. If effective, arthritis gloves should become more widely available in the NHS to help people with RA and IA manage hand symptoms and improve performance of daily activities, work and leisure. If not, services can determine whether to cease supplying these to reduce service costs. Trial registration ISRCTN Registry: ISRCTN25892131 Registered 05/09/2016 Electronic supplementary material The online version of this article (doi:10.1186/s12891-017-1583-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Yeliz Prior
- Centre for Health Sciences Research (OT), University of Salford, Frederick Road, L701 Allerton Building, Salford, Greater Manchester, M6 6PU, UK.,Mid Cheshire NHS Trust, Leighton Hospital, Leighton, Crewe, UK
| | - Chris Sutton
- Lancashire Clinical Trials Unit, UCLAN, Preston, UK
| | - Sarah Cotterill
- Centre for Biostatistics, School of Health Sciences, University of Manchester, Manchester, UK
| | - Jo Adams
- Health Sciences, University of Southampton, Southampton, UK
| | - Elizabeth Camacho
- Centre for Health Economics, Division of Population Health, Health Services Research, and Primary Care, School of Health Sciences, University of Manchester, Manchester, UK
| | - Nazina Arafin
- Centre for Health Sciences Research (OT), University of Salford, Frederick Road, L701 Allerton Building, Salford, Greater Manchester, M6 6PU, UK
| | - Jill Firth
- Pennine Musculoskeletal Partnership Ltd, Oldham, UK
| | - Terence O'Neill
- Arthritis Research UK Centre for Epidemiology, University of Manchester & NIHR Manchester Musculoskeletal Biomedical Research Unit, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Sciences Centre, Manchester, UK
| | - Yvonne Hough
- St Helens and Knowsley Teaching Hospitals NHS Trust, St Helens Hospital, St Helens, UK
| | | | - Alison Hammond
- Centre for Health Sciences Research (OT), University of Salford, Frederick Road, L701 Allerton Building, Salford, Greater Manchester, M6 6PU, UK.
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Williamson E, McConkey C, Heine P, Dosanjh S, Williams M, Lamb SE. Hand exercises for patients with rheumatoid arthritis: an extended follow-up of the SARAH randomised controlled trial. BMJ Open 2017; 7:e013121. [PMID: 28404610 PMCID: PMC5775458 DOI: 10.1136/bmjopen-2016-013121] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVES The Stretching And strengthening for Rheumatoid Arthritis of the Hand (SARAH) randomised controlled trial evaluated the effectiveness of a hand exercise programme and demonstrated it was clinically effective and cost-effective at 12 months. The aim of this extended follow-up was to evaluate the effects of the SARAH programme beyond 12 months. METHODS Using postal questionnaires, we collected the Michigan Hand Questionnaire hand function (primary outcome), activities of daily living and work subscales, pain troublesomeness, self-efficacy and health-related quality of life. All participants were asked how often they performed hand exercises for their rheumatoid arthritis. Mean difference in hand function scores were analysed by a linear model, adjusted for baseline score. RESULTS Two-thirds (n=328/490, 67%) of the original cohort provided data for the extended follow-up. The mean follow-up time was 26 months (range 19-40 months).There was no difference in change in hand function scores between the two groups at extended follow-up (mean difference (95% CI) 1.52 (-1.71 to 4.76)). However, exercise group participants were still significantly improved compared with baseline (p=0.0014) unlike the best practice usual care group (p=0.1122). Self-reported performance of hand exercises had reduced substantially. CONCLUSIONS Participants undertaking the SARAH exercise programme had improved hand function compared with baseline >2 years after randomisation. This was not the case for the control group. However, scores were no longer statistically different between the groups indicating the effect of the programme had diminished over time. This reduction in hand function compared with earlier follow-up points coincided with a reduction in self-reported performance of hand exercises. Further intervention to promote long-term adherence may be warranted. TRIAL REGISTRATION NUMBER ISRCTN89936343; Results.
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Affiliation(s)
- Esther Williamson
- Centre for Rehabilitation Research, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
| | | | - Peter Heine
- Centre for Rehabilitation Research, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
| | - Sukhdeep Dosanjh
- Clinical Trials Unit, University of Warwick, Coventry, United Kingdom
| | - Mark Williams
- Department of Sports and Health Sciences, Oxford Brookes University, Oxford, United Kingdom
| | - Sarah E Lamb
- Centre for Rehabilitation Research, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
- Clinical Trials Unit, University of Warwick, Coventry, United Kingdom
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Dritsaki M, Petrou S, Williams M, Lamb SE. An empirical evaluation of the SF-12, SF-6D, EQ-5D and Michigan Hand Outcome Questionnaire in patients with rheumatoid arthritis of the hand. Health Qual Life Outcomes 2017; 15:20. [PMID: 28118833 PMCID: PMC5259980 DOI: 10.1186/s12955-016-0584-6] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2016] [Accepted: 12/29/2016] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND The aim of this study was to assess the psychometric properties, namely acceptability, validity, reliability, interpretability and responsiveness of the EuroQol EQ-5D (EQ-5D visual analogue (VAS) and EQ-5D (utility)), Short Form 12 Dimensions (SF-12), SF-6D and Michigan Hand Outcome Questionnaire (MHQ) in patients with rheumatoid arthritis (RA) of the hand. METHODS The empirical investigation was based upon data from a randomised controlled trial of 488 adults with rheumatoid arthritis who had pain and dysfunction of the hands and/or wrists. Participants completed the EQ-5D, SF-12 and MHQ at baseline and at 4 and 12 months follow up. Acceptability was measured using completion rates over time; construct validity using the "known groups" approach, based on pain troublesomeness; convergent validity using spearman's rho correlation (ρ); reliability using internal consistency (Cronbach's alpha); interpretability using minimal important differences (MID); and responsiveness using effect sizes and standardised response means (SRM) stratified by level of self-rated improvement in hand and wrist function or level of self-rated benefit and satisfaction from trial treatments. RESULTS At baseline, the study population had a mean age of 62.4 years, a mean MHQ score of 52.1 and included 76% women. The EQ-5D (utility) had the highest completion rates across time points. All instruments discriminated between pre-specified groups based on pain troublesomeness. Convergent validity analysis indicated that the MHQ score correlated strongly with the EQ-5D (ρ = 0.65) and SF-6D (ρ = 0.63) utility scores. The MHQ was most responsive at detecting change in indicators of RA pain severity between baseline and 4 months, whilst minimal important differences varied considerably across PROMs. CONCLUSIONS The instruments evaluated in this study displayed varying psychometric properties in the context of RA of the hand. The selection of a preferred instrument in evaluative studies should ultimately depend on the relative importance placed on individual psychometric properties and the importance placed on generation of health utilities for economic evaluation purposes.
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Affiliation(s)
- Melina Dritsaki
- Nuffield Department of Orthopaedic Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK.
| | - Stavros Petrou
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Mark Williams
- Department of Sport and Health Sciences, Oxford Brookes University, Oxford, UK
| | - Sarah E Lamb
- Nuffield Department of Orthopaedic Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
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Roberts S, Ramklass S, Joubert R. Kinesio Taping ® of the metacarpophalangeal joints and its effect on pain and hand function in individuals with rheumatoid arthritis. SOUTH AFRICAN JOURNAL OF PHYSIOTHERAPY 2016; 72:314. [PMID: 30135891 PMCID: PMC6093141 DOI: 10.4102/sajp.v72i1.314] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2016] [Accepted: 08/30/2016] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND In persons suffering from rheumatoid arthritis (RA), the metacarpophalangeal (MCP) joints are commonly affected, resulting in inflammation, pain, joint instability, diminished grip strength and difficulties with function. However, the effectiveness of Kinesio Taping® of the MCP joints in alleviating the symptoms has not been established. AIM To determine the effectiveness of bilateral Kinesio Taping® of the MCP joints on pain, range of motion, grip strength and hand function in elderly individuals previously diagnosed with RA. METHODS A repeated measure, experimental design was used over a 7-week period with the Kinesio Taping group (n = 30) receiving bilateral space correction Kinesio Taping® of the MCP joints with a joint protection (JP) group (n = 31) participating in JP workshops. The Kinesio Tape® was worn for 3 days a week with four applications during the data collection process. For the control group, 2-hour JP educational-behavioural workshops were run weekly for 4 weeks. Weekly assessments were completed for grip strength, ulnar deviation and pain (VAS), and two pre-intervention assessments and one post-intervention assessment was completed for the Michigan Hands Outcomes Questionnaire (MHQ). RESULTS Kinesio Taping® of the MCP joints showed a significant decrease in pain (p = 0.001) and improved range of motion (p = 0.001 bilaterally). JP was found to have a significant improvement in grip strength (p = 0.001 bilaterally) and in the work (p = 0.01) and activities of daily living (ADL) (p = 0.01) sections of the MHQ. No significant difference was found between groups after intervention in the majority of outcomes (p = 0.24) except for grip strength where a significant difference was found. CONCLUSION Kinesio Taping® of the MCP joints is an effective conservative intervention to improve pain and MCP ulnar deviation in individuals with RA.Significance of the work: Kinesio Taping® of the MCP joints of individuals with RA showed a significant decrease in pain (p = 0.00) and improved range of motion (p = 0.001 bilaterally). JP was found to significantly improve grip strength (p = 0.001 bilaterally) and in the work (p = 0.01) and ADL (p = 0.01) sections of the MHQ. No significant difference was found between groups after intervention in the majority of outcomes (p = 0.24) except for grip strength where a significant difference was found (p = 0.001).
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Affiliation(s)
| | - Serela Ramklass
- School of Clinical Medicine, University of KwaZulu-Natal, South Africa
| | - Robin Joubert
- Department of Occupational Theraphy, University of Kwa-Zulu Natal, South Africa
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Srikesavan CS, Shay B, Szturm T. Task-Oriented Training with Computer Games for People with Rheumatoid Arthritis or Hand Osteoarthritis: A Feasibility Randomized Controlled Trial. Games Health J 2016; 5:295-303. [DOI: 10.1089/g4h.2016.0005] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Cynthia Swarnalatha Srikesavan
- Centre for Rehabilitation Research in Oxford (RRIO), Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford, United Kingdom
| | - Barbara Shay
- Department of Physical Therapy, College of Rehabilitation Sciences, University of Manitoba, Winnipeg, Canada
| | - Tony Szturm
- Department of Physical Therapy, College of Rehabilitation Sciences, University of Manitoba, Winnipeg, Canada
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79
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Hammond A, Prior Y. The effectiveness of home hand exercise programmes in rheumatoid arthritis: a systematic review. Br Med Bull 2016; 119:49-62. [PMID: 27365455 DOI: 10.1093/bmb/ldw024] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/03/2016] [Indexed: 11/13/2022]
Abstract
INTRODUCTION Rheumatoid arthritis (RA) commonly reduces hand function. We systematically reviewed trials to investigate effects of home hand exercise programmes on hand symptoms and function in RA. SOURCES OF DATA We searched: Medline (1946-), AMED, CINAHL, Physiotherapy Evidence Database, OT Seeker, the Cochrane Library, ISI Web of Science from inception to January 2016. AREAS OF AGREEMENT Nineteen trials were evaluated. Only three were randomized controlled trials with a low risk of bias (n = 665). Significant short-term improvements occurred in hand function, pain and grip strength, with long-term improvements in hand and upper limb function and pinch strength. AREAS OF CONTROVERSY Heterogeneity of outcome measures meant meta-analysis was not possible. GROWING POINTS Evaluation of low and moderate risk of bias trials indicated high-intensity home hand exercise programmes led to better short-term outcomes than low-intensity programmes. Such programmes are cost-effective. AREAS TIMELY FOR DEVELOPING RESEARCH Further research is required to evaluate methods of helping people with RA maintain long-term home hand exercise.
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Affiliation(s)
- Alison Hammond
- Centre for Health Sciences Research, University of Salford, Salford, UK
| | - Yeliz Prior
- Centre for Health Sciences Research, University of Salford, Salford, UK
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Nichols VP, Williamson E, Toye F, Lamb SE. A longitudinal, qualitative study exploring sustained adherence to a hand exercise programme for rheumatoid arthritis evaluated in the SARAH trial. Disabil Rehabil 2016; 39:1856-1863. [PMID: 27558097 DOI: 10.1080/09638288.2016.1212111] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
PURPOSE This study explores the experience of participants taking part in a hand exercise programme for people with rheumatoid arthritis with a focus on adherence. The exercise programme was tested in a randomised controlled trial. This parallel qualitative study will inform future implementation into clinical practice. METHOD Twenty-seven semi-structured interviews from 14 participants were undertaken at two time points (4 and 12 months after randomisation). We collected data of participants' experiences over time. This was guided by an interview schedule. Interview data were analysed using interpretative phenomenological analysis which is informed by phenomenological and hermeneutic theory. We recruited participants from National Health Service rheumatology and therapy departments. RESULTS At 4 months, 11/14 participants reported continuing with the exercises. By 12 months, 7/13 participants still reported exercising. The ability to establish a routine determined whether participants adhered to the exercise programme. This was sometimes influenced by practical issues. We also identified facilitators and barriers to regular exercise in the themes of the following: the therapeutic encounter, perceived benefit of exercises, attitude of mind, confidence, and unpredictability. CONCLUSIONS Establishing a routine was an important step towards participants being able to exercise independently. Therapists provided participants with skills to continue to exercise while dealing with changes in symptoms and schedules. Potential barriers to long-term exercise adherence need to be taken into account and addressed for successful implementation of this programme. Implications for Rehabilitation Behavioural change components such as the use of an exercise planner (stating intentions of where, when and how), daily diary sheets, and joint goal setting enhance adherence to a hand exercise programme for RA by helping to establish routines. Exercise routines need to be flexible enough to fit in with life and symptom changes whilst delivering a sufficient dosage. Therapists facilitate this process by using behavioural components alongside more commonly used aspects of care (assessment, education, advice, and encouragement) to enable people with RA to become independent exercisers.
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Affiliation(s)
- Vivien P Nichols
- a Warwick Clinical Trials Unit, Division of Health Sciences, Warwick Medical School, University of Warwick , Coventry , UK
| | - Esther Williamson
- b Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences , University of Oxford , Oxford , UK
| | - Francine Toye
- c Physiotherapy Research Unit , Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Trust , Oxford , UK
| | - Sarah E Lamb
- a Warwick Clinical Trials Unit, Division of Health Sciences, Warwick Medical School, University of Warwick , Coventry , UK.,b Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences , University of Oxford , Oxford , UK
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Rome K, Clark H, Gray J, McMeekin P, Plant M, Dixon J. Clinical effectiveness and cost-effectiveness of foot orthoses for people with established rheumatoid arthritis: an exploratory clinical trial. Scand J Rheumatol 2016; 46:187-193. [PMID: 27466000 DOI: 10.1080/03009742.2016.1196500] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVES Foot orthoses are commonly prescribed as an intervention for people with rheumatoid arthritis (RA). Data relating to the cost-effectiveness of foot orthoses in people with RA are limited. The aim was to evaluate the clinical and cost-effectiveness of two types of foot orthoses in people with established RA. METHOD A single-blind randomized controlled trial was undertaken to compare custom-made foot orthoses (CMFOs) and simple insoles (SIs) in 41 people with established RA. The Foot Function Index (FFI) was used to measure foot pain, disability, and functional limitation. Costs were estimated from the perspective of the UK National Health Service (NHS), societal (patient and family) perspective, and secondary care resource use in terms of the intervention and staff time. Effects were assessed in terms of health gain expressed as quality-adjusted life years (QALYs). RESULTS At baseline, 20 participants received a CMFO and 21 participants received an SI. After 16 weeks foot pain improved in both the CMFOs (p = 0.000) and the SIs (p < 0.01). However, disability scores improved for CMFOs (p < 0.001) but not for SIs (p = 0.40). The cost-effectiveness results demonstrated no difference in cost between the arms (CMFOs: £159.10; SIs: £79.10; p = 0.35), with the CMFOs being less effective in terms of cost per QALY gain (p < 0.001). CONCLUSIONS In people with established RA, semi-rigid customized foot orthoses can improve pain and disability scores in comparison to simple insoles. From a cost-effectiveness perspective, the customized foot orthoses were far more expensive to manufacture, with no significant cost per QALY gain.
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Affiliation(s)
- K Rome
- a Rehabilitation and Research Institute, School of Podiatry , AUT University , Auckland , New Zealand
| | - H Clark
- b Podiatry Department , South Tees Hospitals NHS Foundation Trust , Middlesbrough , UK
| | - J Gray
- c Department of Public Health and Wellbeing , Northumbria University , Newcastle upon Tyne , UK
| | - P McMeekin
- c Department of Public Health and Wellbeing , Northumbria University , Newcastle upon Tyne , UK
| | - M Plant
- d Rheumatology Department , South Tees Hospitals NHS Foundation Trust , Middlesbrough , UK
| | - J Dixon
- e Health and Social Care Institute , Teesside University , Middlesbrough , UK
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Adams J. Being useful: Why clear, understandable research that communicates our usefulness matters. Br J Occup Ther 2016. [DOI: 10.1177/0308022616642254] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Jo Adams
- Professor of Musculoskeletal Health, Faculty of Health Sciences, University of Southampton, Southampton, UK
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Lee HY, Nam JK, Lee SD, Lee DH, Han JY, Yun YJ, Lee JH, Park HL, Park SH, Kwon JN. Moxibustion as an adjuvant for benign prostatic hyperplasia with lower urinary tract symptoms: a protocol for a parallel-group, randomised, controlled pilot trial. BMJ Open 2015; 5:e008338. [PMID: 26656981 PMCID: PMC4679882 DOI: 10.1136/bmjopen-2015-008338] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION This study aims to explore the feasibility of using moxibustion as a supplementary intervention and to assess the sample size for verifying the effectiveness and safety of integrative treatment involving moxibustion compared with conventional treatment for patients with benign prostatic hyperplasia accompanying moderate to severe lower urinary tract symptoms. METHODS AND ANALYSIS A total of 60 patients diagnosed with benign prostatic hyperplasia by a urologist based on prostate size, prostate-specific antigen and clinical symptoms will participate of their own free will; urologists will monitor the patients and evaluate their symptoms. The patients will be randomised to either a conventional group or an integrative group with a 1:1 allocation according to computer-generated random numbers concealed in opaque, sealed, sequentially numbered envelopes. Watchful waiting or oral medication including α blocker, 5α-reductase inhibitors or antimuscarinic drugs will be offered as conventional treatment. Integrative treatment will include moxibustion therapy in addition to the conventional treatment. The moxibustion therapy will be conducted twice a week for 4 weeks on the bilateral acupoints SP6, LR3 and CV4 by a qualified Korean medical doctor. The primary outcome will be the International Prostate Symptom Score (IPSS) after eight sessions. The secondary outcomes will be the post-void residual urine volume, the maximum urinary flow rate, IPSS, the results of a Short-Form 36-Question Health Survey after 12 weeks, and the patients' global impression of changes at each visit. ETHICS AND DISSEMINATION Written informed consent will be obtained from all participants. This study was approved by the institutional review boards of both Pusan National University Yangsan Hospital and Pusan National University Korean Medicine Hospital. The trial results will be disseminated through open-access journals and conferences. TRIAL REGISTRATION NUMBER NCT02051036.
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Affiliation(s)
- Hye-Yoon Lee
- Department of Internal Medicine, Pusan National University Korean Medicine Hospital, Yangsan, South Korea Department of Korean Medicine, School of Korean Medicine, Pusan National University, Yangsan, South Korea
| | - Jong-Kil Nam
- Department of Urology, Pusan National University Yangsan Hospital, Yangsan, South Korea Department of Urology, Pusan National University School of Medicine, Yangsan, South Korea
| | - Sang-Don Lee
- Department of Urology, Pusan National University Yangsan Hospital, Yangsan, South Korea Department of Urology, Pusan National University School of Medicine, Yangsan, South Korea
| | - Dong-Hoon Lee
- Department of Urology, Pusan National University Yangsan Hospital, Yangsan, South Korea Department of Urology, Pusan National University School of Medicine, Yangsan, South Korea
| | - Ji-Yeon Han
- Department of Urology, Pusan National University Yangsan Hospital, Yangsan, South Korea Department of Urology, Pusan National University School of Medicine, Yangsan, South Korea
| | - Young-Ju Yun
- Department of Internal Medicine, Pusan National University Korean Medicine Hospital, Yangsan, South Korea Division of Clinical Medicine, School of Korean Medicine, Pusan National University, Yangsan, South Korea
| | - Ji-Hye Lee
- Department of Internal Medicine, Pusan National University Korean Medicine Hospital, Yangsan, South Korea Department of Korean Medical Science, School of Korean Medicine, Pusan National University, Yangsan, South Korea
| | - Hye-Lim Park
- Department of Internal Medicine, Pusan National University Korean Medicine Hospital, Yangsan, South Korea Department of Korean Medicine, School of Korean Medicine, Pusan National University, Yangsan, South Korea
| | - Seong-Ha Park
- Department of Internal Medicine, Pusan National University Korean Medicine Hospital, Yangsan, South Korea Division of Clinical Medicine, School of Korean Medicine, Pusan National University, Yangsan, South Korea
| | - Jung-Nam Kwon
- Department of Internal Medicine, Pusan National University Korean Medicine Hospital, Yangsan, South Korea Division of Clinical Medicine, School of Korean Medicine, Pusan National University, Yangsan, South Korea
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