Physical therapists' management of rheumatoid arthritis: results of a Dutch survey

Physical therapy in patients with rheumatoid arthritis and axial spondyloarthritis: the patients' perspective

OBJECTIVE

To assess the duration, frequency, and content of individual physical therapy (PT) in patients with rheumatoid arthritis (RA) or axial spondyloarthritis (axSpA).

METHOD

In this cross-sectional study, an electronic questionnaire aimed at people with RA and axSpA was distributed through various communication channels of the Dutch Arthritis Foundation. It comprised questions on sociodemographic and health characteristics, received PT (currently and/or in the past year) and, if applicable, its duration, frequency, and content (active exercises, manual treatment, physical modalities, and/or counselling/education).

RESULTS

The study included 257 and 94 patients with self-reported diagnoses of RA and axSpA, of whom 163 (63%) and 77 (82%) currently or had recently received individual PT. The duration of individual PT was long-term (> 3 months) in 79% of RA and 83% of axSpA patients, with an average frequency of once per week in most. Although active exercises and counselling/education were each reported by ≥ 73% of the patients with RA and axSpA who received long-term individual PT, passive treatment modalities were also often offered (≥ 89%), in particular massage, kinesiotaping, and/or passive mobilization. The same pattern was seen in patients receiving short-term PT.

CONCLUSION

The majority of patients with RA and axSpA received PT currently or in the past year, usually individually, long-term, and at a frequency of once a week. Although active exercises and education are recommended in guidelines, passive treatment options that are not advised were relatively often reported. An implementation study to identify barriers and facilitators regarding adherence to clinical practice guidelines seems warranted.

Do physical therapists follow evidence-based guidelines when managing musculoskeletal conditions? Systematic review

OBJECTIVES

Physicians often refer patients with musculoskeletal conditions to physical therapy. However, it is unclear to what extent physical therapists' treatment choices align with the evidence. The aim of this systematic review was to determine what percentage of physical therapy treatment choices for musculoskeletal conditions agree with management recommendations in evidence-based guidelines and systematic reviews.

DESIGN

Systematic review.

SETTING

We performed searches in Medline, Embase, Cumulative Index to Nursing and Allied Health Literature, Cochrane Central Register of Controlled Trials, Allied and Complementary Medicine, Scopus and Web of Science combining terms synonymous with 'practice patterns' and 'physical therapy' from the earliest record to April 2018.

PARTICIPANTS

Studies that quantified physical therapy treatment choices for musculoskeletal conditions through surveys of physical therapists, audits of clinical notes and other methods (eg, audits of billing codes, clinical observation) were eligible for inclusion.

PRIMARY AND SECONDARY OUTCOMES

Using medians and IQRs, we summarised the percentage of physical therapists who chose treatments that were recommended, not recommended and had no recommendation, and summarised the percentage of physical therapy treatments provided for various musculoskeletal conditions within the categories of recommended, not recommended and no recommendation. Results were stratified by condition and how treatment choices were assessed (surveys of physical therapists vs audits of clinical notes).

RESULTS

We included 94 studies. For musculoskeletal conditions, the median percentage of physical therapists who chose recommended treatments was 54% (n=23 studies; surveys completed by physical therapists) and the median percentage of patients that received recommended physical therapy-delivered treatments was 63% (n=8 studies; audits of clinical notes). For treatments not recommended, these percentages were 43% (n=37; surveys) and 27% (n=20; audits). For treatments with no recommendation, these percentages were 81% (n=37; surveys) and 45% (n=31; audits).

CONCLUSIONS

Many physical therapists seem not to follow evidence-based guidelines when managing musculoskeletal conditions. There is considerable scope to increase use of recommended treatments and reduce use of treatments that are not recommended.

PROSPERO REGISTRATION NUMBER

CRD42018094979.

Development and testing of candidate items for inclusion in a new rheumatoid arthritis stiffness patient-reported outcome measure

Objective

To qualitatively develop and test a set of candidate items for a new RA stiffness patient-reported outcome measure (PROM) that capture the patient perspective. This is an essential first step in PROM development, prior to quantitative development, assessment and validation.

Methods

Focus groups further examined the previously developed stiffness conceptual model and explored the patient perspective regarding stiffness assessment. Data were analysed using thematic analysis. An iterative process of item development was then performed by the expert study team of researchers, patients and clinicians, based on the two qualitative datasets and informed by measurement theory and guidelines. Finally, these candidate items were tested using formal cognitive interview methodology and subsequently refined.

Results

Sixteen RA patients from the UK participated in focus groups. Data confirmed the conceptual model of the RA patient experience of stiffness and provided insight into stiffness assessment, including suggestions regarding patient-relevant stiffness assessment categories such as impact, location and timing. These data informed the development of 77 candidate stiffness PROM items, including multiple formats for some. Eleven RA patients participated in cognitive interviews. Minor changes were made to items to enhance understanding and 32 items were removed, resulting in 45 candidate PROM items.

Conclusion

Rigorous qualitative methodology and considerable patient involvement has underpinned items for a new RA stiffness PROM with strong content validity. Crucially, patient involvement broadened assessment beyond early morning stiffness duration, which may address existing PROM limitations. Items are now suitable for quantitative item reduction, structural development of the final PROM and validation.

Effects of individual and group exercise programs on pain, balance, mobility and perceived benefits in rheumatoid arthritis with pain and foot deformities

[Purpose] To verify the effects of individual and group exercise programs on pain, balance, mobility and perceived benefits of rheumatoid arthritis patients (RA) with pain and foot deformities. [Subjects and Methods] Thirty patients with RA pain and foot deformity were allocated into two groups: G1: individual exercise program and G2: group exercise program. The variables analyzed were Numerical Rating Scale (NRS) for pain, Berg Balance Scale (BBS) for balance, Timed Up & Go Test (TUG) and Functional Reach (FR) for mobility, and Foot Health Status Questionnaire (FHSQ-Br) for perceived benefits. Both exercise programs consisted of functional rehabilitation exercises and self-care guidance aimed at reducing pain and improving balance and mobility. Intragroup comparisons of variables between A1 (pre-intervention) and A2 (post-intervention) were performed. [Results] Patients in both groups were similar in A1 (pre-intervention) in all the variables analyzed. Comparison between A1 and A2 for each variable showed improvement for G1 in the NRS, BBS, FR, TUG and in four out of ten domains of FHSQ-Br. G2 showed improvement in the NRS, BBS and eight out of ten domains of FHSQ-Br. [Conclusion] Both individual and group programs revealed benefits for patients with RA, however, group exercise programs showed better perception of benefits.

Arthritis management in primary care - A study of physiotherapists' current practice, educational needs and adherence to national guidelines

BACKGROUND

With an increasing number of patients with osteoarthritis (OA) and rheumatoid arthritis (RA) in primary care, our aim was to investigate arthritis-related practice in physiotherapy and to study adherence to evidence-based care.

METHODS

Seventy physiotherapists (PTs) working in primary care were emailed a questionnaire to investigate current practice and the number of roles assumed by PTs, the degree of confidence, educational needs and adherence to national guidelines in managing patients with OA or RA. Interventions supported by national guidelines were compared with reports of treatment modalities in the questionnaire.

RESULTS

Sixty-four (91%) PTs responded, and they reported a higher degree of confidence in assessment, treatment and education of patients with OA than for those with RA (p < 0.001). The total number of roles assumed by the PTs was higher in the management of OA than for RA (p < 0.001). PTs who assumed a greater number of roles also reported a stronger degree of confidence in assessing OA (p = 0.036). Those who assumed fewer roles also reported less confidence in RA treatment (p = 0.045). Recommendations in the guidelines were followed by the majority of PTs for eight of 11 treatment modalities in OA and for six of six in RA.

CONCLUSIONS

PTs reported a lower degree of confidence and the assumption of fewer roles in managing patients with RA compared with OA. There was good adherence to the national guidelines for almost all the treatment modalities listed. Even so, the results indicate a need for education, especially in chronic inflammatory arthritis care.

Rehabilitation needs approached by health professionals at a rheumatism hospital

OBJECTIVE

The aim of the present study was to examine the characteristics of patients referred to occupational therapists (OTs), physiotherapists (PTs) and social workers (SWs) at a rehabilitation unit in a hospital specializing in rheumatology, and the rehabilitation needs that clinicians and patients agreed should be addressed in the encounters with the particular health professional groups.

METHODS

Consecutive hospitalized patients at a rheumatism hospital were recruited by the health professionals. Questions about patient characteristics and rehabilitation needs were posed. Free-text responses to questions about rehabilitation needs were coded by the International Classification of Functioning, Disability, and Health (ICF).

RESULTS

The patients varied considerably in age distribution, disease duration, disability level and diagnoses, and several patients had comorbidities. The rehabilitation needs classified under the component Body Function fell into the chapters: Sensory Functions and Pain (PTs), Functions of Cardiovascular System (PTs), Neuromusculoskeletal and Movement-Related Functions (OTs, PTs); under the Activity and Participation component, these were: General Tasks and Demands (OTs), Mobility (OTs), Self-Care (PTs), Interpersonal Interactions and Relationships (SWs) and Major Life Stress (SWs); and under the Environmental Factors component these were: Products and Technology (OTs) and Services, Systems and Politics (SWs).

CONCLUSIONS

The patients were fairly heterogeneous. The needs identified in the encounters with the different professional groups fell into all three components of the ICF, and there was only a minor overlap between the health professionals at the chapter level of the ICF.

Ability of physiotherapists to undertake evidence-based practice steps: a scoping review

BACKGROUND

Evidence-based practice (EBP) is promoted to ensure quality of care. However, analysis of the skill of physiotherapists in undertaking the steps of EBP, or the impact of EBP on the work of physiotherapists is limited.

OBJECTIVES

To conduct a scoping review into physiotherapists performing the steps of EBP.

DATA SOURCE

Literature concerning the skill of physiotherapists in EBP between 1990 and June 2013 was searched using AMED, Academic Search Complete, CINAHL, PubMed, ERIC, PEDRO and EMBASE databases.

STUDY SELECTION

Twenty-five studies (six qualitative, one mixed methods and 18 quantitative) were selected.

DATA EXTRACTION AND SYNTHESIS

Quantitative and qualitative data were extracted using two appraisal tools to analyse each of the five steps of EBP.

RESULTS

Limited evidence exists to show that physiotherapists undertake the full EBP process. Despite formulating clinical questions and acquiring literature-based evidence, the drivers for conducting literature or evidence searches have not been clarified. The critical appraisal step was mainly assessed in the form of recognition of statistical terms. Only examples of guideline usage support the reflective final assessment step. Physiotherapists report using their peers and other trusted sources in preference to literature, primarily due to time but also due to divergence between the literature-based evidence and other evidence that they use and value (tacit knowledge). A positive impact of EBP on patient outcomes is lacking.

CONCLUSIONS

Understanding the information needs of physiotherapists may be necessary before adoption of the EBP process. The use of professional networks may offer a better means to identify knowledge gaps and translate acquired knowledge into practice, rather than focusing on individual skills in EBP.

Distribution and alteration of lymphatic vessels in knee joints of normal and osteoarthritic mice

OBJECTIVE

To investigate the distribution and alteration of lymphatic vessels and draining function in knee joints of normal and osteoarthritic mice.

METHODS

For the mouse models of osteoarthritis (OA), we used mice with meniscal-ligamentous injury or mice with conditional knockout of the gene for cartilage transforming growth factor β (TGFβ) type II receptor. The severity of cartilage loss and joint destruction was assessed histologically. Capillary and mature lymphatic vessels were identified and analyzed using double immunofluorescence staining and a whole-slide digital imaging system. Lymphatic drainage of knee joints was examined using near-infrared lymphatic imaging. Patient joint specimens obtained during total knee or hip arthroplasty were evaluated to verify the content validity of the mouse findings.

RESULTS

Lymphatic vessels were distributed in soft tissues (mainly around the joint capsule, ligaments, fat pads, and muscles of normal knees). The number of lymphatic vessels, particularly the number of capillaries, was significantly increased in joints of mice with mild OA, while the number of mature lymphatic vessels was markedly decreased in joints of mice with severe OA. OA knees exhibited significantly decreased lymph clearance. The number of both capillary and mature lymphatic vessels was significantly decreased in the joints of patients with OA.

CONCLUSION

The whole-slide digital imaging system is a powerful tool, enabling the identification and assessment of lymphatic microvasculature in the entire mouse knee. Lymphatic capillaries and mature vessels are present in various soft tissues around articular spaces. Abnormalities of lymphatic vessels and draining function, including significantly reduced numbers of mature vessels and impaired clearance, are present in OA joints.

A qualitative study of barriers to the implementation of a rheumatoid arthritis guideline among generalist and specialist physical therapists

BACKGROUND

Although the increasing complexity and expansion of the body of knowledge in physical therapy have led to specialized practice areas to provide better patient care, the impact of specialization on guideline implementation has been scarcely studied. Objectives The objective of this study was to identify the similarities and differences in barriers to the implementation of a Dutch rheumatoid arthritis (RA) guideline by generalist and specialist physical therapists. Design This observational study consisted of 4 focus group interviews in which 24 physical therapists (13 generalist and 11 specialist physical therapists) participated.

METHODS

Physical therapists were asked to discuss barriers to the implementation of the RA guideline. Data were analyzed qualitatively using a directed approach to content analysis. Both the interviews and the interview analysis were informed by a previously developed conceptual framework.

RESULTS

Besides a number of similarities (eg, lack of time), the present study showed important, although subtle, differences in barriers to the implementation of the RA guideline between generalist physical therapists and specialist physical therapists. Generalist physical therapists more frequently reported difficulties in interpreting the guideline (cognitive barriers) and had less favorable opinions about the guideline (affective barriers) than specialist physical therapists. Specialist physical therapists were hampered by external barriers that are outside the scope of generalist physical therapists, such as a lack of agreement about the roles and responsibilities of medical professionals involved in the care of the same patient.

CONCLUSIONS

The identified differences in barriers to the implementation of the RA guideline indicated that the effectiveness of implementation strategies could be improved by tailoring them to the level of specialization of physical therapists. However, it is expected that tailoring implementation strategies to barriers that hamper both generalist and specialist physical therapists will have a larger effect on the implementation of the RA guideline.