Access and perceived need for physical and occupational therapy in chronic arthritis

Microporation-Mediated Transdermal Delivery of In Situ Gel Incorporating Etodolac-Loaded PLGA Nanoparticles for Management of Rheumatoid Arthritis

Management of rheumatoid arthritis (RA) requires long-term administration of different medications since there has been no cure until now. Etodolac (ETD) is a nonsteroidal anti-inflammatory drug commonly used for RA management. However, its long-term administration resulted in severe side effects. This study aimed to develop a transdermal in situ gel incorporating ETD-loaded polymeric nanoparticles (NPs) to target the affected joints for long-term management of RA. Several PLGA NPs incorporating 1% ETD were prepared by nanoprecipitation and optimized according to the central composite design. The optimum NPs (F1) exhibited 96.19 ± 2.31% EE, 282.3 ± 0.62 nm PS, 0.383 ± 0.04 PDI, and -6.44 ± 1.69 ZP. A hyaluronate coating was applied to F1 (H-F1) to target activated macrophages at inflammation sites. H-F1 exhibited 287.4 ± 4.2 nm PS, 0.267 ± 0.02 PDI, and -23.7 ± 3.77 ZP. Pluronic F-127 in situ gel (H-F1G) showed complete gelation at 29 °C within 5 min. ETD permeation from H-F1G was sustained over 48 h when applied to microporated skin and exhibited significant enhancement of all permeation parameters. Topical application of H-F1G (equivalent to 8 mg ETD) to Wistarrat microporated skin every 48 h resulted in antirheumatic therapeutic efficacy comparable to commercial oral tablets (10 mg/kg/day).

Do physical therapists follow evidence-based practices for treatment of inflammatory arthritis? Results from an online survey

BACKGROUND

Physical therapists (PTs) should know how to best treat patients with inflammatory arthritis.

OBJECTIVE

To document interventions chosen by PTs for patients with rheumatoid arthritis (RA) and ankylosing spondylitis (AS) and whether choices follow evidence-based practice.

METHODS

Licensed musculoskeletal PTs in Quebec, Canada responded to an online survey. Descriptive statistics illustrated proportions for each treatment choice and inferential statistics explored associations with demographic and practice-related factors.

RESULTS

There were 298 PTs who responded to the survey. For both RA and AS respectively, most common interventions were mobility exercises (91.0%; 98.3%) and patient education (90.1%; 92.8%). For both cases, slightly >60% selected strengthening exercises. Passive forms of therapy were chosen by 36% of PTs for RA and 58% for AS. Aerobic exercise was rarely selected. PTs working in the public sector were less likely to use manual therapy for both RA (Odds Ratio (OR) 0.43, 95% confidence interval (CI) 0.22,0.86) and AS (OR 0.46, 95% CI 0.22,0.97).

CONCLUSIONS

Most PTs chose mobility exercises and patient education, representing evidence-based approaches. Despite current recommendations, strengthening and especially aerobic exercises were not used as much. There is a need to increase awareness regarding the benefits of strengthening and aerobic exercise for these patients.

Sociocultural and Economic Disparities in Physical Therapy Utilization Among Insured Older Adults With Rheumatoid Arthritis

OBJECTIVE

To examine influences of sociocultural and economic determinants on physical therapy (PT) utilization for older adults with rheumatoid arthritis (RA).

METHODS

In these annual cross-sectional analyses between 2012 and 2016, we accessed Medicare enrollment data and fee-for-service claims. The cohort included Medicare beneficiaries with RA based on 3 diagnosis codes or 2 codes plus a disease-modifying antirheumatic drug medication claim. We defined race and ethnicity and dual Medicare/Medicaid coverage (proxy for income) using enrollment data. Adults with a Current Procedural Terminology code for PT evaluation were classified as utilizing PT services. Associations between race and ethnicity and dual coverage and PT utilization were estimated with logistic regression analyses. Potential interactions between race and ethnicity status and dual coverage were tested using interaction terms.

RESULTS

Of 106,470 adults with RA (75.1% female; aged 75.8 [SD 7.3] years; 83.9% identified as non-Hispanic White, 8.8% as non-Hispanic Black, 7.2% as Hispanic), 9.6-12.5% used PT in a given year. Non-Hispanic Black (adjusted odds ratio [aOR] 0.77, 95% CI 0.73-0.82) and Hispanic (aOR 0.92, 95% CI 0.87-0.98) individuals had lower odds of PT utilization than non-Hispanic White individuals. Adults with dual coverage (lower income) had lower odds of utilization than adults with Medicare only (aOR 0.44, 95% CI 0.43-0.46). There were no significant interactions between race and ethnicity status and dual coverage on utilization.

CONCLUSION

We found sociocultural and economic disparities in PT utilization in older adults with RA. We must identify and address the underlying factors that influence these disparities in order to mitigate them.

The association between socioeconomic status and joint replacement of the hip and knee: A population-based cohort study of older adults in Tasmania

BACKGROUND

A socioeconomic gradient exists in the utilisation of total hip replacements (THR) and total knee replacements (TKR) for osteoarthritis. However, the relations between socioeconomic status (SES) and time to THR or TKR is unknown.

AIM

To describe the association between SES and time to THR and TKR.

METHODS

1072 older-adults residing in Tasmania, Australia were studied. Incident primary THR and TKR were determined by data linkage to the Australian Orthopaedic Association National Joint Replacement Registry. At baseline, each participant's area-level SES was determined by the Index of Relative Socioeconomic Advantage and Disadvantage (IRSAD), from the Australian Bureau of Statistics' 2001 census data. IRSAD was analysed in two ways; 1) categorised into quartiles, whereby quartile 1 represented the most socioeconomically disadvantaged group, 2) the cohort dichotomised at the quartile 1 cut-point.

RESULTS

The mean age was 63.0 (±7.5) years, and 51% were women. Over the median follow-up of 12.9 (Interquartile range: 12.2-13.9) years, 56 (5%) participants had a THR, and 79 (7%) had a TKR. Compared to the most disadvantaged quartile, less disadvantaged participants were less likely to have a THR (i.e. less disadvantaged participants had a longer time to THR) (HR: 0.56, 95% CI 0.32, 1.00) but not TKR (HR: 0.90, 95% CI 0.53, 1.54). However, the former became non-significant after adjustment for pain and radiographic osteoarthritis, suggesting that the associations may be mediated by these factors.

CONCLUSIONS

This study suggests that time to joint replacement was determined according to the symptoms/need of the participants rather than their SES. This article is protected by copyright. All rights reserved.

Sociodemographic and Clinical Correlates of Physical Therapy Utilization in Adults With Symptomatic Knee Osteoarthritis

BACKGROUND

Physical therapy is essential for conservative management of symptomatic knee osteoarthritis (OA). However, physical therapy utilization data are limited for knee OA.

OBJECTIVE

The purpose of this study is to identify correlates of physical therapy utilization among adults with symptomatic knee OA.

DESIGN

The design consisted of secondary analysis using baseline data from a randomized controlled trial of 350 adults with physician-diagnosed symptomatic knee OA.

METHODS

Patients completed baseline surveys regarding demographics, pain, function, medical history, and prior physical therapy utilization for symptomatic knee OA. Multivariable logistic regression identified correlates of physical therapy utilization, with models adjusted for body mass index and age. Interactions of race and sex with all other characteristics were evaluated.

RESULTS

One hundred and eighty-one patients (52%) reported prior physical therapy utilization. Factors independently associated with increased odds of physical therapy utilization were female sex (odds ratio [OR] = 3.06, 95% CI = 1.58-5.93), bachelor degree or higher degree (OR = 2.44, 95% CI = 1.15-5.16), prior knee injury (OR = 1.86, 95% CI = 1.08-3.19), and duration of knee OA symptoms (OR = 2.16, 95% CI = 1.09-4.29 for >5-10 years; OR = 2.11, 95% CI = 1.10-4.04 for >10 years). Whites who had received a joint injection were >3 times as likely to have utilized physical therapy (OR = 3.69, 95% CI = 1.94-7.01); this relationship did not exist for non-whites who had received joint injections.

LIMITATIONS

A sample enrolled in an exercise study may limit generalizability. Self-report of physical therapy may misclassify utilization. It cannot be determined whether lack of utilization resulted from lack of referral or from patients choosing not to attend physical therapy.

CONCLUSION

Physical therapy is underutilized to manage symptomatic knee OA. Women and those with a bachelor degree or higher degree, prior knee injury, and longer duration of knee OA symptoms were more likely to have used therapy previously. Differences by race in the link between joint injection and physical therapy utilization may reflect a reduced likelihood of referral and decreased use of health interventions for symptomatic knee OA among non-whites, or both.

Patient-perceived health service needs in inflammatory arthritis: A systematic scoping review

BACKGROUND

Care that is patient-centred is more likely to be sustainable and associated with improved health outcomes. This approach to care requires an understanding of patients' health service needs, yet few studies have directly investigated the perceived health service needs of people with inflammatory arthritis.

OBJECTIVES

To systematically identify the existing literature relating to patient perceived health service needs for inflammatory arthritis.

METHODS

A systematic review of MEDLINE, EMBASE, CINAHL, and PsycINFO was conducted (1990-2016). Studies examining patients' perceived needs relating to health services for inflammatory arthritis were identified. Descriptive data regarding study design and methodology were extracted and risk of bias assessed. Findings were collated and categorized thematically.

RESULTS

In total, 27 of 1405 (16 qualitative, 9 quantitative, and 2 mixed-methods) studies were relevant. The main areas of perceived need related to (1) Communication: consumers wanted clear, empathic communication, and to be involved with decision-making. (2) Characteristics of ongoing care: adequate consultation length with continuity and timely care were valued. (3) Factors influencing care-seeking included individual attitudes, disease severity, finances and family expectations. (4) Allied health and complementary and alternative medicines (CAM) were perceived as useful by many. The reporting of CAM use to doctors was variable, with several factors contributing to under-reporting.

CONCLUSIONS

This review identified patients' perceived needs for better communication with their health providers, the heterogeneity of influences determining when care is sought and preferences regarding non-pharmacologic therapies. Aligning patients' perceived needs with evidence-based therapy for people with inflammatory arthritis will be important in optimizing patient outcomes.

[Occupational therapy in rheumatoid arthritis: what rheumatologists need to know?]

Interventions focusing on education and self-management of rheumatoid arthritis (RA) by the patient improves adherence and effectiveness of early treatment. The combination of pharmacologic and rehabilitation treatment aims to maximize the possibilities of intervention, delaying the appearance of new symptoms, reducing disability and minimizing sequelae, decreasing the impact of symptoms on patient's functionality. Occupational therapy is a health profession that aims to improve the performance of daily activities by the patient, providing means for the prevention of functional limitations, adaptation to lifestyle changes and maintenance or improvement of psychosocial health. Due to the systemic nature of RA, multidisciplinary follow-up is necessary for the proper management of the impact of the disease on various aspects of life. As a member of the health team, occupational therapists objective to improve and maintaining functional capacity of the patient, preventing the progression of deformities, assisting the process of understanding and coping with the disease and providing means for carrying out the activities required for the engagement of the individual in meaningful occupations, favoring autonomy and independence in self-care activities, employment, educational, social and leisure. The objective of this review is to familiarize the rheumatologist with the tools used for assessment and intervention in occupational therapy, focusing on the application of these principles to the treatment of patients with RA.

Minimal evidence of response shift in the absence of a catalyst

BACKGROUND

Individuals with chronic conditions experience fluctuations in health status and thus may experience response shift. We sought to test the hypothesis that response shift effects would be non-significant among individuals with chronic disease who experienced relatively small changes in their health status over a 1-year period.

METHODS

This secondary analysis utilized longitudinal cohort data on a community-based sample (n = 776) representing four chronic diseases (arthritis, heart failure, diabetes, or chronic obstructive pulmonary disease). Information on health-care utilization was obtained from the provincial health insurance database. Participants completed the SF-36 twice annually. Parameter invariance over 1 year in a second-order SF-36 factor structure was evaluated by adapting Oort's approach by fitting a second-order measurement structure with first-order factors for the SF-36 subscales and second-order factors for physical and mental health status while accommodating ordinal data.

RESULTS

Over 80 % of participants had no hospitalizations or emergency room visits over follow-up. The model had an acceptable fit when all measurement model parameters were constrained at both time points (RMSEA = .035, CFI = .97). There was no substantial difference in fit when measurement model parameters (item thresholds, first-order factor intercepts, and factor loadings) were allowed to vary over time.

CONCLUSION

Among chronically ill individuals with stable health, substantial response shift effects were not detected. These results support the theoretical proposition that response shift is not expected to occur in patients with relatively stable conditions.

Wait times for physical and occupational therapy in the public system for people with arthritis in quebec

PURPOSE

Although arthritis is the leading cause of pain and disability in Canada, and physical therapy (PT) and occupational therapy (OT) are beneficial both for chronic osteoarthritis (OA) and for inflammatory arthritis such as rheumatoid arthritis (RA), there appear to be problems with access to such services. The aim of this study was to document wait times from referral by physician to consultation with PT or OT in the public health care system for people with arthritis in Quebec, Canada.

METHOD

Appointments were requested by telephone, using hypothetical case scenarios; wait times were defined as the time between initial request and appointment date. Descriptive statistics were used to examine the wait times in relation to diagnosis, service provider and geographic area.

RESULTS

For both scenarios (OA and RA) combined, 13% were offered an appointment within 6 months, 13% offered given an appointment within 6-12 months, 24% were told they would need to wait longer than 12 months, and 22% were refused services. The remaining 28% were told they would require an evaluation appointment for functional assessment before being given an appointment for therapy. No difference was found between RA and OA diagnoses.

CONCLUSIONS

Our study suggests that most people with arthritis living in the province of Quebec are not receiving publicly accessible PT or OT intervention in a timely manner.

Effects of an individually tailored Web-based chronic pain management program on pain severity, psychological health, and functioning

BACKGROUND

It is estimated that 30% of adults in the United States experience daily chronic pain. This results in a significant burden on the health care system, in particular primary care, and on the workplace. Chronic pain management with cognitive-behavioral psychological treatment is effective in reducing pain intensity and interference, health-related quality of life, mood, and return to work. However, the population of individuals with chronic pain far exceeds the population of therapists that can provide this care face-to-face. The use of tailored, Web-based interventions for the management of chronic pain could address limitations to access by virtue of its unlimited scalability.

OBJECTIVE

To examine the effects of a tailored Web-based chronic pain management program on subjective pain, activity and work interference, quality of life and health, and stress.

METHODS

Eligible participants accessed the online pain management program and informed consent via participating employer or health care benefit systems; program participants who completed baseline, 1-, and 6-month assessments were included in the study. Of the 645 participants, the mean age was 56.16 years (SD 12.83), most were female (447/645, 69.3%), and white (505/641, 78.8%). Frequent pain complaints were joint (249/645, 38.6%), back (218/645, 33.8%), and osteoarthritis (174/654, 27.0%). The online pain management program used evidence-based theories of cognitive behavioral intervention, motivational enhancement, and health behavior change to address self-management, coping, medical adherence, social support, comorbidities, and productivity. The program content was individually tailored on several relevant participant variables.

RESULTS

Both pain intensity (mean 5.30, SD 2.46), and unpleasantness (mean 5.43, SD 2.52) decreased significantly from baseline to 1-month (mean 4.16, SD 2.69 and mean 4.24, 2.81, respectively) and 6-month (mean 3.78, SD 2.79 and mean 3.78, SD 2.79, respectively) assessments (P<.001). The magnitude of the 6-month effects were large. Trends for decreases in pain interference (36.8% reported moderate or enormous interference) reached significance at 6 months (28.9%, P<.001). The percentage of the sample reporting fair or poor quality of life decreased significantly from 20.6% at baseline to 16.5% at 6 months (P=.006).

CONCLUSIONS

Results suggest that the tailored online chronic pain management program showed promising effects on pain at 1 and 6 months posttreatment and quality of life at 6 months posttreatment in this naturalistic study. Further research is warranted to determine the significance and magnitude of the intervention's effects in a randomized controlled trial.

The challenge of obtaining information necessary for multi-criteria decision analysis implementation: the case of physiotherapy services in Canada

BACKGROUND

As fiscal constraints dominate health policy discussions across Canada and globally, priority-setting exercises are becoming more common to guide the difficult choices that must be made. In this context, it becomes highly desirable to have accurate estimates of the value of specific health care interventions.Economic evaluation is a well-accepted method to estimate the value of health care interventions. However, economic evaluation has significant limitations, which have lead to an increase in the use of Multi-Criteria Decision Analysis (MCDA). One key concern with MCDA is the availability of the information necessary for implementation. In the Fall 2011, the Canadian Physiotherapy Association embarked on a project aimed at providing a valuation of physiotherapy services that is both evidence-based and relevant to resource allocation decisions. The framework selected for this project was MCDA. We report on how we addressed the challenge of obtaining some of the information necessary for MCDA implementation.

METHODS

MCDA criteria were selected and areas of physiotherapy practices were identified. The building up of the necessary information base was a three step process. First, there was a literature review for each practice area, on each criterion. The next step was to conduct interviews with experts in each of the practice areas to critique the results of the literature review and to fill in gaps where there was no or insufficient literature. Finally, the results of the individual interviews were validated by a national committee to ensure consistency across all practice areas and that a national level perspective is applied.

RESULTS

Despite a lack of research evidence on many of the considerations relevant to the estimation of the value of physiotherapy services (the criteria), sufficient information was obtained to facilitate MCDA implementation at the local level.

CONCLUSIONS

The results of this research project serve two purposes: 1) a method to obtain information necessary to implement MCDA is described, and 2) the results in terms of information on the benefits provided by each of the twelve areas of physiotherapy practice can be used by decision-makers as a starting point in the implementation of MCDA at the local level.