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Hopewell S, Srikesavan C, Evans A, Er F, Rangan A, Preece J, Francis A, Massa MS, Feldmann M, Lamb S, Nanchahal J. Anti-TNF (adalimumab) injection for the treatment of pain-predominant early-stage frozen shoulder: the Anti-Freaze-Feasibility randomised controlled trial. BMJ Open 2024; 14:e078273. [PMID: 38692727 PMCID: PMC11086567 DOI: 10.1136/bmjopen-2023-078273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 03/01/2024] [Indexed: 05/03/2024] Open
Abstract
OBJECTIVE The Anti-Freaze-F (AFF) trial assessed the feasibility of conducting a definitive trial to determine whether intra-articular injection of adalimumab can reduce pain and improve function in people with pain-predominant early-stage frozen shoulder. DESIGN Multicentre, randomised feasibility trial, with embedded qualitative study. SETTING Four UK National Health Service (NHS) musculoskeletal and related physiotherapy services. PARTICIPANTS Adults ≥18 years with new episode of shoulder pain attributable to early-stage frozen shoulder. INTERVENTIONS Participants were randomised (centralised computer generated 1:1 allocation) to either ultrasound-guided intra-articular injection of: (1) adalimumab (160 mg) or (2) placebo (saline (0.9% sodium chloride)). Participants and outcome assessors were blinded to treatment allocation. Second injection of allocated treatment (adalimumab 80 mg) or equivalent placebo was administered 2-3 weeks later. PRIMARY FEASIBILITY OBJECTIVES: (1) Ability to screen and identify participants; (2) willingness of eligible participants to consent and be randomised; (3) practicalities of delivering the intervention; (4) SD of the Shoulder Pain and Disability Index (SPADI) score and attrition rate at 3 months. RESULTS Between 31 May 2022 and 7 February 2023, 156 patients were screened of whom 39 (25%) were eligible. The main reasons for ineligibility were other shoulder disorder (38.5%; n=45/117) or no longer in pain-predominant frozen shoulder (33.3%; n=39/117). Of the 39 eligible patients, nine (23.1%) consented to be randomised (adalimumab n=4; placebo n=5). The main reason patients declined was because they preferred receiving steroid injection (n=13). All participants received treatment as allocated. The mean time from randomisation to first injection was 12.3 (adalimumab) and 7.2 days (placebo). Completion rates for patient-reported and clinician-assessed outcomes were 100%. CONCLUSION This study demonstrated that current NHS musculoskeletal physiotherapy settings yielded only small numbers of participants, too few to make a trial viable. This was because many patients had passed the early stage of frozen shoulder or had already formulated a preference for treatment. TRIAL REGISTRATION NUMBER ISRCTN 27075727, EudraCT 2021-03509-23, ClinicalTrials.gov NCT05299242 (REC 21/NE/0214).
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Affiliation(s)
- Sally Hopewell
- Oxford Clinical Trials Research Unit, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Cynthia Srikesavan
- Centre for Rehabilitation Research in Oxford, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- College of Medicine and Health, University of Exeter, Exeter, UK
| | - Alison Evans
- Kennedy Institute of Rheumatology, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Fema Er
- Oxford Clinical Trials Research Unit, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Amar Rangan
- South Tees Hospitals NHS Foundation Trust, The James Cook University Hospital, Middlesbrough, UK
- Department of Health Sciences, University of York, York, UK
| | - Jane Preece
- Patient and Public Involvement Representative, Kidderminster, UK
| | - Anne Francis
- Oxford Clinical Trials Research Unit, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - M Sofia Massa
- Oxford Clinical Trials Research Unit, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Marc Feldmann
- Kennedy Institute of Rheumatology, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Sarah Lamb
- College of Medicine and Health, University of Exeter, Exeter, UK
| | - Jagdeep Nanchahal
- Kennedy Institute of Rheumatology, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
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Comer C, Williamson E, McIlroy S, Srikesavan C, Dalton S, Melendez-Torres GJ, Lamb SE. Exercise treatments for lumbar spinal stenosis: A systematic review and intervention component analysis of randomised controlled trials. Clin Rehabil 2024; 38:361-374. [PMID: 37715644 PMCID: PMC10829420 DOI: 10.1177/02692155231201048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Accepted: 08/27/2023] [Indexed: 09/18/2023]
Abstract
OBJECTIVE To analyse the components used in exercise interventions for people with symptoms of neurogenic claudication due to lumbar spinal stenosis and identify components associated with successful interventions. DATA SOURCES Eligible papers published up to April 2023 from MEDLINE, EMBASE, CINAHL, PEDro, CENTRAL, Web of Science, and trial registry websites. REVIEW METHODS Literature searches were performed by an Information Specialist. We searched for randomised trials evaluating exercise interventions for people with neurogenic claudication symptoms (the primary symptom of lumbar spinal stenosis). Two authors independently performed study selection, data extraction, and quality assessments using the Cochrane Risk of Bias tool Version 2 and the TIDieR checklist for intervention reporting. Details of intervention components were extracted, tabulated, and synthesised using an intervention component analysis approach. RESULTS We found thirteen trials reporting 23 exercise interventions delivered to 1440 participants. These featured 60 different components. Most exercise interventions included supervision and flexion-based exercises. Balance exercises were rarely included. Exercise components featured more frequently in successful interventions included stretches, strength or trunk muscle exercises, fitness exercises, especially cycling, and psychologically informed approaches. Interpretation is limited by low study numbers and heterogeneity. No conclusions could be drawn about exercise supervision or dose. DISCUSSION Exercise interventions for people with neurogenic claudication typically feature multiple components. Common features such as supervision, lumbar flexion, and aerobic fitness exercises and also less common features such as stretches, strengthening exercises, and psychologically informed approaches warrant consideration for inclusion when designing and optimising exercise interventions for people with lumbar spinal stenosis.
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Affiliation(s)
- Christine Comer
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, Faculty of Medicine, University of Leeds, UK
- Leeds Community Healthcare Musculoskeletal and Rehabilitation Services, Leeds Community Healthcare NHS Trust, UK
| | - Esther Williamson
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, UK
- Faculty of Health and Life Sciences, University of Exeter, Exeter, UK
| | - Suzanne McIlroy
- Physiotherapy Department, King's College Hospital NHS Foundation Trust, UK
- Health Psychology Section, The Institute of Psychiatry, Psychology & Neuroscience (IoPPN), King's College London, UK
| | - Cynthia Srikesavan
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, UK
- Faculty of Health and Life Sciences, University of Exeter, Exeter, UK
| | | | | | - Sarah E Lamb
- Faculty of Health and Life Sciences, University of Exeter, Exeter, UK
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Srikesavan C, Dean B, Toye F, Bolt A, Thurley N. Experiences of people with hand osteoarthritis and perceptions of clinicians and carers on quality of life and treatment services: A qualitative synthesis. Hand Ther 2023; 28:121-132. [PMID: 38033524 PMCID: PMC10683712 DOI: 10.1177/17589983231210762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 10/11/2023] [Indexed: 12/02/2023]
Abstract
Introduction We aimed to synthesise the experiences of people living with hand osteoarthritis (HOA) and the perceptions of clinicians and carers relating to the quality of life and treatment services. Methods We undertook a systematic search on MEDLINE, Embase, and CINAHL electronic databases for qualitative studies in HOA. We used the Critical Appraisal Skills Programme (CASP) checklist to assess methodological quality and thematically-synthesise the findings. We used GRADE-CERQual (Grading of Recommendations Assessment, Development, and Evaluation- Confidence in the Evidence from Reviews of Qualitative Research) to assess the quality of the evidence. Results We identified 13 studies involving people with HOA (288 women and 39 men, average age 61.4 years) and clinicians. Five themes were identified from studies involving people with HOA: i) My hands are painful whenever I use them; ii) It stops me doing everyday activities; iii) It stops me doing things I value; iv) It's psychologically challenging and v) I find ways of doing things. The quality of evidence was moderate except for pain with low quality of evidence. Most studies were conducted in Europe and the United Kingdom with participants recruited predominantly from hospital settings. We were not able to synthesise the three studies that involved clinicians as each explored different topics of HOA. There were no studies that involved carers. Conclusions Our findings highlighted the impact of HOA in various areas of life and the need for personalised psychological support in practice.
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Affiliation(s)
- Cynthia Srikesavan
- Nuffield Department of Orthopaedics and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- Faculty of Health and Life Sciences, University of Exeter, Exeter, UK
| | - Benjamin Dean
- Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Francine Toye
- Physiotherapy Research Unit, Oxford University Hospitals NHS Trust, Nuffield Orthopaedic Centre, Oxford, UK
| | - Alex Bolt
- University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
| | - Neal Thurley
- Bodleian Health Care Libraries, University of Oxford, Oxford, UK
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Hopewell S, Kenealy N, Knight R, Rangan A, Dutton S, Srikesavan C, Feldmann M, Lamb S, Nanchahal J. Anti-TNF (adalimumab) injection for the treatment of adults with frozen shoulder during the pain predominant stage protocol for a multi-centre, randomised, double blind, parallel group, feasibility trial. NIHR Open Res 2023; 2:28. [PMID: 37881307 PMCID: PMC10593336 DOI: 10.3310/nihropenres.13275.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Accepted: 04/18/2023] [Indexed: 10/27/2023]
Abstract
Objectives The Anti-Freaze-F trial will assess the feasibility of conducting a large randomised controlled trial to assess whether intra-articular injection of anti-TNF (adalimumab) can reduce pain and improve function in people with pain predominant early stage frozen shoulder. Methods and analysis We are conducting a multi-centre, randomised feasibility study, with an embedded qualitative sub-study. We will recruit adults ≥18 years with a new episode of shoulder pain attributable to early stage frozen shoulder, recruited from at least five UK NHS musculoskeletal and related physiotherapy services. Participants (n=84) will be randomised (centralised computer generated 1:1 allocation) to receive either: 1) intra-articular injection of anti-TNF (adalimumab 160mg) or 2) placebo injection (saline [0.9% sodium chloride]), both under ultrasound guidance. A second injection of the allocated treatment (adalimumab 80mg) or equivalent volume of placebo will be administered 2-3 weeks later. All participants will receive a physiotherapy advice leaflet providing education and advice about frozen shoulder and pain management. The primary feasibility objectives are: 1) the ability to screen and identify potential participants with pain predominant early stage frozen shoulder; 2) willingness of eligible participants to consent and be randomised to intervention; 3) practicalities of delivering the intervention, including time to first injection and number of participants receiving second injection; 4) standard deviation of the Shoulder Pain and Disability Index (SPADI) score and attrition rate at 3 months (i.e. 12 weeks) post-randomisation in order to estimate the sample size for a definitive trial. We will also assess follow up rates and viability of patient-reported outcome measures and range of shoulder motion for a definitive trial. Research Ethics Committee approval (REC 21/NE/0214). Trial registration number ISRCTN 27075727; EudraCT number: 2021-003509-23; ClinicalTrials.gov NCT05299242.
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Affiliation(s)
- Sally Hopewell
- Oxford Clinical Trials Research Unit / Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Nicola Kenealy
- Kennedy Institute of Rheumatology, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Ruth Knight
- Oxford Clinical Trials Research Unit / Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Amar Rangan
- James Cook University Hospital, South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK
- Hull York Medical School and Department of Health Sciences, University of York, York, UK
| | - Susan Dutton
- Oxford Clinical Trials Research Unit / Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Cynthia Srikesavan
- Centre for Rehabilitation Research in Oxford, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Marc Feldmann
- Kennedy Institute of Rheumatology, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Sarah Lamb
- College of Medicine and Health, University of Exeter, Exeter, UK
| | - Jagdeep Nanchahal
- Kennedy Institute of Rheumatology, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
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Mavragani A, Davey Z, Srikesavan C, Hart L, Butcher D, Cipriani A. Implementation of a Web-Based Resilience Enhancement Training for Nurses: Pilot Randomized Controlled Trial. J Med Internet Res 2023; 25:e43771. [PMID: 36787181 PMCID: PMC9975925 DOI: 10.2196/43771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 12/22/2022] [Accepted: 01/12/2023] [Indexed: 02/15/2023] Open
Abstract
BACKGROUND Global workforce challenges faced by health care providers are linked to low levels of job satisfaction, recruitment, retention, and well-being, with detrimental impacts on patient care outcomes. Resilience-building programs can provide support for staff who endure highly stressful environments, enhance resilience, and support recruitment and retention, with web-based formats being key to increasing accessibility. OBJECTIVE We aimed to examine participants' engagement with a newly developed Resilience Enhancement Online Training for Nurses (REsOluTioN), explore its acceptability, and compare levels of resilience and psychological well-being in nurses who completed REsOluTioN with those who did not. METHODS We carried out a pilot randomized trial (1:1), conducted at a single site (mental health and community trust in South England) between August 2021 and May 2022. Local research ethics approvals were obtained. Nurses were invited to participate and were randomly assigned to a waitlist group or REsOluTioN group. Training lasted for 4 weeks, consisting of prereading, web-based facilitated sessions, and mentorship support. We evaluated trial engagement, acceptability of training, and pre-post changes in resilience, measured by the Brief Resilience Scale, and psychological well-being, measured by the Warwick Edinburgh Mental Wellbeing Scale. Qualitative participant feedback was collected. Consolidated Standards of Reporting Trials 2010 extension guidelines for reporting pilot and feasibility trials were used. RESULTS Of 108 participants recruited, 93 completed the study. Participants' mean age was 44 (SD 10.85) years. Most participants were female (n=95, 88.8%), White (n=95, 88.8%), and worked in community settings (n=91, 85.0%). Sixteen facilitated and 150 mentoring sessions took place. Most REsOluTioN program participants reported the sessions helped improve their resilience (n=24, 72.8%), self-confidence (n=24, 72.7%), ability to provide good patient care (n=25, 75.8%), relationships with colleagues (n=24, 72.7%), and communication skills (n=25, 75.8%). No statistically significant differences between training and control groups and time on well-being (F1,91=1.44, P=.23, partial η2=0.02) and resilience scores (F1,91=0.33, P=.57, partial η2=0.004) were revealed; however, there were positive trends toward improvement in both. Nurse participants engaged with the REsOluTioN program and found it acceptable. Most found web-based training and mentoring useful and enjoyed learning, reflection, networking, and participatory sessions. CONCLUSIONS The REsOluTioN program was acceptable, engaging, perceived as useful, and nurses were keen for it to be implemented to optimize resilience, psychological health, communication, and workplace environments. The study has evidenced that it is acceptable to implement web-based resilience programs with similar design features within busy health care settings, indicating a need for similar programs to be carefully evaluated. Mentorship support may also be a key in optimizing resilience. Trial limitations include small sample size and reduced statistical power; a multicenter randomized controlled trial could test effectiveness of the training on a larger scale. TRIAL REGISTRATION ClinicalTrials.gov NCT05074563; https://clinicaltrials.gov/ct2/show/NCT05074563. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) RR2-10.2196/37015.
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Affiliation(s)
| | - Zoe Davey
- Oxford Institute for Nursing, Midwifery and Allied Health Research, Oxford Brookes University, Oxford, United Kingdom
| | - Cynthia Srikesavan
- Oxford Institute for Nursing, Midwifery and Allied Health Research, Oxford Brookes University, Oxford, United Kingdom
| | - Liam Hart
- Research and Development, Oxford Health NHS Foundation Trust, Oxford, United Kingdom
| | - Dan Butcher
- Oxford Institute for Nursing, Midwifery and Allied Health Research, Oxford Brookes University, Oxford, United Kingdom
| | - Andrea Cipriani
- Department of Psychiatry, University of Oxford, Oxford, United Kingdom
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Griffiths F, Srikesavan C, Ward L, Boniface G, Williamson E, Lamb SE. Longitudinal qualitative study of living with neurogenic claudication. BMJ Open 2022; 12:e060128. [PMID: 36104131 PMCID: PMC9476140 DOI: 10.1136/bmjopen-2021-060128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVES Neurogenic claudication (NC) causes pain and reduced mobility, particularly in older people, and can negatively affect mental and social well-being, so limiting successful ageing. This qualitative study explored how people with NC changed over 12 months. DESIGN A longitudinal qualitative study using semi-structured interviews. SETTING Participants were recruited from a UK clinical trial of a physiotherapy intervention for NC. PARTICIPANTS Interviews were undertaken at baseline, 1 month after receiving any intervention and at 12 months. We analysed 30 sets of three interviews. RESULTS Interview data were summarised for each time point into biopsychosocial domains: pain, mobility and activities of daily living, psychological impact, and social and recreational participation. Through comparative analysis we explored participant trajectories over time.Progressive improvement in at least one domain was experienced by 13 participants, but there was variability in trajectories with early improvements that remained the same, transient changes and no change also commonly observed.Eleven participants described co-present improvement trajectories in all domains. Three participants described co-present improvement in all domains except participation; one had never stopped their participation and two had unattainable expectations. Five participants described co-present improvement in one domain and deterioration in another and 14 participants described co-present no change in one domain and change in another.There was evidence of interaction between domains; for example, improved mobility led to improved participation and for some participants, specific factors influenced change. Of the 15 participants who experienced improved participation, 10 reported improvements in all other domains and five participants did not; for two, pain did not prevent participation, one used a walking aid and two had a positive psychological outlook. CONCLUSION The daily lived experiences of older adults with NC are variable and include interaction between biopsychosocial domains. Therapist understanding of these trajectories and their interactions may help to provide personalised therapy TRIAL REGISTRATION NUMBER: ISRCTN12698674.
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Affiliation(s)
- Frances Griffiths
- Warwick Medical School, University of Warwick, Coventry, West Midlands, UK
| | - Cynthia Srikesavan
- Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, Oxfordshire, UK
| | - Lesley Ward
- Department of Sport, Exercise & Rehabilitation, Northumbria University, Newcastle upon Tyne, Tyne and Wear, UK
| | - Graham Boniface
- Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, Oxfordshire, UK
| | - Esther Williamson
- Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, Oxfordshire, UK
- College of Medicine and Health, University of Exeter, Exeter, Devon, UK
| | - Sarah E Lamb
- Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, Oxfordshire, UK
- College of Medicine and Health, University of Exeter, Exeter, Devon, UK
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Davey Z, Srikesavan C, Cipriani A, Henshall C. It’s What We Do: Experiences of UK Nurses Working during the COVID-19 Pandemic: Impact on Practice, Identity and Resilience. Healthcare (Basel) 2022; 10:healthcare10091674. [PMID: 36141286 PMCID: PMC9498531 DOI: 10.3390/healthcare10091674] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Revised: 08/19/2022] [Accepted: 08/24/2022] [Indexed: 01/28/2023] Open
Abstract
The COVID-19 pandemic increased pressure on a nursing workforce already facing high levels of stress, burnout, and fatigue in the United Kingdom (UK) and internationally. The contribution of nurses to keeping the public safe was widely recognised as they met the challenges of delivering complex patient care during the healthcare crisis. However, the psychological impact of this on nurses’ health and wellbeing has been substantial, and the number of nurses leaving the profession in the UK is rising. The aim of this study was to explore the experiences of nurses working during the COVID-19 pandemic and the impact of this on their psychological health, wellbeing and resilience. The study is part of a wider project to develop and pilot an online resilience intervention for nurses during COVID-19. Five focus groups with 22 nurses were carried out online. Data was analysed thematically using the Framework Method. Four key themes relating to positive and negative impacts of working during the pandemic were identified: Rapid changes and contexts in flux; loss and disruption; finding opportunities and positive transformation; and reinforcing and strengthening identity. Implications for coping and resilience in nursing, nursing identities and workforce development are discussed.
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Affiliation(s)
- Zoe Davey
- Oxford Institute of Nursing Midwifery and Allied Health Research, Faculty of Health and Life Sciences, Oxford Brookes University, Oxford OX3 0FL, UK
- Correspondence:
| | - Cynthia Srikesavan
- Oxford Institute of Nursing Midwifery and Allied Health Research, Faculty of Health and Life Sciences, Oxford Brookes University, Oxford OX3 0FL, UK
| | - Andrea Cipriani
- Oxford Health NHS Foundation Trust, Warneford Hospital, Oxford OX3 7JX, UK
- Department of Psychiatry, University of Oxford, Oxford OX3 7JX, UK
- Oxford Precision Psychiatry Lab, NIHR Oxford Health, Oxford OX3 7JX, UK
| | - Catherine Henshall
- Oxford Institute of Nursing Midwifery and Allied Health Research, Faculty of Health and Life Sciences, Oxford Brookes University, Oxford OX3 0FL, UK
- Oxford Health NHS Foundation Trust, Warneford Hospital, Oxford OX3 7JX, UK
- Oxford Precision Psychiatry Lab, NIHR Oxford Health, Oxford OX3 7JX, UK
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Srikesavan C, Davey Z, Cipriani A, Henshall C. Resilience Enhancement Online Training for Nurses (REsOluTioN): Protocol for a Pilot Randomized Controlled Trial. JMIR Res Protoc 2022; 11:e37015. [PMID: 35862692 PMCID: PMC9359309 DOI: 10.2196/37015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Accepted: 07/14/2022] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Globally, nurses are facing increased pressure to provide high-quality complex patient care within environments with scarce resources in terms of staffing, infrastructure, or financial reward. The strain and demand on the psychological health and well-being of nurses during COVID-19 has been substantial, with many experiencing burnout; as such, interventions to enhance resilience within the workplace are required. A face-to-face resilience enhancement training program for nurses that was effective in improving resilience levels was translated into a 4-week online training program, Resilience Enhancement Online Training for Nurses (REsOluTioN), to enable greater accessibility for nurses. OBJECTIVE This study aims to compare levels of resilience, psychological health, and well-being in nurses before and after the online resilience training compared to a wait list control group. It will also explore participants' engagement with the trial and their acceptability of the online training. METHODS This is a two-arm, parallel, randomized controlled trial with a 6-week follow-up period. Up to 100 registered nonagency nurses working at a National Health Service hospital trust in South England will be recruited. Four cohorts will run, and participants will be randomized into a wait list control group or to REsOluTioN. Pre- and postonline surveys will collect study outcome measure data. In the REsOluTioN arm, data will be collected on the perceived usefulness of the online training via an online survey. Institutional and health research authority approvals have been obtained. RESULTS REsOluTioN will aim to empower nurses to maintain and enhance their resilience while working under challenging clinical conditions. The online training will be interactive with input from mentors, health care leaders, and peers to promote engagement and enhanced communication, and will create a forum where nurses can express their views and concerns, without hierarchical infrastructures inhibiting them. This can increase self-knowledge and learning around workplace resilience coping strategies and provide a safe space to validate feelings through mentorship and peer support. Findings will be reported in accordance with the CONSORT (Consolidated Standards of Reporting Trials) guidelines. The trial is now finished and was conducted between August 2021 and May 2022. CONCLUSIONS The REsOluTioN trial will enable preliminary data to be gathered to indicate the online training's effectiveness in enhancing nurses' resilience in the workplace, with the potential for larger scale follow-up studies to identify its value to nurses working across a range of health care settings. TRIAL REGISTRATION ClinicalTrials.gov NCT05074563; https://clinicaltrials.gov/ct2/show/NCT05074563. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/37015.
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Affiliation(s)
- Cynthia Srikesavan
- Oxford School of Nursing and Midwifery, Faculty of Health and Life Sciences, Oxford Brookes University, Oxford, United Kingdom
| | - Zoe Davey
- Oxford School of Nursing and Midwifery, Faculty of Health and Life Sciences, Oxford Brookes University, Oxford, United Kingdom
| | - Andrea Cipriani
- Department of Psychiatry, University of Oxford, Oxford, United Kingdom
| | - Catherine Henshall
- Oxford School of Nursing and Midwifery, Faculty of Health and Life Sciences, Oxford Brookes University, Oxford, United Kingdom
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Srikesavan C, Williamson E, Thompson JY, Cranston T, Swales C, Lamb SE. The online version of an evidence-based hand exercise program for people with rheumatoid arthritis: A mixed-method, proof-of-concept study. J Hand Ther 2022; 35:468-476. [PMID: 33279362 DOI: 10.1016/j.jht.2020.10.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Revised: 09/17/2020] [Accepted: 10/19/2020] [Indexed: 02/03/2023]
Abstract
INTRODUCTION The Strengthening And stretching for Rheumatoid Arthritis of the Hand (SARAH) program is a tailored, 12-week hand and arm exercise program recommended in the National Institute for Health and Care Excellence guidelines. It includes seven mobility exercises and four strength exercises against resistance. An online version of the SARAH program (mySARAH) has been developed to allow direct access for people with rheumatoid arthritis. PURPOSE The purpose of this study was to assess the feasibility, acceptability, and clinical impact of mySARAH in people with rheumatoid arthritis. STUDY DESIGN This is a mixed-method, proof-of-concept study. METHODS mySARAH is a self-guided, online version of the SARAH program with six exercise training and review sessions. Participants were observed as they worked through four of the six online sessions. They were also asked to demonstrate the SARAH exercises. Participants undertook two sessions independently at home. At the baseline and 12 weeks, hand pain, hand function, and grip strength were measured. At 12 weeks, feedback on mySARAH, and perceived recovery were also collected. Approximately one month later, a telephone follow-up was conducted to explore participants' experiences with mySARAH. Pain, hand function, and perceived recovery were also assessed. RESULTS Eleven participants (males/females: 3/8) with a median (interquartile range) age of 63 (17) years took part. Six participants completed all mySARAH sessions. About 512 exercise and load-setting demonstrations were observed and 491 (96%) were performed correctly. Improvements in grip strength and hand function were observed with no increase in pain. Most of the participants reported improvement and provided positive feedback. All participants perceived mySARAH as a useful resource. Features to improve the online exercise diary such as recording and tracking exercise dose and face-to-face or remote support by phone or Skype from health professionals were suggested to optimize user engagement. CONCLUSIONS Initial evaluation of mySARAH indicates that mySARAH was feasible, acceptable, and beneficial to participants. Further iteration and evaluation are needed before large-scale implementation.
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Affiliation(s)
- Cynthia 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
| | - Jacqueline Y Thompson
- Centre for Rehabilitation Research in Oxford, Botnar Research Centre, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
| | - Tim Cranston
- Oxford Clinical Trials Unit, Botnar Research Centre, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
| | - Catherine Swales
- University of Oxford Medical School, Botnar Research Centre, Nuffield Orthopaedic Centre, 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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Abstract
Aims Osteoarthritis (OA) affecting the thumb carpometacarpal joint (CMCJ) is a common painful condition. In this study, we aimed to explore clinicians’ approach to management with a particular focus on the role of specific interventions that will inform the design of future clinical trials. Methods We interviewed a purposive sample of 24 clinicians, consisting of 12 surgeons and 12 therapists (four occupational therapists and eight physiotherapists) who managed patients with CMCJ OA. This is a qualitative study using semi-structured, online interviews. Interviews were audio-recorded, transcribed verbatim, and analyzed using thematic analysis. Results A total of 14 themes were developed, six of which were developed relating to the clinical management of CMCJ OA: 1) A flexible ‘ladder’ approach starting with conservative treatment first; 2) The malleable role of steroid injection; 3) Surgery as an invasive and risky last resort; 4) A shared and collaborative approach; 5) Treating the whole person; and 6) Severity of life impact influences treatment. The remaining eight themes were developed relating to clinical trial barriers and facilitators: 1) We need to embrace uncertainty; 2) You are not losing out by taking part; 3) It is difficult to be neutral about certain treatments; 4) Difficult to recruit to ‘no treatment’ ; 5) Difficult to recruit to a trial comparing no surgery to surgery; 6) Patients are keen to participate in research; 7) Burden on staff and participants; and 8) A enthusiasm for a variety of potential trial arms. Conclusion Our findings contribute to a better understanding of how clinicians manage thumb CMCJ OA in their practice settings. Our study also provides useful insights informing the design of randomized clinical trials involving steroid injections and surgery in people with thumb CMCJ OA. Cite this article: Bone Jt Open 2022;3(4):321–331.
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Affiliation(s)
- Benjamin J. F. Dean
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), Botnar Research Centre, University of Oxford, Oxford, UK
| | - Cynthia Srikesavan
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), Botnar Research Centre, University of Oxford, Oxford, UK
| | | | - Francine Toye
- Physiotherapy Research Unit, Oxford University Hospitals NHS Trust, Nuffield Orthopaedic Centre, Oxford, UK
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11
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Keene DJ, Srikesavan C, Achten J, Tutton E, Dutton SJ, Marian IR, Grant R, Gould J, Herbert K, Athwal A, Appelbe D, Lamb SE, Costa ML. Flexibility and resistance exercises versus usual care for improving pain and function after distal radius fracture in adults aged 50 years or over: protocol for the WISE randomised multicentre feasibility trial. Pilot Feasibility Stud 2022; 8:55. [PMID: 35256000 PMCID: PMC8898994 DOI: 10.1186/s40814-022-01011-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 02/18/2022] [Indexed: 11/26/2022] Open
Abstract
Background Distal radius fractures represent about 1 in 5 of all fractures treated in UK hospitals. Most distal radius fractures occur in women aged 50 years or over after a fall. Distal radius fractures are managed using splints or casting, some are also treated with surgical fixation. Patients often experience long-term muscle weakness of the hand and arm that may impact their ability to do daily activities such as personal hygiene, routine household chores and food preparation. We propose a structured and tailored flexibility and resistance exercise programme for the hand and arm supplemented with behaviour change strategies to help perform daily exercise. The main aim of our study is to assess the feasibility of conducting a definitive randomised controlled trial. Methods This study is a multicentre, parallel-group individually randomised feasibility trial. We will recruit a minimum of 72 adults aged 50 years or over with distal radius fracture treated surgically or non-surgically from at least three UK National Health Service (NHS) hospitals. They will be randomised 1:1:1 to receive usual care, usual care and independent exercise with a single therapy session or usual care and supervised exercise with three therapy sessions over 12 weeks. Our primary feasibility objectives are (1) patient engagement assessed by recruitment, (2) acceptability of the interventions assessed by adherence and patient and clinician experience and (3) retention of participants in the trial. Outcome measures will be assessed at baseline, 3 months and at 6 months after randomisation. A qualitative sub-study will explore the experiences of the trial participants and therapists delivering the exercises. Discussion A definitive trial will be considered feasible without major modifications if our progression criteria are met. If successful, the findings will inform the design of a future definitive RCT to evaluate the clinical and cost-effectiveness of the WISE exercise programme. Trial registration ISRCTN12290145.
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Srikesavan C, Toye F, Brealey S, Goodchild L, Northgraves M, Charalambous CP, Rangan A, Lamb S. Experiences and perceptions of trial participants and healthcare professionals in the UK Frozen Shoulder Trial (UK FROST): a nested qualitative study. BMJ Open 2021; 11:e040829. [PMID: 34117042 PMCID: PMC8202103 DOI: 10.1136/bmjopen-2020-040829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES To explore the experiences and perceptions of trial participants and healthcare professionals in the UK Frozen Shoulder Trial (UK FROST), a multicentre randomised controlled trial that compared manipulation under anaesthesia (MUA), arthroscopic capsular release (ACR) with a 12-week early structured physiotherapy programme (ESP) in people with unilateral frozen shoulder referred to secondary care. DESIGN Nested qualitative study with semistructured interviews. We used constant comparison method to develop our themes. SETTING This qualitative study was nested within the UK FROST. PARTICIPANTS 44 trial participants (ESP: 14; MUA: 15; ACR: 15), and 8 surgeons and 8 physiotherapists who delivered the treatments in the trial. RESULTS Trial participants found UK FROST treatments acceptable and satisfactory in terms of content, delivery and treatment benefits. Participants in all arms experienced improvements in pain, shoulder movements, and function. Participants said they would choose the same treatment that they received in the trial.Surgeons and physiotherapists felt that the content and delivery of UK FROST treatments was not significantly different to their routine practice except for the additional number of physiotherapy sessions offered in the trial. They had mixed feelings about the effectiveness of UK FROST treatments. Both stressed the value of including hydrodilatation as a comparator of other treatment options. Physiotherapists raised concerns about the capacity to deliver the number of UK FROST physiotherapy sessions in routine clinical settings.Shared perceptions of trial participants, surgeons and physiotherapists were: (1) Pain relief and return of shoulder movements and function are important outcomes and (2) Adherence to exercises leads to better outcomes. CONCLUSION In general, our findings indicated that trial participants, and surgeons and physiotherapists who delivered the treatments had positive experiences and perceptions in the UK FROST. Early qualitative investigations to explore the feasibility of delivering treatments in real-world settings are suggested in future trials in the frozen shoulder. TRIAL REGISTRATION NUMBER International Standard Randomised Controlled Trial Register, ID: ISRCTN48804508. Registered on 25 July 2014; Results.
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Affiliation(s)
- Cynthia Srikesavan
- Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Francine Toye
- Physiotherapy Research Unit, Oxford University Hospitals NHS Foundation Trust Nuffield Orthopaedic Centre, Oxford, UK
| | - Stephen Brealey
- York Trials Unit, ARRC Building, Department of Health Sciences, University of York, York, UK
| | - Lorna Goodchild
- The James Cook University Hospital, South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK
| | | | - Charalambos P Charalambous
- Blackpool Teaching Hospitals NHS Foundation Trust, Blackpool, UK
- School of Medicine, University of Central Lancashire, Preston, UK
| | - Amar Rangan
- York Trials Unit, ARRC Building, Department of Health Sciences, University of York, York, UK
| | - Sarah Lamb
- Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- College of Medicine and Health, University of Exeter, Exeter, UK
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Tonga E, Williamson E, Srikesavan C, Özen T, Sarıtaş F, Lamb SE. A hand exercise mobile app for people with rheumatoid arthritis in Turkey: design, development and usability study. Rheumatol Int 2021; 41:1151-1160. [PMID: 33870452 DOI: 10.1007/s00296-021-04860-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Accepted: 04/07/2021] [Indexed: 10/21/2022]
Abstract
To design and develop a smartphone application for a structured hand exercise programme for patients with rheumatoid arthritis (RA) in Turkey and to test its usability. We followed a two-stage process: (1) Design and Development and (2) Usability testing. In stage 1, we used a qualitative user-centered design approach. We conducted a focus group (8 therapists and people with RA) to discuss the content, features and design to produce a prototype of the application. In a second focus group session, the participants tested the prototype, provided feedback and further revisions were made. In stage 2, 17 participants with RA used the app for 4 to 6 weeks. The System Usability Scale and the adapted Usability, Satisfaction and Ease to Use Questionnaires were used to measure usability, ease of use. Semi-structured interviews were conducted to explore user experiences with the application with 17 participants. In stage 1, the following themes were identified from the focus groups (a) login techniques (b) self-monitoring (c) exercises, (d) exercise diary, (e) information, (f) behavioral change and encouragement (g) exercise adherence. In stage 2, 3 themes were determined from interviews: (a) learning and accuracy, (b) ease of use, (c) motivation and adherence. USE and SUS scores indicated that users reported a high level of usability, satisfaction and ease of use. A mobile app for hand exercise for people with RA was developed using a mixed-method and iterative design. Participants perceived the mobile app as easy to use with high levels of satisfaction.
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Affiliation(s)
- Eda Tonga
- Faculty of Health Sciences, Department of Physiotherapy and Rehabilitation, Marmara University, Başıbüyük Campus, Başıbüyük St. 3484, Maltepe, Istanbul, Turkey.
| | - Esther Williamson
- Centre for Rehabilitation Research, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford, UK
| | - Cynthia Srikesavan
- Centre for Rehabilitation Research, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford, UK
| | - Tuğçe Özen
- Faculty of Health Sciences, Department of Physiotherapy and Rehabilitation, Marmara University, Başıbüyük Campus, Başıbüyük St. 3484, Maltepe, Istanbul, Turkey
| | - Fatih Sarıtaş
- Haydarpasa Numune Research and Education Hospital, Rheumatology Clinic, Istanbul, Turkey
| | - Sarah E Lamb
- Centre for Rehabilitation Research, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford, UK.,Collage of Medicine and Health, University of Exeter, Exeter, UK
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Brealey S, Northgraves M, Kottam L, Keding A, Corbacho B, Goodchild L, Srikesavan C, Rex S, Charalambous CP, Hanchard N, Armstrong A, Brooksbank A, Carr A, Cooper C, Dias J, Donnelly I, Hewitt C, Lamb SE, McDaid C, Richardson G, Rodgers S, Sharp E, Spencer S, Torgerson D, Toye F, Rangan A. Surgical treatments compared with early structured physiotherapy in secondary care for adults with primary frozen shoulder: the UK FROST three-arm RCT. Health Technol Assess 2020; 24:1-162. [PMID: 33292924 DOI: 10.3310/hta24710] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Frozen shoulder causes pain and stiffness. It affects around 10% of people in their fifties and is slightly more common in women. Costly and invasive surgical interventions are used, without high-quality evidence that these are effective. OBJECTIVES To compare the clinical effectiveness and cost-effectiveness of three treatments in secondary care for adults with frozen shoulder; to qualitatively explore the acceptability of these treatments to patients and health-care professionals; and to update a systematic review to explore the trial findings in the context of existing evidence for the three treatments. DESIGN This was a pragmatic, parallel-group, multicentre, open-label, three-arm, randomised superiority trial with unequal allocation (2 : 2 : 1). An economic evaluation and a nested qualitative study were also carried out. SETTING The orthopaedic departments of 35 hospitals across the UK were recruited from April 2015, with final follow-up in December 2018. PARTICIPANTS Participants were adults (aged ≥ 18 years) with unilateral frozen shoulder, characterised by restriction of passive external rotation in the affected shoulder to < 50% of the opposite shoulder, and with plain radiographs excluding other pathology. INTERVENTIONS The inventions were early structured physiotherapy with a steroid injection, manipulation under anaesthesia with a steroid injection and arthroscopic capsular release followed by manipulation. Both of the surgical interventions were followed with post-procedural physiotherapy. MAIN OUTCOME MEASURES The primary outcome and end point was the Oxford Shoulder Score at 12 months post randomisation. A difference of 5 points between early structured physiotherapy and manipulation under anaesthesia or arthroscopic capsular release or of 4 points between manipulation under anaesthesia and arthroscopic capsular release was judged clinically important. RESULTS The mean age of the 503 participants was 54 years; 319 were female (63%) and 150 had diabetes (30%). The primary analyses comprised 473 participants (94%). At the primary end point of 12 months, participants randomised to arthroscopic capsular release had, on average, a statistically significantly higher (better) Oxford Shoulder Score than those randomised to manipulation under anaesthesia (2.01 points, 95% confidence interval 0.10 to 3.91 points; p = 0.04) or early structured physiotherapy (3.06 points, 95% confidence interval 0.71 to 5.41 points; p = 0.01). Manipulation under anaesthesia did not result in statistically significantly better Oxford Shoulder Score than early structured physiotherapy (1.05 points, 95% confidence interval -1.28 to 3.39 points; p = 0.38). No differences were deemed of clinical importance. Serious adverse events were rare but occurred in participants randomised to surgery (arthroscopic capsular release,n = 8; manipulation under anaesthesia,n = 2). There was, however, one serious adverse event in a participant who received non-trial physiotherapy. The base-case economic analysis showed that manipulation under anaesthesia was more expensive than early structured physiotherapy, with slightly better utilities. The incremental cost-effectiveness ratio for manipulation under anaesthesia was £6984 per additional quality-adjusted life-year, and this intervention was probably 86% cost-effective at the threshold of £20,000 per quality-adjusted life-year. Arthroscopic capsular release was more costly than early structured physiotherapy and manipulation under anaesthesia, with no statistically significant benefit in utilities. Participants in the qualitative study wanted early medical help and a quicker pathway to resolve their shoulder problem. Nine studies were identified from the updated systematic review, including UK FROST, of which only two could be pooled, and found that arthroscopic capsular release was more effective than physiotherapy in the long-term shoulder functioning of patients, but not to the clinically important magnitude used in UK FROST. LIMITATIONS Implementing physiotherapy to the trial standard in clinical practice might prove challenging but could avoid theatre use and post-procedural physiotherapy. There are potential confounding effects of waiting times in the trial. CONCLUSIONS None of the three interventions was clearly superior. Early structured physiotherapy with a steroid injection is an accessible and low-cost option. Manipulation under anaesthesia is the most cost-effective option. Arthroscopic capsular release carries higher risks and higher costs. FUTURE WORK Evaluation in a randomised controlled trial is recommended to address the increasing popularity of hydrodilatation despite the paucity of high-quality evidence. TRIAL REGISTRATION Current Controlled Trials ISRCTN48804508. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 71. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Stephen Brealey
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - Matthew Northgraves
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - Lucksy Kottam
- The James Cook University Hospital, South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK
| | - Ada Keding
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - Belen Corbacho
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | | | - Cynthia Srikesavan
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Oxford, UK
| | - Saleema Rex
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - Charalambos P Charalambous
- Department of Orthopaedics, Blackpool Victoria Hospital, Blackpool, UK.,School of Medicine, University of Central Lancashire, Preston, UK
| | - Nigel Hanchard
- School of Health & Life Sciences, Teesside University, Middlesbrough, UK
| | | | | | - Andrew Carr
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Oxford, UK
| | - Cushla Cooper
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Oxford, UK
| | - Joseph Dias
- University Hospitals of Leicester NHS Trust, Leicester, UK
| | | | - Catherine Hewitt
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - Sarah E Lamb
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Oxford, UK
| | - Catriona McDaid
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | | | - Sara Rodgers
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | | | - Sally Spencer
- Postgraduate Medical Institute, Edge Hill University, Ormskirk, UK
| | - David Torgerson
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - Francine Toye
- Physiotherapy Research Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Amar Rangan
- York Trials Unit, Department of Health Sciences, University of York, York, UK.,The James Cook University Hospital, South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK.,Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Oxford, UK
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Rangan A, Brealey SD, Keding A, Corbacho B, Northgraves M, Kottam L, Goodchild L, Srikesavan C, Rex S, Charalambous CP, Hanchard N, Armstrong A, Brooksbank A, Carr A, Cooper C, Dias JJ, Donnelly I, Hewitt C, Lamb SE, McDaid C, Richardson G, Rodgers S, Sharp E, Spencer S, Torgerson D, Toye F. Management of adults with primary frozen shoulder in secondary care (UK FROST): a multicentre, pragmatic, three-arm, superiority randomised clinical trial. Lancet 2020; 396:977-989. [PMID: 33010843 DOI: 10.1016/s0140-6736(20)31965-6] [Citation(s) in RCA: 73] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 06/26/2020] [Accepted: 07/08/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Manipulation under anaesthesia and arthroscopic capsular release are costly and invasive treatments for frozen shoulder, but their effectiveness remains uncertain. We compared these two surgical interventions with early structured physiotherapy plus steroid injection. METHODS In this multicentre, pragmatic, three-arm, superiority randomised trial, patients referred to secondary care for treatment of primary frozen shoulder were recruited from 35 hospital sites in the UK. Participants were adults (≥18 years) with unilateral frozen shoulder, characterised by restriction of passive external rotation (≥50%) in the affected shoulder. Participants were randomly assigned (2:2:1) to receive manipulation under anaesthesia, arthroscopic capsular release, or early structured physiotherapy. In manipulation under anaesthesia, the surgeon manipulated the affected shoulder to stretch and tear the tight capsule while the participant was under general anaesthesia, supplemented by a steroid injection. Arthroscopic capsular release, also done under general anaesthesia, involved surgically dividing the contracted anterior capsule in the rotator interval, followed by manipulation, with optional steroid injection. Both forms of surgery were followed by postprocedural physiotherapy. Early structured physiotherapy involved mobilisation techniques and a graduated home exercise programme supplemented by a steroid injection. Both early structured physiotherapy and postprocedural physiotherapy involved 12 sessions during up to 12 weeks. The primary outcome was the Oxford Shoulder Score (OSS; 0-48) at 12 months after randomisation, analysed by initial randomisation group. We sought a target difference of 5 OSS points between physiotherapy and either form of surgery, or 4 points between manipulation and capsular release. The trial registration is ISRCTN48804508. FINDINGS Between April 1, 2015, and Dec 31, 2017, we screened 914 patients, of whom 503 (55%) were randomly assigned. At 12 months, OSS data were available for 189 (94%) of 201 participants assigned to manipulation (mean estimate 38·3 points, 95% CI 36·9 to 39·7), 191 (94%) of 203 participants assigned to capsular release (40·3 points, 38·9 to 41·7), and 93 (94%) of 99 participants assigned to physiotherapy (37·2 points, 35·3 to 39·2). The mean group differences were 2·01 points (0·10 to 3·91) between the capsular release and manipulation groups, 3·06 points (0·71 to 5·41) between capsular release and physiotherapy, and 1·05 points (-1·28 to 3·39) between manipulation and physiotherapy. Eight serious adverse events were reported with capsular release and two with manipulation. At a willingness-to-pay threshold of £20 000 per quality-adjusted life-year, manipulation under anaesthesia had the highest probability of being cost-effective (0·8632, compared with 0·1366 for physiotherapy and 0·0002 for capsular release). INTERPRETATION All mean differences on the assessment of shoulder pain and function (OSS) at the primary endpoint of 12 months were less than the target differences. Therefore, none of the three interventions were clinically superior. Arthoscopic capsular release carried higher risks, and manipulation under anaesthesia was the most cost-effective. FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
- Amar Rangan
- York Trials Unit, Department of Health Sciences, University of York, York, UK; Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Oxford, UK; The James Cook University Hospital, South Tees Hospitals National Health Service (NHS) Foundation Trust, Middlesbrough, UK.
| | - Stephen D Brealey
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - Ada Keding
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - Belen Corbacho
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - Matthew Northgraves
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - Lucksy Kottam
- The James Cook University Hospital, South Tees Hospitals National Health Service (NHS) Foundation Trust, Middlesbrough, UK
| | - Lorna Goodchild
- The James Cook University Hospital, South Tees Hospitals National Health Service (NHS) Foundation Trust, Middlesbrough, UK
| | - Cynthia Srikesavan
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Oxford, UK
| | - Saleema Rex
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - Charalambos P Charalambous
- Department of Orthopaedics, Blackpool Victoria Hospital, Blackpool, UK; School of Medicine, University of Central Lancashire, Preston, UK
| | - Nigel Hanchard
- School of Health and Social Care, Teesside University, Middlesbrough, UK
| | | | | | - Andrew Carr
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Oxford, UK
| | - Cushla Cooper
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Oxford, UK
| | - Joseph J Dias
- University Hospitals of Leicester NHS Trust, Leicester, UK
| | | | - Catherine Hewitt
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - Sarah E Lamb
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Oxford, UK
| | - Catriona McDaid
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | | | - Sara Rodgers
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | | | - Sally Spencer
- Postgraduate Medical Institute, Edge Hill University, Ormskirk, UK
| | - David Torgerson
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - Francine Toye
- Physiotherapy Research Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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Williamson E, Srikesavan C, Thompson J, Tonga E, Eldridge L, Adams J, Lamb SE. Translating the Strengthening and Stretching for Rheumatoid Arthritis of the Hand Programme from clinical trial to clinical practice: An effectiveness–implementation study. Hand Therapy 2020. [DOI: 10.1177/1758998320948538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Introduction The Strengthening and Stretching for Rheumatoid Arthritis of the Hand programme is a hand exercise programme for people with rheumatoid arthritis. It was clinically effective when delivered during a clinical trial but there was a need to evaluate translation into routine care. Methods We conducted an effectiveness–implementation study. We adapted the trial training into an online format for National Health Service hand therapists. Educational outcomes included confidence and capability to deliver the programme. Implementation outcomes included training reach and adoption. Therapists were invited to collect clinical outcomes. Patients receiving the programme provided data on function (Michigan Hand Questionnaire function scale), pain and grip strength at baseline, treatment discharge and four-month follow-up. Results A total of 790 therapists (188 National Health Service organizations) enrolled in the training; 584/790 (74%) therapists (162 National Health Service organizations) completed the training; 448/790 therapists (145 National Health Service organizations) (57%) evaluated the training and were confident (447/448, 99.8%) and capable (443/448, 99%) to deliver the programme with 85% intending to adopt it (379/448). Follow-up data were provided by 116/448 (26%) therapists. Two-thirds (77/116; 51 National Health Service organizations) reported adopting the programme. One hundred and eighteen patients (15 National Health Service trusts) participated. Patients reported improved function (mean change Michigan Hand Questionnaire scores: 10 (95% CI 6.5–13.6) treatment discharge; 7 (95% CI 3.8–10.2) 4-month follow-up). Grip strength increased 24.5% (left) and 31% (right). Pain was stable. Discussion Online training was an effective way to train therapists with good reach. Clinical outcomes were similar to the clinical trial providing preliminary evidence of successful translation into routine care.
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Affiliation(s)
- Esther Williamson
- Centre for Rehabilitation Research, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Cynthia Srikesavan
- Centre for Rehabilitation Research, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Jacqueline Thompson
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
| | - Eda Tonga
- Department of Physiotherapy and Rehabilitation, Faculty of Health Sciences, Marmara University, Istanbul, Turkey
| | - Lucy Eldridge
- Oxford Clinical Trials Research Unit, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Jo Adams
- Health Sciences, University of Southampton, Southampton, UK
| | - Sarah E Lamb
- Centre for Rehabilitation Research, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- College of Medicine and Health, University of Exeter, Exeter, UK
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Tonga E, Srikesavan C, Williamson E, Lamb SE. Components, design and effectiveness of digital physical rehabilitation interventions for older people: A systematic review. J Telemed Telecare 2020; 28:162-176. [PMID: 32517544 DOI: 10.1177/1357633x20927587] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND With the rapid advancement in digital technologies, the use of digital health applications is increasing day by day. Although a large number of digital applications have been developed for rehabilitation of older people, there has been no review of the evidence for effectiveness of these interventions. METHODS The aim of our study was to review the evidence of digital rehabilitation interventions on outcomes including pain, function and quality of life in older people. We focused on digital interventions that are designed to improve and restore physical functioning. We searched six electronic bibliographic databases and included randomised controlled trials. Cochrane risk of bias tool and Cochrane's Grading of Recommendations, Assessment, Development and Evaluation approach was used to evaluate the risk of bias and grade the evidence. RESULTS Eight trials were included. The short-term effects of digital rehabilitation interventions on physical activity, quality of life, vertigo symptoms and falls are uncertain. Quality of trials was rated as very low to moderate evidence. CONCLUSION More research is needed to estimate effectiveness of these interventions.
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Affiliation(s)
- Eda Tonga
- Department of Physiotherapy and Rehabilitation, Marmara University, Turkey
| | - Cynthia Srikesavan
- The Centre for Rehabilitation Research, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, UK
| | - Esther Williamson
- The Centre for Rehabilitation Research, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, UK
| | - Sarah E Lamb
- The Centre for Rehabilitation Research, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, UK.,Collage of Medicine and Health, University of Exeter, UK
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Tonga E, Srikesavan C, Williamson E, Lamb S. AB1351-HPR A HAND EXERCISES MHEALTH APP FOR PATIENTS WITH RHEUMATOID ARTHRITIS: DEVELOPMENT, DESIGN AND USABILITY STUDY IN TURKEY. Ann Rheum Dis 2020. [DOI: 10.1136/annrheumdis-2020-eular.5496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Background:The Strengthening and Stretching for Rheumatoid Arthritis of the Hand (SARAH) programme has been shown to provide long term improvement in hand function for patients with rheumatoid arthritis (RA) affecting their hands. In Turkey, limited number of physiotherapists work in rheumatology departments so there is an opportunity to use the digital technologies for exercise prescription and follow up to improve access to treatment.Growing research evidence supports the effectiveness of mHealth interventions for improving exercise adherence and motivation.To our knowledge,there is no hand exercises mHealth program for patients with rheumatoid arthritis designed by experts with the user-centered method.Objectives:The aim of our study is to develop and design a smartphone application for structured hand exercise program for patients with RA in Turkey and to test its usability.Methods:We used a qualitative user-centered design approach with 2 phases.PHASE 1:we conducted focus group meetings to discuss the content, feature and design of app to produce a prototype version of smartphone software for RA hand training program.The Focus Group consisted of two physiotherapists and three hand therapists working in the field in different rheumatology or hand rehabilitation clinics,two software-computer engineers, and three patients with RA who had previously participated in hand therapy. The focus group met 4 times during phase 1. PHASE 2:we investigated the usability of prototype version of the rheumatoid hand exercise smartphone app software. All focus group members (n=10) and 6 patients used the app for one week.All users filled the usability questionnaire and provided written feedback on the app. Revisions were made and the revised version was tested. We put the revised app in digital markets in Turkish and English.Results:The major themes identified from the Focus Group discussions during phase 1 were (a)Login techniques (b)self-monitoring (c)exercises types/frequency/diary, (d) patient education, (e)behavioral change and encouragement (f)exercise adherence. Patients and therapist all agreed the login needed to be easy. Patients wanted to be able to monitor their pain levels and hand function in the app. Patients thought the SARAH exercise were suitable for the app. A patient said:‘SARAH exercises is beneficial for my hand and tendon gliding exercise,I will be happy to see these exercises in app’. Patients wanted exercise reminders using push up notifications to encourage exercise were proposed and included.A patient commented ‘in themorning and after work, motivational push up messages could be beneficial for exercise habit.”During the phase 2,we identified a need for education on how to use digital app, ways to provide patient follow up to monitor adherence, the need to allow patients to select the amount of notifications. This feedback was incorporated into the final version.Conclusion:mHealth applications represent an easily accessible bridge between patients and health professionals for home-based programs. Using a user-centered approach ensured that we developed an application that met the needs of therapists and patients. Physiotherapists are using the app in rheumatology clinics in Turkey and long-term usability and feasibility studies are ongoing.References:[1]Argent R, Patient Involvement With Home-Based Exercise Programs: Can Connected Health Interventions Influence Adherence? JMIR Mhealth Uhealth 2018.[2]Lamb SE, Strengthening and Stretching for Rheumatoid Arthritis of the Hand Trial (SARAH).Lancet. 2015,385(9966).[3]Azevedo R, Smartphone application for rheumatoid arthritis self-management: cross-sectional study revealed the usefulness, willingness to use and patients’ needs.Rheumatol Int.2015, 35(10).Disclosure of Interests:None declared
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Srikesavan C, Bhardwaj P, Gobinath K, Ramalingam AT, Sabapathy S. Tamil Translation, Cross-Cultural Adaptation, and Pilot Testing of the Disabilities of Arm, Shoulder, and Hand Questionnaire. Indian J Orthop 2019; 53:602-606. [PMID: 31488926 PMCID: PMC6699208 DOI: 10.4103/ortho.ijortho_713_17] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND The Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire is a commonly used patient-reported outcome measure of symptoms and function in people with upper limb conditions. The objectives of this study were to translate and cross-culturally adapt the DASH questionnaire for Tamil population in India and pilot test the questionnaire for feasibility and acceptability. MATERIALS AND METHODS The translation and cross-cultural adaptation process recommended by the developers of the DASH questionnaire was followed. The prefinal Tamil DASH was tested in people with a wide range of upper limb conditions. Acceptability and feasibility was evaluated by patient feedback and the time taken to complete the questionnaire. RESULTS Around 11 items were adapted to improve the relevance of the questionnaire for Tamil population. Thirty patients were recruited for pilot testing. The prefinal Tamil DASH was found to be relevant and comprehensible to patients (n = 29, Males/Females: 21/8; mean (SD) age: 34 (11.3) years) and feasible to administer. One item "Sexual activities" had more non-respondents (n = 16, 55%). Upon consultation with the developers, an item "Wash and blow dry hair" was further modified and the final Tamil DASH was produced. CONCLUSION Evaluation of reliability, validity and responsiveness in a large sample would inform the use of Tamil DASH in clinical and research settings.
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Affiliation(s)
| | - Praveen Bhardwaj
- Department of Plastic and Reconstructive Surgery, Hand and Microsurgery, Burns and Maxillofacial Surgery, Ganga Medical Centre and Hospitals Pvt. Ltd., Coimbatore, Tamil Nadu, India,Address for correspondence: Dr. Praveen Bhardwaj, Ganga Medical Centre and Hospitals Pvt. Ltd., 313, Mettupalayam Road, Coimbatore - 641 043, Tamil Nadu, India. E-mail:
| | - K Gobinath
- Department of Physiotherapy, Ganga Medical Centre and Hospitals Pvt. Ltd., Coimbatore, Tamil Nadu, India
| | | | - Srikesavan Sabapathy
- Department of Physiotherapy, Trauma Unit, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Richmond H, Lait C, Srikesavan C, Williamson E, Moser J, Newman M, Betteley L, Fordham B, Rees S, Lamb SE, Bruce J. Development of an exercise intervention for the prevention of musculoskeletal shoulder problems after breast cancer treatment: the prevention of shoulder problems trial (UK PROSPER). BMC Health Serv Res 2018; 18:463. [PMID: 29914494 PMCID: PMC6006920 DOI: 10.1186/s12913-018-3280-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Accepted: 06/05/2018] [Indexed: 02/06/2023] Open
Abstract
Background Musculoskeletal shoulder problems are common after breast cancer treatment. There is some evidence to suggest that early postoperative exercise is safe and may improve shoulder function. We describe the development and delivery of a complex intervention for evaluation within a randomised controlled trial (RCT), designed to target prevention of musculoskeletal shoulder problems after breast cancer surgery (The Prevention of Shoulder Problems Trial; PROSPER). Methods A pragmatic, multicentre RCT to compare the clinical and cost-effectiveness of best practice usual care versus a physiotherapy-led exercise and behavioural support intervention in women at high risk of shoulder problems after breast cancer treatment. PROSPER will recruit 350 women from approximately 15 UK centres, with follow-up at 6 and 12 months. The primary outcome is shoulder function at 12 months; secondary outcomes include postoperative pain, health related quality of life, adverse events and healthcare resource use. A multi-phased approach was used to develop the PROSPER intervention which was underpinned by existing evidence and modified for implementation after input from clinical experts and women with breast cancer. The intervention was tested and refined further after qualitative interviews with patients newly diagnosed with breast cancer; a pilot RCT was then conducted at three UK clinical centres. Discussion The PROSPER intervention incorporates three main components: shoulder-specific exercises targeting range of movement and strength; general physical activity; and behavioural strategies to encourage adherence and support exercise behaviour. The final PROSPER intervention is fully manualised with clear, documented pathways for clinical assessment, exercise prescription, use of behavioural strategies, and with guidance for treatment of postoperative complications. This paper adheres to TIDieR and CERT recommendations for the transparent, comprehensive and explicit reporting of complex interventions. Trial registration International Standard Randomised Controlled Trial Number: ISRCTN 35358984.
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Affiliation(s)
- Helen Richmond
- Warwick Clinical Trials Unit, Division of Health Sciences, University of Warwick, Coventry, CV4 7AL, UK
| | - Clare Lait
- Gloucestershire Care Services NHS Trust, 1010 Gloucester Business Park, Pioneer Avenue, Brockworth, Gloucester, GL, 3 4AW, UK
| | - Cynthia Srikesavan
- Botnar Research Centre, Nuffield Department of Orthopaedics Rheumatology & Musculoskeletal Sciences, University of Oxford, Windmill Road, Oxford, OX3 7LD, UK
| | - Esther Williamson
- Botnar Research Centre, Nuffield Department of Orthopaedics Rheumatology & Musculoskeletal Sciences, University of Oxford, Windmill Road, Oxford, OX3 7LD, UK
| | - Jane Moser
- Physiotherapy Research Unit, Oxford University Hospitals NHS Foundation Trust, Nuffield Orthopaedic Centre, Windmill Road, Oxford, OX3 7HE, UK
| | - Meredith Newman
- Botnar Research Centre, Nuffield Department of Orthopaedics Rheumatology & Musculoskeletal Sciences, University of Oxford, Windmill Road, Oxford, OX3 7LD, UK.,Physiotherapy Research Unit, Oxford University Hospitals NHS Foundation Trust, Nuffield Orthopaedic Centre, Windmill Road, Oxford, OX3 7HE, UK
| | - Lauren Betteley
- Warwick Clinical Trials Unit, Division of Health Sciences, University of Warwick, Coventry, CV4 7AL, UK
| | - Beth Fordham
- Botnar Research Centre, Nuffield Department of Orthopaedics Rheumatology & Musculoskeletal Sciences, University of Oxford, Windmill Road, Oxford, OX3 7LD, UK
| | - Sophie Rees
- Warwick Clinical Trials Unit, Division of Health Sciences, University of Warwick, Coventry, CV4 7AL, UK
| | - Sarah E Lamb
- Warwick Clinical Trials Unit, Division of Health Sciences, University of Warwick, Coventry, CV4 7AL, UK.,Botnar Research Centre, Nuffield Department of Orthopaedics Rheumatology & Musculoskeletal Sciences, University of Oxford, Windmill Road, Oxford, OX3 7LD, UK
| | - Julie Bruce
- Warwick Clinical Trials Unit, Division of Health Sciences, University of Warwick, Coventry, CV4 7AL, UK.
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Srikesavan C, Bryer C, Ali U, Williamson E. Web-based rehabilitation interventions for people with rheumatoid arthritis: A systematic review. J Telemed Telecare 2018; 25:263-275. [PMID: 29669470 DOI: 10.1177/1357633x18768400] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND Rehabilitation approaches for people with rheumatoid arthritis include joint protection, exercises and self-management strategies. Health interventions delivered via the web have the potential to improve access to health services overcoming time constraints, physical limitations, and socioeconomic and geographic barriers. The objective of this review is to determine the effects of web-based rehabilitation interventions in adults with rheumatoid arthritis. METHODS Randomised controlled trials that compared web-based rehabilitation interventions with usual care, waiting list, no treatment or another web-based intervention in adults with rheumatoid arthritis were included. The outcomes were pain, function, quality of life, self-efficacy, rheumatoid arthritis knowledge, physical activity and adverse effects. Methodological quality was assessed using the Cochrane Risk of Bias tool and quality of evidence with the Grading of Recommendations Assessment, Development and Evaluation approach. RESULTS Six source documents from four trials ( n = 567) focusing on self-management, health information or physical activity were identified. The effects of web-based rehabilitation interventions on pain, function, quality of life, self-efficacy, rheumatoid arthritis knowledge and physical activity are uncertain because of the very low quality of evidence mostly from small single trials. Adverse effects were not reported. CONCLUSION Large, well-designed trials are needed to evaluate the clinical and cost-effectiveness of web-based rehabilitation interventions in rheumatoid arthritis.
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Affiliation(s)
- Cynthia Srikesavan
- 1 Centre for Rehabilitation Research in Oxford, University of Oxford, UK
| | | | - Usama Ali
- 3 Centre for Statistics in Medicine, Oxford Clinical Trials Research Unit & Centre for Rehabilitation Research in Oxford, University of Oxford, UK
| | - Esther Williamson
- 1 Centre for Rehabilitation Research in Oxford, University of Oxford, UK
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Srikesavan C, Williamson E, Sugavanam P, Adams J, Eldridge L, Lamb SE. O32 Impact evaluation of an online training on the Strengthening And Stretching for Rheumatoid Arthritis of the Hand (SARAH) programme recommended in the NICE guidelines for rheumatoid arthritis. Rheumatology (Oxford) 2018. [DOI: 10.1093/rheumatology/key075.214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Cynthia Srikesavan
- Centre for Rehabilitation Research in Oxford, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UNITED KINGDOM
| | - Esther Williamson
- Centre for Rehabilitation Research in Oxford, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UNITED KINGDOM
| | - Priya Sugavanam
- Centre for Rehabilitation Research in Oxford, Nuffield Department of Orthopaedics, 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, University of Southampton, Southampton, UNITED KINGDOM
| | - Lucy Eldridge
- Oxford Clinical Trials Research Unit, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UNITED KINGDOM
| | - Sarah E Lamb
- Centre for Rehabilitation Research in Oxford, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UNITED KINGDOM
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Srikesavan C, Williamson E, Hunter J, Cranston T, Adams J, Lamb SE. 282 Usability testing of an online version of the Strengthening and Stretching for Rheumatoid Arthritis of the Hand (SARAH) programme for people with rheumatoid arthritis. Rheumatology (Oxford) 2018. [DOI: 10.1093/rheumatology/key075.506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Cynthia Srikesavan
- Centre for Rehabilitation Research in Oxford, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, University of Oxford, Oxford, UNITED KINGDOM
| | - Esther Williamson
- Centre for Rehabilitation Research in Oxford, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, University of Oxford, Oxford, UNITED KINGDOM
| | - John Hunter
- Centre for Rehabilitation Research in Oxford, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, University of Oxford, Oxford, UNITED KINGDOM
| | - Tim Cranston
- Oxford Clinical Trials Unit, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, University of Oxford, Oxford, UNITED KINGDOM
| | - Jo Adams
- Centre for Innovation and Leadership in Health Sciences, Faculty of Health Sciences, University of Southampton, University of Southampton, Southampton, UNITED KINGDOM
| | - Sarah E Lamb
- Centre for Rehabilitation Research in Oxford, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, University of Oxford, Oxford, UNITED KINGDOM
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Bryer C, Srikesavan C, Williamson E. E52. EFFECTS OF WEB-BASED INTERVENTIONS ON PHYSICAL FUNCTION AND ACTIVITY, PAIN AND QUALITY OF LIFE IN PATIENTS WITH RHEUMATOID ARTHRITIS: A SYSTEMATIC REVIEW. Rheumatology (Oxford) 2017. [DOI: 10.1093/rheumatology/kex063.051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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