Outcomes that matter most to burn patients: A national multicentre survey study in the Netherlands

BACKGROUND

The use of patient-reported outcomes to improve burn care increases. Little is known on burn patients' views on what outcomes are most important, and about preferences regarding online Patient Reported Outcome Measures (PROMs). Therefore, this study assessed what outcomes matter most to patients, and gained insights into patient preferences towards the use of online PROMs.

METHODS

Adult patients (≥18 years old), 3-36 months after injury completed a survey measuring importance of outcomes, separately for three time periods: during admission, short-term (<6 months) and long-term (6-24 months) after burn injury. Both open and closed-ended questions were used. Furthermore, preferences regarding the use of patient-reported outcome measures in burn care were queried.

RESULTS

A total of 140 patients were included (response rate: 27%). 'Not having pain' and 'good wound healing' were identified as very important outcomes. Also, 'physical functioning at pre-injury level', 'being independent' and 'taking care of yourself' were considered very important outcomes. The top-ten of most important outcomes largely overlapped in all three time periods. Most patients (84%) had no problems with online questionnaires, and many (67%) indicated that it should take up to 15 minutes. Patients' opinions differed widely on the preferred frequency of follow-up.

CONCLUSIONS

Not having pain and good wound healing were considered very important during the whole recovery of burns; in addition, physical functioning at pre-injury level, being independent, and taking care of yourself were deemed very important in the short and long-term. These outcomes are recommended to be used in burn care and research, although careful selection of outcomes remains crucial as patients prefer online questionnaires up to 15 minutes.

The degree of joint range of motion limitations after burn injuries during recovery

INTRODUCTION

The aim of this study was to determine the degree of ROM limitations of extremities, joints and planes of motion after burns and its prevalence over time.

METHOD

The database of a longitudinal multicenter cohort study in the Netherlands (2011-2012) was used. From patients with acute burns involving the neck, shoulder, elbow, wrist, hip, knee and ankle joints that had surgery, ROM of 17 planes of motion was assessed by goniometry at 3, 6 weeks, 3-6-9 and 12 months after burns and at discharge.

RESULTS

At 12 months after injury, 12 out of 17 planes of motion demonstrated persistent joint limitations. The five unlimited planes of motion were all of the lower extremity. The most severely limited joints at 12 months were the neck, ankle, wrist and shoulder. The lower extremity was more severely limited in the early phase of recovery whereas at 12 months the upper extremity was more severely limited.

CONCLUSION

The degree of ROM limitations and prevalence varied over time between extremities, joints and planes of motion. This study showed which joints and planes of motion should be watched specifically concerning the development of scar contracture.

The added value of extending the EQ-5D-5L with an itching item for the assessment of health-related quality of life of burn patients: an explorative study

INTRODUCTION

Health-related quality of life (HRQL) is an important outcome in burn care and research. An advantage of a generic HRQL instrument, like the EQ-5D, is that it enables comparison of outcomes with other conditions and the general population. However, the downside is that it does not include burn specific domains, like scar issues or itching. Adding extra items to a generic instrument might overcome this issue. This study explored the potential and added value of extending the EQ-5D-5L with a burn-specific item, using a itching item as an example.

METHODS

The EQ-5D-5L and the Patient and Observer Scar Assessment Scale (POSAS) was completed by adult patients 5-7 years after injury. A separate POSAS itching item was used to study the added value of an itching item for the EQ-5D-5L. The EQ-5D-5L + Itching was created by adding the POSAS itching item to the EQ-5D-5L. Five psychometric properties were compared between EQ-5D-5L and EQ-5D-5L + Itching: distribution (e.g. ceiling), informativity cf. Shannon's indices, convergent validity, dimension dependency, and explanatory power respectively.

RESULTS

A total of 243 patients were included, of whom 49% reported any itching on the POSAS. Adding an itching item to the EQ-5D-5L decreased the ceiling effect, and resulted in increased absolute informativity (H' = 4.76 vs. H' = 3.64) and relative informativity (J' = 0.34 vs. J' = 0.31). The extra itching item decreased the convergent validity (Spearman's rank correlation coefficient = -0.51 vs. -0.59). Mutual dependency of dimensions existed, showing that all other items were dominant over the itching item. Adding the itching item to the standard EQ-5D-5L barely improved explanatory power (49.3% vs. 49.0%).

CONCLUSIONS

PThe present study showed adding a burn-specific item to the EQ-5D-5L is possible and has potential. However, 5 to 7 years after injury, adding an itching item to the EQ-5D-5L provides little additional information; the gain in terms of added value is relatively small. Apart from instances where itching information is specifically needed, a strong case is not present for adding an itching item to the EQ-5D-5L for long-term (>5 yr after burns) HRQL assessment in burn patients. In early time periods after burn, the added value might be greater and we recommend exploring this potential in future studies, ideally on multiple timepoints after burn.

Exploring the relation between the EQ-5D-5L pain/discomfort and pain and itching in a sample of burn patients

BACKGROUND

The EQ-5D domain pain/discomfort (PD) uses one item to capture pain and other aspects of discomfort, like itching. This study explored how pain, itching and the EQ-5D-5L PD domain relate to each other in a sample of burn patients.

METHODS

Adult burn patients completed the EQ-5D-5L and the Patient and Observer Scar Assessment Scale (POSAS) 5-7 years after sustaining their injury. The POSAS includes a separate pain and an itching item. Spearman's correlation coefficient established the association between the EQ-5D-5L PD and the POSAS pain and itching item. With multivariable regression analysis the linear association between the POSAS pain and itching item and EQ-5D-5L PD domain was tested.

RESULTS

Data from 245 patients were included. Mean EQ-5D-5L index value was 0.87 and 39.2% reported at least slight problems on the EQ-5D-5L PD domain. Most patients gave corresponding answers on the EQ-5D-5L PD domain and on the POSAS pain (73%) and itching (70%) item. Spearman correlation coefficients of the EQ-5D-5L PD domain with the POSAS pain and itching were 0.468 (p < 0.001) and 0.473 (p < 0.001), respectively. Among respondents with pain and without itching and respondents with itching and without pain, Spearman correlation coefficients were 0.585 (p = 0.076) and 0.408 (p = 0.001), respectively. POSAS pain (unstandardized Beta = 0.14) and POSAS itching (unstandardized Beta = 0.08) were significantly associated with EQ-5D-5L PD domain (p < 0.001).

CONCLUSIONS

Our findings indicate that, in a sample of burn patients, pain and itching are captured by the broader EQ-5D-5L PD domain. The EQ-5D-5L PD domain can thus be used to assess pain and itching in relation to HRQL, but the POSAS pain and itching items are more sensitive. The EQ-5D-5L is, however, no replacement of the POSAS when the POSAS is used for its primary aim; assessment of scar quality.

TRIAL REGISTRATION

Netherlands Trial Register (NTR6407).

Doxepin cream is not effective in reducing itch in burn scar patients: A multicenter triple-blind randomized clinical crossover trial

OBJECTIVE

To evaluate the effect of doxepin hydrochloride 5% cream on reducing pruritus in burn scar patients compared to a placebo cream.

METHOD

We conducted a multicenter triple-blind randomized clinical placebo-controlled crossover trial in which burn patients ≥18 years with an itch intensity ≥3 on a Visual Analogue Scale (VAS) were randomized between a doxepin-placebo or placebo-doxepin treatment protocol. Patients used each cream during two weeks with a wash-out period of one week in between. Primary outcome was change in itch intensity in two weeks' time using the VAS. Secondary outcome included the impact of itch (Burn Itch Questionnaire). Other parameters were the use of hydrating cream, silicon treatment, pressure garments, and other antipruritic medication.

RESULTS

Twenty-seven patients were included. The change in itch intensity (VAS) was not different during the doxepin and placebo period (p=0.994); neither the doxepin cream nor placebo cream reduced itch intensity. However, based on the Burn Itch Questionnaire, we observed a statistically significant decrease in itch intensity and improvement in impact scores in both treatment groups, but no difference in the degree of reduction between the groups.

CONCLUSION

Doxepin cream was not effective in reducing pruritus in our burn patient study population.

Nursing problems in patients with toxic epidermal necrolysis and Stevens-Johnson syndrome in a Dutch burn centre: A 30-year retrospective study

OBJECTIVE

Multiple studies have been published on toxic epidermal necrolysis (TEN) and Stevens-Johnsen syndrome (SJS). Nursing care is an important part of the treatment of TEN patients. Unfortunately, limited information on nursing in TEN/SJS patients has been published in the current literature. Nursing research is needed to improve the complex nursing care required for these rare patients. Therefore, the objective was to assess nursing problems in TEN patients in a burn centre setting over a 30-year period.

METHODS

The data for this study were gathered retrospectively from nursing records of all patients with TEN/SJS admitted to Burn Centre Rotterdam between January 1987 and December 2016. Dutch burn centres were recently accepted as expertise centres for TEN patients. Nursing problems were classified using the classification of nursing problems of the Dutch Nursing Society.

RESULTS

A total of 69 patients were admitted with SJS/TEN. Fifty-nine patient files were available. The most frequently reported nursing problems (>20% of the patients) were wounds, threatened or disrupted vital functions, dehydration or fluid imbalance, pain, secretion problems and fever. Furthermore, TEN-specific nursing problems were documented, including oral mucosal lesions and ocular problems. The highest number of concomitant nursing problems occurred during the period between days three and 20 after onset of the disease and varied by nursing problem.

CONCLUSIONS

The most frequently reported nursing problems involved physical functions, especially on days three to 20 after onset of the disease. With this knowledge, we can start nursing interventions early in the treatment, address problems at the first sign and inform patients and their families or relatives of these issues early in the disease process. A next step to improve nursing care for TEN patients is to acquire knowledge on the optimal interventions for nursing problems.

A systematic review on surgical and nonsurgical debridement techniques of burn wounds

OBJECTIVE

To provide a complete overview of all burn debridement techniques studied in recent literature and to find the best evidence with regard to efficiency and safety.

METHOD

A systematic review was performed. Searches were conducted in electronic databases such as PubMed, Embase, Cochrane, CINAHL, Web of Science, and Academic Search Premier. All studies published from 1990 onwards, on the efficiency and/or safety of burn debridement techniques in patients with thermal burn injuries of any age, were included. Primary outcomes were time to complete wound healing and time to complete debridement. Randomized trials were critically appraised.

RESULTS

Twenty-seven studies, including four randomized clinical trials, were included. Time to wound healing in the conventional tangential excision (seven studies), hydrosurgery (eight studies), enzymatic debridement (eleven studies), and shock waves group (one study) ranged from 13-30, 11-13, 19-33, and 16 days, respectively. Time to complete debridement ranged from 5-10, 4-23, and 1-9 days, respectively. Furthermore, secondary outcomes (including grafting, mortality, and scar quality) were compared between the debridement categories.

CONCLUSION

Convincing evidence in favor of any of these techniques is currently lacking. Future studies regarding (new) debridement techniques need to use standardized and validated outcome measurement tools to allow improved standardization and comparisons across studies.

Application of hydrosurgery for burn wound debridement: An 8-year cohort analysis

INTRODUCTION

During the last decade, the Versajet™ hydrosurgery system has become popular as a tool for tangential excision in burn surgery. Although hydrosurgery is thought to be a more precise and controlled manner for burn debridement prior to skin grafting, burn specialists decide individually whether hydrosurgery should be applied in a specific patient or not. The aim of this study was to gain insight in which patients hydrosurgery is used in specialized burn care in the Netherlands.

METHODS

A retrospective study was conducted in all patients admitted to a Dutch burn centre between 2009 and 2016. All patients with burns that underwent surgical debridement were included. Data were collected using the national Dutch Burn Repository R3.

RESULTS

Data of 2113 eligible patients were assessed. These patients were treated with hydrosurgical debridement (23.9%), conventional debridement (47.7%) or a combination of these techniques (28.3%). Independent predictors for the use of hydrosurgery were a younger age, scalds, a larger percentage of total body surface area (TBSA) burned, head and neck burns and arm burns. Differences in surgical management and clinical outcome were found between the three groups.

CONCLUSION

The use of hydrosurgery for burn wound debridement prior to skin grafting is substantial. Independent predictors for the use of hydrosurgery were mainly burn related and consisted of a younger age, scalds, a larger TBSA burned, and burns on irregularly contoured body areas. Randomized studies addressing scar quality are needed to open new perspectives on the potential benefits of hydrosurgical burn wound debridement.

[Determining depth of burns using laser Doppler imaging]

Early accurate assessment of burn depth is important to determine the optimal treatment of burns (conservative versus surgery). Laser Doppler imaging (LDI) is a technique that allows accurate measurement of burn depth by measuring dermal perfusion. Although it has been demonstrated that LDI led to faster decisions as to whether or not to operate, this has not lead to shorter wound healing time or cost savings in Dutch burn care. LDI is used in all Dutch burn centres. In case of doubt about the depth of a burn in primary or secondary care, referral to a burn centre is advisable.

Indications and Predictors for Reconstructive Surgery After Hand Burns

PURPOSE

The objective of this study was to analyze the prevalence, indications, and type of reconstructive surgery and predictors of the outcomes of reconstructive surgery after hand burns.

METHODS

A retrospective cohort study was conducted that included all patients admitted with acute hand burns in the Dutch burn centers from January 1998 through December 2002. The details of reconstruction including frequency, timing, indication, and techniques were collected over a 10-year follow-up period.

RESULTS

Hand burns were seen in 42% (n = 562 of 1,334) of all patients admitted with acute burns. Reconstructive surgery during the 10-year follow-up period was required in 15%. Contractures, especially of the first web space and little finger, were the most frequent indications for reconstructive surgery. Web spaces 1 to 3 and the little finger were the location most frequently operated on. The most frequently performed surgical technique was release of the contractures and the use of a random flap. Eighty percent of the reconstructive surgery patients required more than 1 reconstructive procedure, most often within 2 years of the initial injury. Secondary operations at the same location were required in 12%. In 40% of the patients, the first reconstructive surgery was performed within the first postburn year. Significant independent factors related to the need for reconstructive hand surgery were a larger area of full-thickness burns and surgical treatment of the hand during the acute phase.

CONCLUSIONS

Reconstructive surgery was required in 15% of patients who sustained hand burns. The majority of the patients requiring reconstructive surgery of the hand needed 2 or more operations to correct the contractures of the hand. Contractures of the little finger and first web space were the locations most frequently operated on. Patients with more extensive burns and who required hand surgery during the acute phase were more likely to need reconstructive surgery.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic IV.

Return to work after specialised burn care: A two-year prospective follow-up study of the prevalence, predictors and related costs

BACKGROUND

Burn injuries may cause long-term disability and work absence, and therefore result in high healthcare and productivity costs. Up to now, detailed information on return to work (RTW) and productivity costs after burns is lacking.

AIMS

The aim of this study was to accurately assess RTW after burn injuries, to identify predictors of absenteeism and to calculate healthcare and productivity costs from a societal perspective.

METHODS

A prospective cohort study was conducted in the burn centre of Rotterdam, the Netherlands, including all admitted working-age patients from 1 August 2011 to 31 July 2012. At 3, 12 and 24 months post-burn, patients were sent a questionnaire: including the Work and Medical Consumption questionnaire for the assessment of work absence and medical consumption and the EQ-5D-3L plus a cognitive dimension to assess post-burn and pre-burn quality of life (QOL). Cost analyses were from a societal perspective according the micro-costing method and the friction cost method was applied for the calculation of productivity loss. Univariate logistic regression was used to identify predictors of absenteeism at three months.

RESULTS

A total of 104 patients were included in the study with a mean total body surface area (TBSA) burned of 8% (median 4%). 66 respondents were pre-employed, at 3 months 70% was back at work, at 12 months 92% and 8% had not returned to work at time of final follow-up at 24 months. Predictors of absenteeism at 3 months were: TBSA, length of stay, ICU-admission and surgery. Mean costs related to loss in productivity were €11.916 [95% CI 8.930-14.902] and accounted for 30% of total costs in pre-employed respondents in the first two years.

CONCLUSION

This two-year follow-up study demonstrates that burn injuries cause substantial and prolonged productivity loss amongst burn survivors with mixed burn severity. This absenteeism contributes to already high societal costs of burn injuries. Predictors of absenteeism found in this study were primarily fixed patient and treatment related factors, future studies should focus on modifiable factors, in order to improve RTW outcomes. Also, more attention in the rehabilitation trajectory is needed to optimally support RTW in burn survivors.

Epidemiology and trends in severe burns in the Netherlands

INTRODUCTION

The aim of this study was to characterize the epidemiology of severe burns in the Netherlands, including trends in burn centre admissions, non burn centre admissions and differences by age.

METHODS

Patients with burn-related primary admission in a Dutch centre from 1995 to 2011 were included. Nationwide prospectively collected data were used from three separate historical databases and the uniform Dutch Burn Repository R3 (2009 onwards). General hospital data were derived from the National Hospital Discharge Register. Age and gender-adjusted rates were calculated by direct standardization, using the 2005 population as the reference standard.

RESULTS

The annual number of admitted patients increased from 430 in 1995 to 747 in 2011, incidence rates increased from 2.72 to 4.66 per 100,000. Incidence rates were high in young children, aged 0-4 years and doubled from 10.26 to 22.96 per 100,000. Incidence rates in persons from 5 up to 59 increased as well, in older adults (60 years and older) admission rates were stable. Overall burn centre mortality rate was 4.1%, and significantly decreased over time. There was a trend towards admissions of less extensive burns, median total burned surface area (TBSA) decreased from 8% to 4%. Length of stay and length of stay per percent TBSA decreased over time as well.

CONCLUSIONS

Data on 9031 patients admitted in a 17-year period showed an increasing incidence rate of burn-related burn centre admissions, with a decreasing TBSA and decreasing in-burn centre mortality. These data are important for prevention and establishment of required burn care capacity.

Accuracy of burn size assessment prior to arrival in Dutch burn centres and its consequences in children: a nationwide evaluation

BACKGROUND

Total body surface area (TBSA) burned, expressed as percentage is one of the most important aspects of the initial care of a burn victim. It determines whether transfer to a burn centre is necessary as well as the need for, and amount of, intravenous fluid resuscitation. Numerous studies, however, have highlighted inaccuracies in TBSA assessment. Therefore, the differences in burn size estimates between referrers and burn centre's in children and its consequences in terms of transfer and intravenous fluid resuscitation were investigated.

METHODS

This study involved two time periods from January 2002 until March 2004 and January 2007 until August 2008. All referred children admitted to a Dutch Burn centre within 24h post burn were eligible. Data were obtained from patient records retrospectively and in part prospectively.

RESULTS

A total of 323 and 299 children were included in periods 1 and 2, respectively. Referring physicians overestimated burn size with a factor two (mean difference: 6% TBSA ± 5.5). About one in five children was referred to a burn centre without fulfilling the criteria for referral with regard to burn size (assessed by burn specialists) special localisation or inhalation trauma. Proportions of children receiving intravenous fluid resuscitation regardless of indication increased from 33% to 49% (p<0.01). The received volumes tended to be higher than necessary.

CONCLUSIONS

Referring physicians overestimate burn size in children admitted to Dutch burn centres. This has little negative consequences, however, in terms of unindicated transfers to a burn centre or unnecessary fluid resuscitation.

Reliability and validity of the Manchester Triage System in a general emergency department patient population in the Netherlands: results of a simulation study

OBJECTIVE

To assess the reliability and validity of the Manchester Triage System (MTS) in a general emergency department patient population.

METHODS

A prospective evaluation study was conducted in two general hospitals in the Netherlands. Emergency department nurses from both hospitals triaged 50 patient vignettes into one of five triage categories in the MTS. Triage ratings were compared with the ratings of two Dutch MTS experts to measure inter-rater reliability. Nineteen days after triaging the patient vignettes, triage nurses were asked to rate the same vignettes again to measure test-retest reliability. Reliability in relation to the work experience of emergency department nurses was also studied. Validity was assessed by calculating percentages for overtriage, undertriage, sensitivity and specificity.

RESULTS

Inter-rater reliability was "substantial" (weighted kappa 0.62 (95% CI 0.60 to 0.65)) and test-retest reliability was high (intraclass correlation coefficient 0.75 (95% CI 0.72 to 0.77)). No significant association was found between the experience of emergency department nurses and the reliability score (kappa). Undertriage occurred more frequently than overtriage, especially in elderly patients (25.3% vs 7.6%). Sensitivity for urgent patients in the MTS was 53.2% and specificity was 95.1%. The patient vignettes representing children aged <16 years revealed a higher sensitivity (83.3%).

CONCLUSIONS

Inter-rater reliability is "moderate" to "substantial" and test-retest reliability is high. The reliability of the MTS is not influenced by nurses' work experience. Undertriage mainly occurs in the MTS categories orange and yellow. The MTS is more sensitive for children who need immediate or urgent care than for other patients in the emergency department.

Reliability and validity of the Health Outcomes Burn Questionnaire for infants and children in The Netherlands

The Health Outcomes Burn Questionnaire (HOBQ) is a self-administered questionnaire to monitor outcome after burns in young children. This study aimed to assess feasibility, reliability and validity of the Dutch version of the HOBQ. The HOBQ was adapted into Dutch and tested in a population of children aged 0-4 years with a primary admission to a Dutch burn centre in March 2001-February 2004. Parents of 413 children were sent a questionnaire. To assess validity, a generic outcome instrument was included, the Infant Toddler Quality of Life Questionnaire (ITQOL). The response rate was 50.0% (n=196). Mean self-reported completion time was 16.7 min. The internal consistency of all the HOBQ-scales was good (Cronbach's alpha's>0.69). Test-retest results showed no differences in 7 out of 10 scales. High correlations between HOBQ-scales and conceptually equivalent ITQOL and scales were found in 5 out of 7 comparisons. The majority of the HOBQ-scales (7 out of 10) showed significant differences in the expected direction between children with a long versus short length of stay. Our data support the reliability and validity of the Dutch HOBQ. The HOBQ can be used as a research tool, to monitor functional outcome after burns in young children. Further research in other samples is recommend to fully establish the reliability and validity of the HOBQ.

Functional outcome after burns: a review

We conducted a Medline search (1966-11/2003) on empirical studies into the consequences of burns. The International Classification of Functioning, disabilities and health (ICF) was used to classify dimensions of functional outcome. We included 50 studies, reporting a wide spectrum of ICF-dimensions. The current state of knowledge on the functional outcome after burns was hard to summarise, due to the wide variety in study designs and outcome assessment methods. Some indications on the major functional problems after burns were gained. Problems in mental function were described in subgroups of patients, both in children/adolescents and adults. Restrictions in range of motion were observed in about one-fifth of burn patients, even 5 years after injury. Problems with appearance were reported often (up to 43%), even in patients with minor burns (14%). Problems with work were reported in 21-50% of the adult patients, with permanent incapacity for work in 1-5%. None of the publications gave sufficient information to fully estimate the functional consequences of burns. We recommend the development of a standard core set for measurement and reporting of functional outcome after burns.

Influence of obesity on the development of osteoarthritis of the hip: a systematic review

OBJECTIVE

To evaluate the evidence for the influence of obesity as a risk factor for the occurrence of osteoarthritis (OA) of the hip.

METHODS

A bibliographical search of Medline, EMBASE and the Cochrane library until April 2000 was carried out. Articles describing studies of the relationship between obesity and the occurrence of hip OA were selected. The quality of the studies was assessed with a standardized set of criteria. The outcome of the studies was compared with respect to study characteristics and the quality score for the study. A best-evidence synthesis was used to summarize the results of the individual studies.

RESULTS

Five longitudinal and seven cross-sectional studies were included in this review. There was no association between outcome and study design or methodological quality. The associations between obesity and hip OA were, however, stronger in studies in which the diagnosis of hip OA was based not only on radiological criteria but also on clinical symptoms. Overall, moderate evidence was found for a positive association between obesity and the occurrence of hip OA, with an odds ratio of approximately 2.

CONCLUSION

The evidence for a positive influence of obesity on the development of hip OA is moderate.

Effectiveness of exercise in patients with osteoarthritis of hip or knee: nine months' follow up

OBJECTIVE

To determine whether the effects of an exercise programme in patients with osteoarthritis of hip or knee are sustained at six and nine months' follow up.

METHODS

A randomised, single blind, clinical trial was conducted in a primary care setting. Patients with osteoarthritis of hip or knee (ACR criteria) were selected. Two intervention groups were compared. Both groups received treatment from their general practitioner, including patient education and drug treatment if necessary. The experimental group also received exercise treatment from a physiotherapist in primary care. The treatment period was 12 weeks, with an ensuing 24 week follow up. The main outcome measures were pain, drug use (non-steroidal anti-inflammatory drugs), and observed disability.

RESULTS

201 patients were randomly allocated to the exercise or control group, and 183 patients completed the trial. At 24 weeks exercise treatment was associated with a small to moderate effect on pain during the past week (difference in change between the two groups -11.5 (95% CI -19.7 to -3.3). At 36 weeks no differences were found between the groups.

CONCLUSIONS

Beneficial effects of exercise decline over time and finally disappear.

Muscle strength, pain and disability in patients with osteoarthritis

OBJECTIVE

Reduced muscle strength is regarded as a risk factor for pain and disability in osteoarthritis (OA). Currently, various indices for muscle strength are used when assessing determinants of pain and disability. The goal of the present study was to evaluate these indices of muscle strength.

DESIGN

Isometric muscle strength was measured for 16 muscle actions around the knees and hips in 52 patients with OA of the hip and 70 patients with OA of the knee. Various indices of muscle strength were derived from these measurements, applying five alternative approaches. These approaches ranged from a single overall index to a set of 16 separate indices. The internal consistency of these indices was determined (Cronbach's alpha), and it was determined to what extent they could reveal the association between reduced muscle strength on the one hand and pain and disability on the other hand.

RESULTS

Internal consistency was satisfactory for all indices (Cronbach's alpha >0.74). As expected, reduced muscle strength was associated with increased disability, but no clear relationship could be established between muscle weakness and pain. The strength of these associations did not depend on the approach used to derive the indices for muscle strength.

CONCLUSIONS

The indices did not show major differences with regard to internal consistency or the extent to which the association with pain and disability could be revealed. For reasons of parsimony, approaches resulting in few indices appear to be most useful. However, muscle strength was found to be significantly reduced around affected joints, compared with muscle strength around unaffected joints. Therefore, the most suitable approach for reducing muscle strength data into indices is one that results in as few indices as possible, but with separate indices for muscle strength around affected and unaffected joints.

Range of joint motion and disability in patients with osteoarthritis of the knee or hip

OBJECTIVE

To establish the relationships between the range of joint motion (ROM) and disability in patients with osteoarthritis (OA) of the knee or hip. Two related issues were addressed: (1) the inter-relationships between ROMs of joint actions, and (2) the relationship between ROM and disability.

METHODS

Data on 198 patients with OA of the knee or hip were used. The ROM was assessed bilaterally for the hip and knee, using a goniometer. Disability was assessed using a self-reporting method (questionnaire) and an observational method. Correlation and factor analysis were used to establish the inter-relationships between the ROMs of joint actions. Correlation and multiple regression analyses were carried out to establish the relationships between ROM and disability.

RESULTS

Close inter-relationships were found between the ROMs of the same joint action of the lateral and contralateral joints; inter-relationships between ROMs of different joint actions were substantially weaker. Low ROMs were associated with high levels of disability, both self-reported and observed. Some 25% of the variation in disability levels could be accounted for by differences in ROM. In both knee and hip OA patients, flexion of the knee and extension and external rotation of the hip were found to be most closely associated with disability.

CONCLUSION

Restricted joint mobility, especially in flexion of the knee and extension and external rotation of the hip, appears to be an important determinant of disability in patients with OA.

Effectiveness of exercise therapy in patients with osteoarthritis of the hip or knee: a systematic review of randomized clinical trials

OBJECTIVE

To review the effectiveness of exercise therapy in patients with osteoarthritis (OA) of the hip or knee.

METHODS

A computerized literature search of Medline, Embase, and Cinahl was carried out. Randomized clinical trials on exercise therapy for OA of the hip or knee were selected if treatment had been randomly allocated and if pain, self-reported disability, observed disability, or patient's global assessment of effect had been used as outcome measures. The validity of trials was systematically assessed by independent reviewers. Effect sizes and power estimates were calculated. A best evidence synthesis was conducted, weighting the studies with respect to their validity and power.

RESULTS

Six of the 11 assessed trials satisfied at least 50% of the validity criteria. Two trials had sufficient power to detect medium-sized effects. Effect sizes indicated small-to-moderate beneficial effects of exercise therapy on pain, small beneficial effects on both disability outcome measures, and moderate-to-great beneficial effects according to patient's global assessment of effect.

CONCLUSION

There is evidence of beneficial effects of exercise therapy in patients with OA of the hip or knee. However, the small number of good studies restricts drawing firm conclusions.

Effectiveness of exercise therapy in patients with osteoarthritis of the hip or knee: a systematic review of randomized clinical trials

OBJECTIVE

To review the effectiveness of exercise therapy in patients with osteoarthritis (OA) of the hip or knee.

METHODS

A computerized literature search of Medline, Embase, and Cinahl was carried out. Randomized clinical trials on exercise therapy for OA of the hip or knee were selected if treatment had been randomly allocated and if pain, self-reported disability, observed disability, or patient's global assessment of effect had been used as outcome measures. The validity of trials was systematically assessed by independent reviewers. Effect sizes and power estimates were calculated. A best evidence synthesis was conducted, weighting the studies with respect to their validity and power.

RESULTS

Six of the 11 assessed trials satisfied at least 50% of the validity criteria. Two trials had sufficient power to detect medium-sized effects. Effect sizes indicated small-to-moderate beneficial effects of exercise therapy on pain, small beneficial effects on both disability outcome measures, and moderate-to-great beneficial effects according to patient's global assessment of effect.

CONCLUSION

There is evidence of beneficial effects of exercise therapy in patients with OA of the hip or knee. However, the small number of good studies restricts drawing firm conclusions.

Internal consistency and validity of an observational method for assessing disability in mobility in patients with osteoarthritis

OBJECTIVE

To establish the internal consistency and validity of an observational method for assessing disability in mobility in patients with osteoarthritis (OA).

METHODS

Data were obtained from 198 patients with OA of the hip or knee. Results of the observational method were compared with results of self-report methods (questionnaires) on disability in mobility.

RESULTS

Both Cronbach's alpha and Mokken Scale Analysis indicate that the method is internally consistent. Using factor analysis, observed and self-reported disability in mobility were found to be closely associated and could not be differentiated.

CONCLUSIONS

The observational method is internally consistent and indeed measures disability in mobility (high convergent validity), but observations and self-report seem to yield largely equivalent information (low divergent validity). This raises questions regarding the simultaneous use of both observational and self-report methods in the assessment of disability in mobility in OA patients.

The effectiveness of exercise therapy in patients with osteoarthritis of the hip or knee: a randomized clinical trial

OBJECTIVE

To determine the effectiveness of exercise therapy in patients with osteoarthritis (OA) of the hip or knee.

METHODS

A randomized single blind, clinical trial was conducted in a primary care setting. Patients with hip or knee OA by American College of Rheumatology criteria were selected. Two intervention groups were compared. Both groups received treatment from the patients' general practitioner, including patient education and medication if necessary. The experimental group also received exercise therapy from a physiotherapist in primary care. The treatment period was 12 weeks. The main outcome measures were pain, medication use (nonsteroidal antiinflammatory drugs, NSAID) and observed disability.

RESULTS

A total of 201 patients were randomized. Exercise therapy was associated with a reduction of pain in the past week (difference in change -17.0; 95% CI -23.6, -10.4) and observed disability (-0.19; 95% CI -0.38; -0.01). Effect sizes were medium (0.58) and small (0.28), respectively. No effect of exercise therapy was found for the use of NSAID. Additional beneficial effects (p = 0.05) were found for the use of paracetamol (effect size 0.33), global effect as perceived by the patient (effect size 0.68), and muscle strength of the hip (effect size 0.34).

CONCLUSION

After 12 weeks, exercise therapy is effective in reducing pain and disability. The size of the effects is medium and small, respectively.

Validity of Cyriax's concept capsular pattern for the diagnosis of osteoarthritis of hip and/or knee

To analyse the validity of Cyriax's concept of the "capsular pattern" in the diagnosis of osteoarthritis (OA) of hip and knee, data on 200 patients were analysed. The capsular pattern with limitations of medial rotation, flexion, and abduction, was not present as a distinct pattern in patients with OA of the hip. In patients with OA of the knee, an indication of the existence of a capsular pattern of the knee, with limited ranges of motion for both flexion and extension was found in subgroups of patients. It is concluded that the capsular pattern cannot be regarded as a valid test for the diagnosis of OA of the hip or knee. Further investigations in subgroups of patients are recommended.

A survey of physical therapy goals and interventions for patients with back and knee pain

BACKGROUND AND PURPOSE

The physical therapy management of patients with pain often lacks a theoretical or conceptual basis. The purpose of this study was to compare treatments of patients with back and knee pain with a treatment framework (conceptual model) that we developed. This framework emphasizes physiological recovery, or reduction of impairments (eg, reduction of swelling), followed by emphasis on the reduction of disabilities. Expectations were derived concerning treatment goals and interventions in the course of treatment.

SUBJECTS

Patients with back pain (n = 1,085) and patients with knee trauma (n = 416) were treated by 83 Dutch physical therapists.

METHODS

Survey data were gathered on impairments and disabilities and on treatment goals and interventions.

RESULTS

For both groups of patients, two out of a maximum of eight treatment goals were directed at alleviating impairments in accordance with the framework. Goals directed toward the alleviation of disabilities did not show a similar relationship to the framework. For two treatment goals, the course of treatment was in accordance with the framework for both groups of patients.

CONCLUSION AND DISCUSSION

The framework is only partially reflected in Dutch physical therapist practice. The use of such a framework, however, may be a helpful tool in gaining more insight into physical therapy in daily practice.

Pain and disability in patients with osteoarthritis of hip or knee: the relationship with articular, kinesiological, and psychological characteristics

OBJECTIVE

To determine to what extent articular, kinesiological, and psychological factors each contribute to pain and disability in patients with osteoarthritis (OA), after controlling for other factors.

METHODS

Cross sectional study among 200 patients with OA of the hip or knee. Dependent variables include pain (visual analog scale), self-reported disability (questionnaire), and observed disability (performance of standardized tasks). Independent variables include joint degeneration (radiographs), muscle strength (dynamometer), range of joint motion (goniometer), pain coping (behavioral and cognitive strategies), and psychological well being (depression, anxiety, cheerfulness). Multiple regression analysis was used.

RESULTS

Pain was found to be associated with muscle weakness and pain coping (p < 0.05). Disability was associated with muscle weakness, range of joint motion, pain, pain coping, and psychological well being (all p < 0.05). Both pain and disability were most strongly associated with kinesiological characteristics and pain coping.

CONCLUSION

After controlling for the other characteristics, kinesiological and psychological characteristics in patients with OA are each associated with disability. The association with pain is less clear. Future research on mechanisms underlying these associations is warranted.

Diagnosis and treatment in physical therapy: an investigation of their relationship

BACKGROUND AND PURPOSE

The diagnosis made by a physical therapist gives direction to the selection of therapeutic interventions. Therefore, in an investigation, specific relationships between diagnoses and therapeutic interventions are expected. This study was designed to test whether such relationships exist.

SUBJECTS AND METHODS

Data on diagnosis, treatment goals, and interventions were gathered on 8,714 patients by 74 physical therapists. The diagnosis and treatment goals were defined in terms of impairments and disabilities.

RESULTS

Specific relationships were found to exist between those impairments and disabilities that were chosen as a basis for forming treatment goals and the application of interventions. These relationships are particularly marked at the impairment level.

CONCLUSION AND DISCUSSION

It is concluded that the diagnostic categories validly predict which interventions are applied and that the selection of interventions depends on which treatment goals are pursued.