Effectiveness of longstanding exercise therapy compared with usual care for people with rheumatoid arthritis and severe functional limitations: a randomised controlled trial

OBJECTIVES

To compare the effectiveness of longstanding (>52 weeks), supervised exercise therapy with usual care in adults with rheumatoid arthritis (RA) and severe functional limitations.

METHODS

Participants were randomised 1:1 to the intervention (individualised goal-setting, active exercises, education and self-management regarding physical activity) or usual care. Primary endpoint was the change in the Patient-Specific Complaints activity ranked 1 (PSC1, 0-10) at 52 weeks. Secondary endpoints included the PSC activities ranked 2 and 3 (PSC2, PSC3), Health Assessment Questionnaire-Disability Index (HAQ-DI), Rheumatoid Arthritis Quality of Life Questionnaire (RAQoL), 6-minute walk test (6MWT), Patient Reported Outcome Measurement Information System Physical Function-10 (PROMIS PF-10) and the Short Form-36 Physical and Mental Component Summary Scales (SF-36 PCS and MCS). (Serious) Adverse events (AEs) were recorded. Measurements were done by blinded assessors. Analyses at 52 weeks were based on the intention-to-treat principle.

RESULTS

In total, 217 people (90% female, age 58.8 (SD 12.9) years) were randomised (n=104 intervention, n=98 usual care available for analyses). At 52 weeks, the improvement of the PSC1 was significantly larger in the intervention group (mean difference (95% CI) -1.7 (-2.4, -1.0)). Except for the SF-36 MCS, all secondary outcomes showed significantly greater improvements favouring the intervention (PSC2 -1.8 (-2.4, -1.1), PSC3 -1.7 (-2.4, -1.0), PROMIS PF-10 +3.09 (1.80, 4.38), HAQ-DI -0.17 (-0.29, -0.06), RAQoL -2.03 (-3.39, -0.69), SF-36 PCS +3.83 (1.49, 6.17) and 6MWT +56 (38, 75) m). One mild, transient AE occurred in the intervention group.

CONCLUSION

Longstanding, supervised exercise therapy was more effective than usual care in people with RA and severe functional limitations.

TRIAL REGISTRATION NUMBER

Netherlands Trial Register (NL8235), included in the International Clinical Trial Registry Platform (https://trialsearch.who.int/Trial2.aspx?TrialID=NL8235).

What works and why in the implementation of eRehabilitation after stroke - a process evaluation

BACKGROUND

Implementation of an eRehabilitation intervention named Fit After Stroke @Home (Fast@home) - including cognitive/physical exercise applications, activity-tracking, psycho-education - after stroke resulted in health-related improvements. This study investigated what worked and why in the implementation.

METHODS

Implementation activities (information provision, integration of Fast@home, instruction and motivation) were performed for 14 months and evaluated, using the Medical Research Council framework for process evaluations which consists of three evaluation domains (implementation, mechanisms of impact and contextual factors). Implementation activities were evaluated by field notes/surveys/user data, it's mechanisms of impact by surveys and contextual factors by field notes/interviews among 11 professionals. Surveys were conducted among 51 professionals and 73 patients. User data (n = 165 patients) were extracted from the eRehabilitation applications.

RESULTS

Implementation activities were executed as planned. Of the professionals trained to deliver the intervention (33 of 51), 25 (75.8%) delivered it. Of the 165 patients, 82 (49.7%) were registered for Fast@home, with 54 patient (65.8%) using it. Mechanisms of impact showed that professionals and patients were equally satisfied with implementation activities (median score 7.0 [IQR 6.0-7.75] versus 7.0 [6.0-7.5]), but patients were more satisfied with the intervention (8.0 [IQR 7.0-8.0] versus 5.5 [4.0-7.0]). Guidance by professionals was seen as most impactful for implementation by patients and support of clinical champions and time given for training by professionals. Professionals rated the integration of Fast@home as insufficient. Contextual factors (financial cutbacks and technical setbacks) hampered the implementation.

CONCLUSION

Main improvements of the implementation of eRehabilitation are related to professionals' perceptions of the intervention, integration of eRehabilitation and contextual factors.Implication for rehabilitationTo increase the use of eRehabilitation by patients, patients should be supported by their healthcare professional in their first time use and during the rehabilitation process.To increase the use of eRehabilitation by healthcare professionals, healthcare professionals should be (1) supported by a clinical champion and (2) provided with sufficient time for learning to work and getting familiar with the eRehabilitation program.Integration of eRehabilitation in conventional stroke rehabilitation (optimal blended care) is an important challenge and a prerequisite for the implementation of eRehabilitation in the clinical setting.

Three out of four working-age patients have fulfilled expectations towards paid employment six months after total hip or knee arthroplasty: a multicentre cohort study

To investigate factors associated with fulfilment of expectations towards paid employment after total hip/knee arthroplasty (THA/TKA). Cohort study including preoperatively employed patients aged 18-64 scheduled for THA/TKA. Expectations were collected preoperatively, and 6 and 12 months postoperatively with the paid employment item of the Hospital-for-Special-Surgery Expectations Surveys (back-to-normal = 1; large improvement = 2; moderate improvement = 3; slight improvement = 4; not applicable = 5). Patients scoring not applicable were excluded. Fulfilment was calculated by subtracting preoperative from postoperative scores (< 0: unfulfilled; ≥ 0: fulfilled). Multivariable logistic regression analyses were conducted separately for THA/TKA at 6 and 12 months postoperatively. Six months postoperatively, 75% of THA patients (n = 237/n = 316) and 72% of TKA patients (n = 211/n = 294) had fulfilled expectations. Older age (TKA:OR 1.08, 95% CI 1.01-1.15) and better postoperative physical functioning (THA:OR 1.10, 95% CI 1.06-1.14; TKA:OR 1.03, 95% CI 1.01-1.06) increased the likelihood of fulfilment. Physical work tasks (THA:OR 0.12, 95% CI 0.03-0.44), preoperative sick leave (TKA:OR 0.33, 95% CI 0.17-0.65), and difficulties at work (THA:OR 0.10, 95% CI 0.03-0.35; TKA:OR 0.41, 95% CI 0.17-0.98) decreased the likelihood of fulfilment. Twelve months postoperatively similar risk factors were found. Three out of four working-age THA/TKA patients had fulfilled expectations towards paid employment at 6 months postoperatively. Preoperative factors associated with fulfilment were older age, mental work tasks, no sick leave, postoperative factors were better physical functioning, and no perceived difficulties at work.

The trajectory of pain and pain intensity in the upper extremity after stroke over time: a prospective study in a rehabilitation population

PURPOSE

To assess the presence of upper extremity pain after stroke over time and the course of its intensity in patients with persistent pain.

MATERIALS AND METHODS

Patients with stroke completed a question on the presence of upper extremity pain (yes/no) and rated its intensity with a visual analogue scale (0-10) at 3, 18, and 30 months after starting multidisciplinary rehabilitation. The presence of upper extremity pain and its intensity over time were analysed with Generalized Estimating Equations models and Linear Mixed Models, respectively.

RESULTS

678 patients were included. The proportions of patients reporting upper extremity pain were 41.8, 36.0, and 32.7% at 3, 18, and 30 months, respectively, with the decline in proportions reaching statistical significance (odds ratio 0.82, 95% confidence interval 0.74-0.92, p < 0.001). At all time points, in those reporting pain the median intensity was 5.0 (interquartile ranges (IQR) 4.0-7.0 at 3 and 3.0-6.0 at 18 and 30 months). In the 73 patients with persistent pain, there was no significant change in intensity over time.

CONCLUSIONS

The proportion of patients reporting upper extremity pain after stroke was considerable, despite a significant decrease in 2.5 years. In patients reporting persistent pain, the intensity did not change over time.IMPLICATIONS FOR REHABILITATIONAbout one-third of patients with stroke reported upper extremity pain at 30 months after starting rehabilitation.In patients with stroke who reported persistent upper extremity pain, there was no significant change in pain intensity over time.There is room for improvement of diagnosis and treatment of upper extremity pain in patients with stroke.

Quality of reporting and nature of harms in clinical trials on supervised exercise in patients with rheumatoid arthritis or axial spondyloarthritis

To describe the quality of reporting and the nature of reported harms in clinical studies on the effectiveness of supervised exercises in patients with rheumatoid arthritis (RA) or axial spondyloarthritis (axSpA). We performed a systematic review, searching eight databases up to February 2023. Randomized controlled trials (RCTs) evaluating supervised exercises in adults with RA or axSpA were considered eligible. Data on harms were extracted according to the CONSORT Harms 2022 Checklist. Among others, it was recorded if harms were prespecified or non-prespecified. Moreover, the nature of reported harms was listed. Forty RCTs were included for RA and 25 for axSpA, of which 29 (73%) and 13 (52%) reported information on harms. In 13 (33%) RCTs in RA and four (16%) in axSpA, the collection of harms outcomes was described in the methods section. Prespecified outcomes were reported by eight (RA) and two (axSpA) RCTs. Non-specified harms outcomes were reported by six (RA) and four (axSpA) RCTs. Prespecified harms outcomes included measures of pain, disease activity, inflammation, and structural joint changes. The nature of non-prespecified harms outcomes varied largely, with pain being most common. A considerable proportion of trials on supervised exercise in RA or axSpA does not or inadequately report harms outcomes. Pain was the most commonly reported prespecified or non-specified harm. For a considerate interpretation of the balance between benefits and harms of supervised exercise in RA or axSpA, use of the CONSORT Harms 2022 Checklist for the design, conduct and reporting of trials is advocated.

Functional limitations of people with rheumatoid arthritis or axial spondyloarthritis and severe functional disability: a cross-sectional descriptive study

The objective of the study is to describe the nature of functional limitations in activities and participation in people with Rheumatoid Arthritis (RA) or axial SpondyloArthritis (axSpA) with severe functional disability. Baseline data from people with RA (n = 206) or axSpA (n = 155) and severe functional disability participating in an exercise trial were used. Their three most limited activities were derived from the Patient Specific Complaint (PSC) instrument and linked to the International Classification of Functioning and Health (ICF). The frequencies of ICF categories were calculated and compared with Activities and Participation items of the ICF Core Sets for RA (32 second-level categories) and Ankylosing Spondylitis (AS) (24 second-level categories). In total 618 and 465 PSC activities were linked to 909 (72 unique in total; 25 unique second-level) and 759 (57 unique in total; 23 unique second-level) ICF categories in RA and axSpA. Taking into account all three prioritized activities, the five most frequent limited activities concerned the ICF chapter "Mobility", and included "Walking" (RA and axSpA 2 categories), "Changing basic body position" (RA and axSpA 1 category), "Stair climbing"(RA) and "Grasping" (RA),"Lifting" (axSpA) and "Maintaining a standing position" (axSpA). In RA, 21/32 (66%) and in axSpA 14/24 (58%) unique second-level categories identified in the prioritized activities are present in the Comprehensive Core Sets. Most limitations of people with RA or axSpA and severe functional disability were seen in the ICF chapter "Mobility". Most of the identified ICF categories were covered by the corresponding items of the ICF RA and AS Core Sets.

Functioning and recovery during stroke rehabilitation: a comparison between pre-stroke frail and non-frail patients

PURPOSE

Pre-stroke frailty in older adults is associated with adverse outcomes after stroke in community-based and hospital-based populations. The aim of our study was to investigate the prevalence of pre-stroke frailty among older stroke survivors receiving medical specialistic rehabilitation and its association with outcomes and recovery.

METHODS

Pre-stroke frailty was measured by the Groningen Frailty Indicator (GFI, score ≥ 4 indicates frailty) in patients ≥ 65 years receiving stroke medical specialistic rehabilitation. Baseline, follow-up and change (i.e. recovery) scores of the Barthel index (BI), Stroke Impact Scale (SIS) 'mobility', 'communication', and 'memory and thinking', Hospital Anxiety and Depression Scale (HADS) and the EuroQoL-5 dimensions (EQ-5D) were compared between frail and non-frail patients with a multivariable regression model adjusting for confounders.

RESULTS

Of 322 included patients (34.2% females, median age 70 years), 43 (13.4%) patients reported pre-stroke frailty. There were no differences in BI or in destination of discharge between pre-stroke frail and non-frail stroke survivors receiving inpatient rehabilitation. However, pre-stroke frailty was associated with worse follow-up scores for all other measures. Recovery in pre-stroke frail patients was less favorable compared to non-frail patients for SIS mobility, HADS subscales and EQ-5D index and visual analogue scale.

CONCLUSION

Pre-stroke frailty was present in a minority of older stroke survivors receiving medical specialistic rehabilitation. BI and destination of discharge did not differ. Nevertheless, pre-stroke frailty was associated with worse functioning at follow-up for most measures of health status and with smaller improvements in mobility, mood and quality of life.

Time to return to work by occupational class after total hip or knee arthroplasty

Aims

For the increasing number of working-age patients undergoing total hip or total knee arthroplasty (THA/TKA), return to work (RTW) after surgery is crucial. We investigated the association between occupational class and time to RTW after THA or TKA.

Methods

Data from the prospective multicentre Longitudinal Leiden Orthopaedics Outcomes of Osteoarthritis Study were used. Questionnaires were completed preoperatively and six and 12 months postoperatively. Time to RTW was defined as days from surgery until RTW (full or partial). Occupational class was preoperatively assessed and categorized into four categories according to the International Standard Classification of Occupations 2008 (blue-/white-collar, high-/low-skilled). Cox regression analyses were conducted separately for THA and TKA patients. Low-skilled blue-collar work was used as the reference category.

Results

A total of 360 THA and 276 TKA patients, preoperatively employed, were included. Patients were mainly high-skilled (THA 57%; TKA 41%) or low-skilled (THA 24%; TKA 38%) white-collar workers. Six months post-THA, RTW rates were 78% of low-skilled blue-collar workers compared to 83% to 86% within other occupational classes, increasing after 12 months to 87% to 90% in all occupational classes. Six months post-TKA, RTW rates were 58% of low-skilled and 64% of high-skilled blue-collar workers compared to 80% to 89% of white-collar workers, and after 12 months 79% of low-skilled blue-collar workers compared to 87% to 92% within other occupational classes. High-skilled white-collar workers (THA: hazard ratio (HR) 2.12 (95% confidence interval (CI) 1.32 to 3.40); TKA: HR 2.31 (95% CI 1.34 to 4.00)) and low-skilled white-collar workers (TKA: HR 1.82 (95% CI 1.04 to 3.18)) had a higher hazard to RTW within six months postoperatively.

Conclusion

Clear differences existed in time to RTW among both THA and TKA patients in each of the groups studied. These findings may help guide tailored patient-specific information during preoperative consultation and advice postoperatively, as well as to create awareness among workers and their employers.

Adherence to the Dutch recommendation for physical activity: prior to and after primary total hip and knee arthroplasty

PURPOSE

To determine the course of adherence to physical activity (PA) recommendation in hip/knee osteoarthritis patients before and after hip/knee arthroplasty (THA/TKA). Moreover, we explored predictors for non-adherence 12 months postoperatively.

MATERIALS AND METHODS

Primary THA/TKA were included in a multicenter observational study. Preoperatively and 6/12 months postoperatively, patients reported engagement in moderate-intensity PA in days/week in the past 6 months (PA-recommendation (≥30 min of moderate-intensity ≥5 days/week)). We included predictors stratified by preoperative adherence: sex, age, BMI, comorbidities, smoking, living/working status, season, mental health, HOOS/KOOS subscales before and 6 months postoperatively, and 6-month adherence.

RESULTS

(1005 THA/972 TKA) Preoperatively, 50% of the population adhered. Adherence increased to 59% at 6 and 12 months. After 12 months, most patients remained at their preoperative PA level, 11% of the preoperative adherers decreased, while 20% of the preoperative non-adherers increased their PA level. In all different groups, adherence to the PA recommendation at 6 months was identified as a predictor (OR-range: 0.16-0.29). In addition, BMI was identified as predictor in the THA adherent (OR = 1.07; 95%CI [1.02-1.15]) and TKA non-adherent groups (OR = 1.08; 95%CI [1.03-1.12]). THA non-adherent group not having paid work (OR = 0.53; 95%CI [0.33-0.85]), and in the TKA adherent group, lower KOOS subscale symptoms (OR = 1.03; 95%CI [1.01-1.05]) were associated with non-adherence.

CONCLUSIONS

Majority of patients remained at their preoperative PA level. Non-adherence at 6 months was highly predictive for 12-month non-adherence.Implications for rehabilitationPhysical activity (PA) is crucial to decrease mortality risk, especially among patients suffering from osteoarthritis, as these patients have the potential to become more physically active after arthroplasty surgery.We found that physical function and pain improved, but 69% of the patients remained at their preoperative PA level, while 11% decreased and 20% increased their PA levels.Using this information shortly after surgery, orthopedic surgeons and other health care professionals can address patients at risk for decreased PA levels and provide PA advice.

Physical Therapy in Systemic Sclerosis: The Patient Perspective

OBJECTIVE

To assess the use, satisfaction, needs, and preferences regarding physical therapy (PT) in patients with systemic sclerosis (SSc).

METHODS

A total of 405 SSc patients, treated in the Leiden University Medical Center multidisciplinary care program and fulfilling American College of Rheumatology (ACR)/European Alliance of Associations for Rheumatology (EULAR) 2013 SSc criteria, received a questionnaire containing 37 questions on use and satisfaction regarding PT over a 2-year period, and their needs and preferences for future PT.

RESULTS

A total of 204 SSc patients (median age 63 years, 81% female) completed the questionnaire. One hundred twenty-eight patients (63%) had used or were using PT in a primary care setting. For 39% of patients not using PT, lack of referral or lack of knowledge was the reason for not using it. The most frequently reported active treatments were muscle-strengthening (n = 92 [72%]), range of motion (n = 77 [60%]), and aerobic exercises (n = 72 [56%]). Specific SSc hand- and mouth-opening exercises were reported by 20 (15%) and 7 (6%) patients, respectively. Manual treatment (massage or passive mobilization) was reported by 83 patients (65%). The mean ± SD satisfaction score (range 0-10) was 8.2 ± 1.6. Regarding patients' needs, 96 patients (47%) of the total group wanted to receive more information concerning PT, and 128 (63%) wanted to continue, start, or restart PT in the near future, with 56 of the 128 patients (44%) favoring individual treatment on a continuous basis.

CONCLUSION

We observed a significant variation in the use and content of PT for SSc patients in a primary care setting. Our results suggest potential underuse of PT care, in particular for hand and oral dysfunction, and underpin the need for initiatives to improve the quality and accessibility of PT care for SSc patients.

Measurement properties and interpretability of the PROMIS item banks in stroke patients: a systematic review

PURPOSE

Both the International Consortium for Health Outcomes Measurement and the National Institutes of Health recommend the use of Patient-Reported Outcomes Measurement Information System (PROMIS®) measures in clinical care and research for stroke patients. This study aimed to systematically review the literature on the measurement properties and interpretability of PROMIS measures in stroke patients.

METHODS

Nine databases were searched from January 1st, 2007 till April 12th, 2021 for studies concerning the measurement properties and interpretability of PROMIS measures in stroke patients. The findings of these studies were analyzed according to the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) guideline for systematic reviews of Patient-Reported Outcome Measures (PROMs).

RESULTS

Ten studies were included. The PROMIS Global Health was studied the most: its two subscales had sufficient structural validity in one study of very good quality, sufficient construct validity with > 75% of hypotheses tested confirmed (high GRADE rating), sufficient internal consistency, i.e. α ≥ 0.70 in two studies (high GRADE rating), sufficient reliability, i.e. ICC ≥ 0.70 in one study of doubtful quality, and indeterminate responsiveness in one study of inadequate quality. For other PROMIS measures, the measurement properties and interpretability were limitedly studied.

CONCLUSION

The PROMIS Global Health showed sufficient structural and construct validity and internal consistency in stroke patients. There is a need for further research on content validity, structural validity, and measurement invariance of PROMIS measures in stroke patients. Trial Registration Information: CRD42020203044 (PROSPERO).

Sex differences in perceived expectations of the outcome of total hip and knee arthroplasties and their fulfillment: an observational cohort study

The influence of sex on preoperative expectations and their fulfillment following total hip and knee arthroplasty (THA/TKA) remains unexplored. We investigated differences between men and women in perceived preoperative expectations on the outcome of THA/TKA and their fulfillment 1 year postoperatively. We performed a cohort study. Expectations were collected preoperatively and 1 year postoperatively using the Hospital for Special Surgery Hip/Knee Replacement Expectations Surveys (HSS-HRES/KRES; not applicable = 0, applicable: back to normal = 1, much = 2/moderate = 3/slight improvement = 4). Fulfillment of expectations was calculated by subtracting preoperative from postoperative scores (score < 0:unfulfilled; score ≥ 0:fulfilled). We included patients with “applicable” expectations. Chi-square and ordinal regression were used to compare expectations and fulfillment regarding sex. 2333 THA (62% women) and 2398 TKA (65% women) patients were included. 77% of THA and 76% of TKA patients completed the HSS-HRES/HSS-KRES both preoperatively and 1 year postoperatively. Men more often perceived items as “applicable”, with differences in 9/20 (HSS-HRES) and 9/19 (HSS-KRES) preoperative items and, respectively, 12/20 (HSS-HRES) and 10/19 (HSS-KRES) postoperative items. The largest differences (> 10%) were found in sexual activity and working ability. 16/20 (HSS-HRES) and 14/19 (HSS-KRES) items showed an increased probability of having higher preoperative expectations of ≥ 10%, in favor of men. In all items, 60% of the respondents indicated that their expectation was fulfilled. Differences were observed in 16/20 (HSS-HRES) and 6/19 (HSS-KRES) items in favor of men. Sex differences were present in expectations and fulfillment, with higher applicability of items, preoperative expectations and fulfillment in men, especially on items related to functional activities.

Trial registration: Trial-ID NTR3348.

Activities and participation after primary total hip arthroplasty; posterolateral versus direct anterior approach in 860 patients

BACKGROUND AND PURPOSE

In the past decade, a shift occurred in surgical total hip arthroplasty (THA) approaches to the posterolateral (PLA) and direct anterior approach (DAA). Comparisons of postoperative activities and participation between surgical approaches for THA are sparse. We therefore investigated the association between PLA and DAA for THA regarding the construct "activity and participation" (ICF model) during the first postoperative year.

PATIENTS AND METHODS

This was an observational cohort study on osteoarthritis patients scheduled for primary THA in 2 hospitals. Questionnaires to assess the ICF domain "activity and participation" were completed preoperatively, and 3, 6, and 12 months postoperatively (HOOS Activities of daily living (ADL) and Sport and Recreation Function (SR), Hospital for Special Surgery Hip Replacement Expectations Survey, and questions regarding return to work). Each hospital exclusively performed one approach (PLA [Alloclassic-Zweymüller stem] or DAA [Taperloc Complete stem]) for uncemented THA. Hospital was included as instrumental variable, thereby addressing bias by (un)measured confounders. Adjusted mixed-effect models were used, stratified by employment.

RESULTS

Total population: 238 PLA (24% employed) and 622 DAA (26% employed) patients. At 12 months, the PLA group had a lower ADL score (-7, 95% CI -12 to -2 points). At 6 months, significantly fewer PLA patients had fulfillment of the expectation sports-performance (OR = 0.3, CI 0.2-0.7]. Other outcomes were comparable. Employed population: At 6 and 12 months, PLA patients scored clinically lower on ADL (respectively -10, CI -19 to 0 and -9, CI -19 to 0 points) and SR (respectively -13, CI -21 to -4 and -9, CI -18 to -1 points). At 6 months, fewer PLA patients fulfilled the expectation joining recreational activities (OR = 0.2, CI 0.1-0.7]. Fulfillment of other expectations was comparable between groups. PLA patients less often returned to work within 3 months (31% vs. 45%), but rates were comparable at 12 months (86% vs. 87%).

INTERPRETATION

Overall, functional recovery regarding "activity and participation" was comparable for PLA and DAA. Among employed patients, DAA resulted in better functional recovery and more fulfillment of expectations compared with PLA patients. DAA might also facilitate faster return to work.

The course of depressive symptoms in the first 12 months post-stroke and its association with unmet needs

AIM

To describe the course of depressive symptoms during the first 12 months post-stroke and its association with unmet needs.

METHODS

A prospective cohort study among stroke patients admitted to inpatient rehabilitation. Depressive symptoms were assessed 3, 6, and 12 months post-stroke using the Hospital Anxiety and Depression Scale, and categorized into three trajectories: no (all times <8), non-consistent (one or two times ≥8), or persistent (all times ≥8) depressive symptoms. Unmet needs were assessed using the Longer-Term Unmet Needs questionnaire. Multivariable logistic regression analyses were used to investigate the association between depressive symptoms and unmet needs.

RESULTS

One hundred and fifty-one patients were included, of whom 95 (62.9%), 38 (25.2%), and 18 (11.9%) had no, non-consistent, or persistent depressive symptoms, respectively. Depressive symptoms three months post-stroke persisted in 43.9% and recurred in 19.5% of patients during the first 12 months post-stroke. Depressive symptoms were significantly associated with the occurrence and number of unmet needs (odds ratio 6.49; p = 0.003 and odds ratio 1.28; p = 0.005, respectively).

CONCLUSIONS

Depressive symptoms three months post-stroke were likely to persist or recur during the first 12 months post-stroke. Depressive symptoms are associated with unmet needs. These results suggest that routine monitoring of depressive symptoms and unmet needs should be considered post-stroke.Implications for rehabilitationPatients with depressive symptoms three months post-stroke have a high risk of developing persistent or recurrent depressive symptoms during the first 12 months post-stroke.Unmet needs are associated with both non-consistent and persistent depressive symptoms post-stroke.These results suggest that health professionals should routinely screen for depressive symptoms and health care needs around three months post-stroke.In patients with depressive symptoms at three months post-stroke early treatment of depressive symptoms and addressing unmet needs should be considered and depressive symptoms should be routinely monitored during the first 12 months post-stroke.

Are There Differences in Long-Term Functioning and Recovery Between Hemorrhagic and Ischemic Stroke Patients Receiving Rehabilitation?

OBJECTIVE

Previous research suggested better recovery in functioning of patients with hemorrhagic as compared to ischemic stroke. Now that more effective acute treatment for ischemic stroke, i.e. thrombolysis and thrombectomy, has become available, this observational cohort study aimed to examine if current rehabilitation outcomes differ between patients with hemorrhagic and ischemic stroke.

MATERIALS AND METHODS

The Barthel Index, 4 domains of the Stroke Impact Scale (SIS) and the EuroQol 5Dimensions were completed in all consecutive patients who received stroke rehabilitation at start of rehabilitation and during follow-up (for Barthel Index at discharge, SIS and EuroQol 5D after three and six months). Outcomes and recovery (i.e. change of scores between baseline and last follow-up) were compared between patients with hemorrhagic stroke and ischemic stroke (total and categorized by initial hospital treatment) using the Kruskall Wallis test. In addition, recovery was compared between ischemic and hemorrhagic stroke in multiple regression analyses with bootstrapping.

RESULTS

Baseline functioning did not differ between 117 patients with a hemorrhagic stroke, 118 ischemic stroke patient treated with reperfusion therapy, and 125 ischemic stroke patients without reperfusion therapy. There were no differences in functioning at follow-up nor in recovery concerning the Barthel Index, SIS domains 'mobility', 'communication', 'memory and thinking' and 'mood and emotions', and EuroQoL 5D between the three categories.

CONCLUSIONS

In a rehabilitation population the recovery and functioning at three or six months did not differ between ischemic stroke patients and hemorrhagic stroke patients, regardless of the hospital treatment they had received.

Effectiveness and cost-effectiveness of longstanding exercise therapy versus usual care in patients with axial spondyloarthritis or rheumatoid arthritis and severe limitations: The protocols of two parallel randomized controlled trials

Objectives

Research on effectiveness and cost‐effectiveness of longstanding exercise therapy in patients with axial SpondyloArthritis (axSpA) or Rheumatoid Arthritis (RA) is scarce, and mainly concerned patients with a relatively favorable health status. We aim to evaluate the effectiveness and cost‐effectiveness of longstanding exercise therapy compared to usual care in the subgroup of patients with axSpA or RA and severe limitations in functioning.

Methods

In two separate, parallel randomized controlled trials the effectiveness and cost‐effectiveness of longstanding, active exercise therapy (52 weeks) compared with usual care (1:1) will be evaluated. The longstanding, active exercise therapy will focus on improving individual limitations in daily activities and participation and will be given by a trained physical therapist in the vicinity of the participant. For each diagnosis, 215 patients with severe limitations in activities and participation will be included. Assessments are performed at baseline, 12, 26, and 52 weeks. The primary outcome measure of effectiveness is the individual level of functioning (activities and participation), as measured with the Patient‐Specific Complaints instrument at 52 weeks. For cost‐effectiveness analyses, the EuroQol (EQ‐5D‐5L) and questionnaires on healthcare use and productivity will be administered. The economic evaluation will be a cost‐utility analysis from a societal perspective. After 52 weeks, the patients in the usual care group are offered longstanding, active exercise therapy as well. Follow‐up assessments are done at 104, 156, and 208 weeks.

Conclusion

The results of these studies will provide insights in the effectiveness and cost‐effectiveness of longstanding exercise therapy in the subgroup of axSpA and RA patients with severe functional limitations.

Clinical Practice Guideline for Physical Therapist Management of People With Rheumatoid Arthritis

OBJECTIVE

This guideline revises the 2008 Royal Dutch Society for Physical Therapy guideline for physical therapy for patients with rheumatoid arthritis (RA).

METHOD

This revised guideline was developed according to the Appraisal of Guidelines for Research and Evaluation tool and the Guidelines International Network standards. A multidisciplinary guideline panel formulated clinical questions based on perceived barriers in current care. For every clinical question, a narrative or systematic literature review was undertaken, where appropriate. The guideline panel formulated recommendations based on the results of the literature reviews, the values and preferences of patients and clinicians, and the acceptability, feasibility, and costs, as described in the Grading of Recommendations Assessment, Development and Evaluation evidence-to-decision framework.

RESULTS

The eventual guideline describes a comprehensive assessment based on the International Classification of Functioning, Disability and Health Core Set for RA. It also includes a description of yellow and red flags to support direct access. Based on the assessment, 3 treatment profiles are distinguished: (1) education and exercise instructions with limited supervision, (2) education and short-term supervised exercise therapy, and (3) education and intensified supervised exercise therapy. Education includes RA-related information, advice, and self-management support. Exercises are based on recommendations concerning the desired frequency, intensity, type, and time-related characteristics of the exercises (FITT factors). Their interpretation is compliant with the individual patient's situation and with public health recommendations for health-enhancing physical activity. Recommended measurement instruments for monitoring and evaluation include the Patient-Specific Complaint instrument, Numeric Rating Scales for pain and fatigue, the Health Assessment Questionnaire Disability Index, and the 6-minute walk test.

CONCLUSION

An evidence-based physical therapy guideline was delivered, providing ready-to-use recommendations on the assessment and treatment of patients with RA. An active implementation strategy to enhance its use in daily practice is advised.

IMPACT

This evidence-based practice guideline guides the physical therapist in the treatment of patients with RA. The cornerstones of physical therapist treatment for patients with RA are active exercise therapy in combination with education. Passive interventions such as massage, electrotherapy, thermotherapy, low-level laser therapy, ultrasound, and medical taping play a subordinate role.

Effect of a comprehensive eRehabilitation intervention alongside conventional stroke rehabilitation on disability and health-related quality of life: A pre-post comparison

Objective

To compare the effect on disability and quality of life, of conventional rehabilitation (control group) with individualized, tailored eRehabilitation intervention alongside conventional rehabilitation (Fast@home; intervention group), for people with stroke.

METHODS

Pre–post design. The intervention comprised cognitive (Braingymmer®) and physical (Telerevalidatie®/Physitrack®) exercises, activity-tracking (Activ8®) and psycho-education. Assessments were made at admission (T0) and after 3 (T3) and 6 months (T6). The primary outcome concerned disability (Stroke Impact Scale; SIS). Secondary outcomes were: health-related quality of life, fatigue, self-management, participation and physical activity. Changes in scores between T0–T3, T3–T6, and T0–T6 were compared by analysis of variance and linear mixed models.

Results

The study included 153 and 165 people with stroke in the control and intervention groups, respectively. In the intervention group, 82 (50%) people received the intervention, of whom 54 (66%) used it. Between T3 and T6, the change in scores for the SIS subscales Communication (control group/intervention group –1.7/–0.3) and Physical strength (–5.7/3.3) were significantly greater in the total intervention group (all mean differences< minimally clinically important differences). No significant differences were found for other SIS subscales or secondary outcomes, or between T0–T3 and T0–T6.

Conclusion

eRehabilitation alongside conventional stroke rehabilitation had a small positive effect on communication and physical strength on the longer term, compared to conventional rehabilitation only.

Healthcare utilization and costs among prolactinoma patients: a cross-sectional study and analysis of determinants

PURPOSE

Prolactinomas are the most prevalent functioning pituitary adenomas. They affect gonadal function as well as health-related quality of life (HRQoL). This study aimed to report healthcare utilization and costs, including their determinants, for prolactinoma patients.

METHODS

Cross-sectional study of 116 adult prolactinoma patients in chronic care in a Dutch tertiary referral center. Patients completed four validated questionnaires, assessing healthcare utilization and costs over the previous 12 months (Medical Consumption Questionnaire), disease bother and needs (Leiden Bother and Needs Questionnaire Pituitary), HRQoL (Short Form-36), and self-reported health status (EuroQol 5D). Regression analyses were used to assess associations between disease-related characteristics and healthcare utilization and costs.

RESULTS

Mean age was 52.0 years (SD 13.7) and median follow-up was 15.0 years (IQR 7.6-26.1). Patients visited the endocrinologist (86.2%), general practitioner (37.9%), and ophthalmologist (25.0%) most frequently. Psychological care was used by 12.9% of patients and 5% were admitted to hospital. Mean annual healthcare costs were €1928 (SD 3319), mainly for pituitary-specific medication (37.6% of total costs), hospitalization (19.4%) and specialist care (16.1%). Determinants for higher healthcare utilization and costs were greater disease bother and needs for support, lower HRQoL, elevated prolactin, and longer disease duration, while tumor size, hypopituitarism and adrenal insufficiency were not significantly associated with healthcare utilization and costs.

CONCLUSION

Healthcare utilization and costs of prolactinoma patients are related to patient-reported HRQoL, bother by disease and needs for support. Therefore, addressing patients' HRQoL and needs is a way forward to improve efficiency of care and patients' health status.

Feasibility of Collecting Multiple Patient-Reported Outcome Measures Alongside the Dutch Arthroplasty Register

Background:

Compliance rates with patient-reported outcome measures (PROMs) collected alongside arthroplasty registries vary in the literature. We described the feasibility of a routinely collected set PROMs alongside the Dutch Arthroplasty Register.

Methods:

The longitudinal Leiden Orthopaedics Outcomes of OsteoArthritis Study is a multicenter (7 hospitals), observational study including patients undergoing total hip or total knee arthroplasty (THA or TKA). A set of PROMs: Short Form-12, EuroQol 5 Dimensions, Hip/Knee injury and Osteoarthritis Outcome Score, Oxford Hip/Knee Score was collected preoperatively and at 6, 12, 24 months, and every 2 years thereafter. Participation rates and response rates were recorded.

Results:

Between June 2012 and December 2014, 1796 THA and 1636 TKA patients were invited, of whom 1043 THA (58%; mean age 68 years [standard deviation, SD: 10]) and 970 TKA patients (59%; mean age 71 years [SD 9.5]) participated in the study. At 6 months, 35 THA/38 TKA patients were lost to follow-up. Response rates were 90% for THA (898/1000) and 89% for TKA (827/932) participants. At 1 and 2 years, 8 and 18 THA and 17 and 11 TKA patients were lost to follow-up, respectively. The response rates among those eligible were 87% (866/992) and 84% (812/972) for THA and 84% (771/917) and 83% (756/906) for TKA patients, respectively. The 2-year questionnaire was completed by 78.5% of the included THA patients and by 77.9% of the included TKA patients.

Conclusions:

About 60% of patients undergoing THA or TKA complete PROMs preoperatively, with more than 80% returning follow-up PROMs. To increase the participation rates, more efforts concerning the initial recruitment of patients are needed.

SF-12 or SF-36 in pituitary disease? Toward concise and comprehensive patient-reported outcomes measurements

PURPOSE

Pituitary diseases severely affect patients' health-related quality of life (HRQoL). The most frequently used generic HRQoL questionnaire is the Short Form-36 (SF-36). The shorter 12-item version (SF-12) can improve efficiency of patient monitoring. This study aimed to determine whether SF-12 can replace SF-36 in pituitary care.

METHODS

In a longitudinal cohort study (August 2016 to December 2018) among 103 endoscopically operated adult pituitary tumor patients, physical and mental component scores (PCS and MCS) of SF-36 and SF-12 were measured preoperatively, and 6 weeks and 6 months postoperatively. Chronic care was assessed with a cross-sectional study (N = 431). Mean differences and agreement between SF-36 and SF-12 change in scores (preoperative vs. 6 months) were assessed with intraclass correlation coefficients (ICC) and limits of agreement, depicting 95% of individual patients.

RESULTS

In the longitudinal study, mean differences between change in SF-36 and SF-12 scores were 1.4 (PCS) and 0.4 (MCS) with fair agreement for PCS (ICC = 0.546) and substantial agreement for MCS (ICC = 0.931). For 95% of individual patients, the difference between change in SF-36 and SF-12 scores varied between -14.0 and 16.9 for PCS and between -7.8 and 8.7 for MCS. Cross-sectional results showed fair agreement for PCS (ICC = 0.597) and substantial agreement for MCS (ICC = 0.943).

CONCLUSIONS

On a group level, SF-12 can reliably reproduce MCS in pituitary patients, although PCS is less well correlated. However, individual differences between SF-36 and SF-12 can be large. For pituitary diseases, alternative strategies are needed for concise, but comprehensive patient-reported outcome measurement.

Changes in the ability to participate in and satisfaction with social roles and activities in patients in outpatient rehabilitation

Background

One of the main aims of rehabilitation is to improve participation. Patient-Reported Outcomes Measurement Information System (PROMIS®) item banks ‘Ability to Participate in Social roles and Activities, (PROMIS-APS) and ‘Satisfaction with Social Roles and Activities’ (PROMIS-SPS) are promising options to measure participation, but the literature on PROMIS measures of (satisfaction with) participation across diagnoses in rehabilitation is limited. Therefore, the objective of this study was to describe levels of and changes in participation, as assessed with the PROMIS-APS and the PROMIS-SPS short forms, of patients in outpatient rehabilitation.

Methods

This study had quantitative, observational design with assessments at admission and discharge. Consecutive patients treated between April and August 2018 receiving outpatient multidisciplinary rehabilitation were the population of this study. The following diagnosis categories were included: brain injury (e.g. stroke), spinal cord and nerve injury, neuromuscular disorder (e.g. lateral sclerosis), amputation, musculoskeletal condition (e.g. osteoarthritis) or heart or lung disease (e.g. myocardial infarction, chronic obstructive pulmonary disease). The main patient-reported outcomes (PRO) of this study were the short form of the PROMIS-APS (8 items, Dutch general population reference score 50.6 [SD 9.5]), and PROMIS-SPS (8 items, Dutch general population reference score 47.5 [SD 8.3].

Results

Of the 1279 patients invited, 777 (61%) completed the online forms at admission. Of those, 329 patients were invited at discharge, with 209 (64%) completing the forms. The mean (SD) T-scores of the PROMIS-APS and PROMIS-SPS were lower at admission (42.7 [SD 7.4]; (41.4 [SD 7.7]) and discharge (43.6 [SD 7.2]; (43.7 [SD 7.8]) than the Dutch general population. The change scores of the PROMIS-APS and PROMIS-SPS were 1.2 (95% CI 0.4–1.9; p = 0.004; effect size 0.16), and 2.4 (95% CI 1.6–3.2; p < 0.0001; effect size 0.31), respectively. In all diagnostic subgroups with > 30 paired measurements statistically significant improvements of PROMIS-APS, PROMIS-SPS or both were seen.

Conclusions

Patients undergoing outpatient rehabilitation had, both at admission and discharge, considerably lower PROMIS-APS and PROMIS-SPS T-scores short forms than the general Dutch population, and showed small T-score improvements at discharge.

Rationale and design of the PaTIO study: PhysiotherApeutic Treat-to-target Intervention after Orthopaedic surgery

Background

Physiotherapy is a proven effective treatment strategy after total knee and hip arthroplasty (TKA/THA), however there is considerable practice variation regarding its timing, content and duration. This study aims to compare the (cost-) effectiveness of a standardized, treat-to-target postoperative physiotherapy strategy with usual postoperative care.

Methods

Using a cluster randomized study design, consecutive patients scheduled for a primary TKA/THA in 18 hospitals in the Netherlands will be assigned to the treat-to-target physio therapy strategy or usual postoperative care. With the treat-to-target strategy a standardized, individually tailored, exercise program is aimed at the attainment of specific functional milestones. Assessments are done at baseline, 6 weeks and 3, 6, 9 and 12 months follow up. The primary outcome will be the Knee injury / Hip disability and Osteoarthritis Outcome Score - Physical Function Short Form (KOOS-PS / HOOS-PS) at 3 months follow up. Secondary outcomes are the numeric rating scale for pain, the Oxford Knee and Hip Scores, performance-based test and the EuroQol 5D-5L for quality of life. Healthcare use, productivity and satisfaction with postoperative care are measured by means of questionnaires. In total, 624 patients will be needed of which 312 TKA and 312 THA patients.

Discussion

The study will provide evidence concerning the (cost-) effectiveness of the treat-to-target postoperative physiotherapy treatment compared to usual postoperative care. The results of this study will address an important evidence gap and will have a significant impact in daily practice of the physio therapist.

Trial registration

Registered in the Dutch Trial Registry on April 15, 2018. Registration number: NTR7129.

A clinical practice guideline for physical therapy in patients with hip or knee osteoarthritis

OBJECTIVE

The purpose of this paper is to revise the 2010 Dutch guideline for physical therapy (PT) in patients with hip or knee osteoarthritis (OA), issued by the Royal Dutch Society for Physical Therapy (KNGF).

METHOD

This revised guideline was developed according to the Appraisal of Guidelines for Research and Evaluation (AGREE) and Guidelines International Network (G-I-N) standards. A multidisciplinary guideline panel formulated clinical questions based on perceived barriers to current care. A narrative or systematic literature review was undertaken in response to each clinical question. The panel formulated recommendations based on evidence and additional considerations, as described in the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) Evidence-to-Decision framework.

RESULTS

A comprehensive assessment should be based on the International Classification of Functioning Disability and Health (ICF) core set for OA, including the identification of OA-related red flags. Based on the assessment, four treatment profiles were distinguished: (1) education and instructions for unsupervised exercises, (2) education and short-term supervised exercise therapy, (3) education and longer term supervised exercise therapy, and (4) education and exercise therapy before and/or after total hip or knee surgery. Education included individualized information, advice, instructions, and self-management support. Exercise programs were tailored to individual OA-related issues, were adequately dosed, and were in line with public health recommendations for physical activity. Recommended measurement instruments included the Patient-Specific Complaints Instrument, the Numeric Pain Rating Scale, the Hip Disability and Osteoarthritis Outcome Score/the Knee Injury Osteoarthritis Outcome Score, and the Six Minute Walk Test.

CONCLUSION

An evidence-based PT guideline for the management of patients with hip or knee OA was developed. To improve quality of care for these patients, an extensive implementation strategy is necessary.

Feasibility, safety, and outcomes of a stratified fast-track care trajectory in pituitary surgery

OBJECTIVE

Discharge policies concerning hospitalization after endoscopic pituitary tumor surgery are highly variable. A few studies support fast-track discharge; however, this is not commonplace. Our goal was to report the transition to and evaluate the feasibility, safety, clinical- and patient-reported outcomes and costs of fast-track care in pituitary surgery.

METHODS

This observational study included 155 patients undergoing pituitary surgery between December 2016 and December 2018. Fast-track care consisted of planned discharge 2-3 days after surgery, followed by daily surveillance by a case manager. All outcomes were compared with patients not eligible for fast-track discharge. The total group (fast-track and non-fast-track) was compared with historic controls (N = 307).

RESULTS

A total of 79/155 patients (51%) were considered eligible for fast-track discharge, of whom 69 (87%) were discharged within 3 days. The total group was discharged more often within 3 days compared with historic controls (49 vs. 20%, p < 0.001), the total length of stay did not differ (5.3 vs. 5.7 days, p = 0.363). Although the total group had more readmissions compared with historic controls (17 vs. 10%, p = 0.002), no life-threatening complications occurred after discharge. On average, clinical- and patient-reported outcomes improved over time, both in the fast-track and non-fast-track groups. The mean overall costs within 30 days after surgery did not differ between the total group € 9992 (SD € 4562) and historic controls € 9818 (SD € 3488) (p = 0.649).

CONCLUSION

A stratified fast-track care trajectory with enhanced postoperative outpatient surveillance after pituitary tumor surgery is safe and feasible. As expected, costs of the fast-track were lower than the non-fast-track group, however we could not prove overall cost-effectiveness compared with the historic controls.

Fatigue, Participation and Quality of Life in Adolescents and Young Adults with Acquired Brain Injury in an Outpatient Rehabilitation Cohort

PURPOSE

To study the association between fatigue and participation and QoL after acquired brain injury (ABI) in adolescents and young adults (AYAs).

MATERIALS & METHODS

Cross-sectional study with AYAs aged 14-25 years, diagnosed with ABI. The PedsQL™ Multidimensional Fatigue Scale, Child & Adolescent Scale of Participation, and PedsQL™4.0 Generic Core Scales were administered.

RESULTS

Sixty-four AYAs participated in the study, 47 with traumatic brain injury (TBI). Median age at admission was 17.6 yrs, 0.8 yrs since injury. High levels of fatigue (median 44.4 (IQR 34.7, 59.7)), limited participation (median 82.5 (IQR 68.8, 92.3)), and diminished QoL (median 63.0 (IQR 47.8, 78.3)) were reported. More fatigue was significantly associated with more participation restrictions (β 0.64, 95%CI 0.44, 0.85) and diminished QoL (β 0.87, 95%CI 0.72, 1.02).

CONCLUSIONS

AYAs with ABI reported high levels of fatigue, limited participation and diminished quality of life with a significant association between fatigue and both participation and QoL. Targeting fatigue in rehabilitation treatment could potentially improve participation and QoL.

Differences in factors influencing the use of eRehabilitation after stroke; a cross-sectional comparison between Brazilian and Dutch healthcare professionals

BACKGROUND

To improve the use of eRehabilitation after stroke, the identification of barriers and facilitators influencing this use in different healthcare contexts around the world is needed. Therefore, this study aims to investigate differences and similarities in factors influencing the use of eRehabilitation after stroke among Brazilian Healthcare Professionals (BHP) and Dutch Healthcare Professionals (DHP).

METHOD

A cross-sectional survey study including 88 statements about factors related to the use of eRehabilitation (4-point Likert scale; 1-4; unimportant-important/disagree-agree). The survey was conducted among BHP and DHP (physical therapists, rehabilitating physicians and psychologists). Descriptive statistics were used to analyse differences and similarities in factors influencing the use of eRehabilitation.

RESULTS

ninety-nine (response rate 30%) BHP and 105 (response rate 37%) DHP participated. Differences were found in the top-10 most influencing statements between BHP and DHP BHP rated the following factors as most important: sufficient support from the organisation (e.g. the rehabilitation centre) concerning resources and time, and potential benefits of the use of eRehabilitation for the patient. DHP rated the feasibility of the use of eRehabilitation for the patient (e.g. a helpdesk and good instructions) as most important for effective uptake. Top-10 least important statements were mostly similar; both BHP and DHP rated problems caused by stroke (e.g. aphasia or cognitive problems) or problems with resources (e.g. hardware and software) as least important for the uptake of eRehabilitation.

CONCLUSION

The results indicate that the use of eRehabilitation after stroke by BHP and DHP is influenced by different factors. A tailored implementation strategy for both countries needs to be developed.

Preparing for an orthopedic consultation using an eHealth tool: a randomized controlled trial in patients with hip and knee osteoarthritis

BACKGROUND

To evaluate the effect of a stand-alone mobile and web-based educational intervention (eHealth tool) compared to usual preparation of a first orthopedic consultation of patients with hip or knee osteoarthritis (OA) on patients' satisfaction.

METHODS

A two-armed randomized controlled trial involving 286 patients with (suspicion of) hip or knee OA, randomly allocated to either receiving an educational eHealth tool to prepare their upcoming consultation (n = 144) or usual care (n = 142). Satisfaction with the consultation on three subscales (range 1-4) of the Consumer Quality Index (CQI - primary outcome) and knowledge (assessed using 22 statements on OA, range 0-22), treatment beliefs (assessed by the Treatment beliefs in OsteoArthritis questionnaire, range 1-5), assessment of patient's involvement in consultation by the surgeon (assessed on a 5-point Likert scale) and patient satisfaction with the outcome of the consultation (numeric rating scale), were assessed.

RESULTS

No differences between groups were observed on the 3 subscales of the CQI (group difference (95% CI): communication 0.009 (- 0.10, 0.12), conduct - 0.02 (- 0.12, 0.07) and information provision 0.02 (- 0.18, 0.21)). Between group differences (95% CI) were in favor of the intervention group for knowledge (1.4 (0.6, 2.2)), negative beliefs regarding physical activities (- 0.19 (- 0.37, - 0.002) and pain medication (- 0.30 (- 0.49, - 0.01)). We found no differences on other secondary outcomes.

CONCLUSIONS

An educational eHealth tool to prepare a first orthopedic consultation for hip or knee OA does not result in higher patient satisfaction with the consultation, but it does influence cognitions about osteoarthritis.

TRIAL REGISTRATION

Dutch Trial Register (trial number NTR6262). Registered 30 January 2017.

Implementation of Physical Activity into routine Clinical pracTice in Rheumatic Musculoskeletal Disease: The IMPACT-RMD study protocol and rationale

Background:

Physical activity is an important intervention for improving disease-related symptoms and systemic manifestations in rheumatic and musculoskeletal disease (RMDs). However, studies suggest that RMD patients report that the lack of individualized and consistent information about physical activity from managing doctors and healthcare professionals, acts as a barrier for engagement. On the other hand, managing doctors and healthcare professionals report lack of knowledge in this area and thus lack of confidence to educate and advise RMD patients about the beneficial effects of physical activity. The aim of the present study therefore, is to develop two e-Learning courses for RMD doctors and health professionals: a) the first one to provide consistent information about the collective benefits of physical activity in RMDs and b) the second on how to implement physical activity advice in routine clinical practice.

Methods:

An international collaboration of seven countries, consisting of one academic institution and one patient organization from each country, will co-develop the two e-Learning courses. The final e-Learning courses will primarily target to improve – through physical activity advice – RMD symptoms which are important for patients.

Discussion:

The main result of this study will be to co-develop two e-Learning courses that can be used by managing RMD doctors and healthcare professionals to be made aware of the overall benefits of physical activity in RMDs as well as how to implement physical activity advise within their practice.

Evaluation of an educational course for primary care physiotherapists on comorbidity-adapted exercise therapy in knee osteoarthritis: an observational study

Objective

The objectives of the present study were to: (1) evaluate the effect of an educational course on competence (knowledge and clinical reasoning) of primary care physical therapists (PTs) in treating patients with knee osteoarthritis (KOA) and comorbidity according to the developed strategy; and (2) identify facilitators and barriers for usage.

Method

The present research was an observational study with a pretest‐posttest design using mixed methods. PTs were offered a postgraduate course consisting of e‐learning and two workshops (blended education) on the application of a strategy for exercise prescription in patients with KOA and comorbidity. Competences were measured by questionnaire on knowledge (administered before and 2 weeks after the course), and a patient vignette to measure clinical reasoning (administered before the course and after a 6 month period of treating patients). Facilitators and barriers for using the strategy were assessed by a questionnaire and semi‐structured interviews.

Results

Thirty‐four PTs were included. Competence (knowledge and clinical reasoning) improved significantly (p < 0.01). Fourteen out of 34 PTs had actually treated patients with KOA and comorbidity, during a 6‐month period. The strategy was found to be feasible in daily practice. The main barriers included the limited number of (self‐) referrals of patients, limited number of reimbursed treatment sessions by insurance companies and a suboptimal collaboration with (referring) physicians.

Conclusion

A blended course on exercise therapy for patients with KOA and comorbidity seems to improve PTs' competence through increasing knowledge and clinical reasoning skills. Identified barriers should be solved before large‐scale implementation of exercise therapy can take place in these complex patients.

Factors associated with willingness to use eRehabilitation after stroke: A cross-sectional study among patients, informal caregivers and healthcare professionals

OBJECTIVE

Despite the increasing availability of eRehabilitation, its use remains limited. The aim of this study was to assess factors associated with willingness to use eRehabilitation.

DESIGN

Cross-sectional survey.

SUBJECTS

Stroke patients, informal caregivers, health-care professionals.

METHODS

The survey included personal characteristics, willingness to use eRehabilitation (yes/no) and barri-ers/facilitators influencing this willingness (4-point scale). Barriers/facilitators were merged into factors. The association between these factors and willingness to use eRehabilitation was assessed using logistic regression analyses.

RESULTS

Overall, 125 patients, 43 informal caregivers and 105 healthcare professionals participated in the study. Willingness to use eRehabilitation was positively influenced by perceived patient benefits (e.g. reduced travel time, increased motivation, better outcomes), among patients (odds ratio (OR) 2.68; 95% confidence interval (95% CI) 1.34-5.33), informal caregivers (OR 8.98; 95% CI 1.70-47.33) and healthcare professionals (OR 6.25; 95% CI 1.17-10.48). Insufficient knowledge decreased willingness to use eRehabilitation among pa-tients (OR 0.36, 95% CI 0.17-0.74). Limitations of the study include low response rates and possible response bias.

CONCLUSION

Differences were found between patients/informal caregivers and healthcare professionals. Ho-wever, for both groups, perceived benefits of the use of eRehabilitation facilitated willingness to use eRehabili-tation. Further research is needed to determine the benefits of such programs, and inform all users about the potential benefits, and how to use eRehabilitation.

Stratified exercise therapy compared with usual care by physical therapists in patients with knee osteoarthritis: A randomized controlled trial protocol (OCTOPuS study)

Objectives

Knee osteoarthritis (OA) is characterized by its heterogeneity, with large differences in clinical characteristics between patients. Therefore, a stratified approach to exercise therapy, whereby patients are allocated to homogeneous subgroups and receive a stratified, subgroup‐specific intervention, can be expected to optimize current clinical effects. Recently, we developed and pilot tested a model of stratified exercise therapy based on clinically relevant subgroups of knee OA patients that we previously identified. Based on the promising results, it is timely to evaluate the (cost‐)effectiveness of stratified exercise therapy compared with usual, “nonstratified” exercise therapy.

Methods

A pragmatic cluster randomized controlled trial including economic and process evaluation, comparing stratified exercise therapy with usual care by physical therapists (PTs) in primary care, in a total of 408 patients with clinically diagnosed knee OA. Eligible physical therapy practices are randomized in a 1:2 ratio to provide the experimental (in 204 patients) or control intervention (in 204 patients), respectively. The experimental intervention is a model of stratified exercise therapy consisting of (a) a stratification algorithm that allocates patients to a “high muscle strength subgroup,” “low muscle strength subgroup,” or “obesity subgroup” and (b) subgroup‐specific, protocolized exercise therapy (with an additional dietary intervention from a dietician for the obesity subgroup only). The control intervention will be usual best practice by PTs (i.e., nonstratified exercise therapy). Our primary outcome measures are knee pain severity (Numeric Rating Scale) and physical functioning (Knee Injury and Osteoarthritis Outcome Score subscale daily living). Measurements will be performed at baseline, 3‐month (primary endpoint), 6‐month (questionnaires only), and 12‐month follow‐up, with an additional cost questionnaire at 9 months. Intention‐to‐treat, multilevel, regression analysis comparing stratified versus usual care will be performed.

Conclusion

This study will demonstrate whether stratified care provided by primary care PTs is effective and cost‐effective compared with usual best practice from PTs.

An Electronic Health Tool to Prepare for the First Orthopedic Consultation: Use and Usability Study

Background

The use of electronic health (eHealth) technology to prepare patients with hip or knee osteoarthritis (OA) for their first orthopedic consultation seems promising. Exploration of the use and usability of an educational eHealth tool may highlight potential modifications that could increase patient engagement and effectiveness.

Objective

This study aimed to (1) identify the use and usability of a stand-alone educational eHealth tool for patients with suspected hip or knee OA, (2) explore whether the recorded questions in the eHealth tool were in line with an existing widely used question prompt list, and (3) investigate whether user characteristics are related to use and usability.

Methods

We used data from 144 participants in the intervention group of a randomized controlled trial, who were asked to use the educational eHealth tool to prepare for their upcoming first orthopedic consultation. We defined users and nonusers based on whether they had opened the tool at least once. Users were characterized as active or superficial depending on the extent of their use of the tool. The recorded questions for the consultation preparation were categorized into themes fitting 3 predefined questions or in a remaining category. Usability was measured using the System Usability Scale (SUS, 0-100). Data were collected including the patient demographic and clinical characteristics, knowledge of OA, and internet and smartphone usage in daily life. The characteristics associated with users and nonusers were analyzed using a multivariable logistic regression analysis.

Results

A total of 116/144 (80.6%) participants used the educational eHealth tool, of whom 87/116 (75.0%) were active users. Of the three components of the tool (information, my consultation, and medication), medication was the least used (34%). On the basis of recorded questions of the users, the fourth predefined question could be proposed. The mean (SD) SUS score was 64.8 (16.0). No difference was found between the SUS scores of superficial and active users (mean difference 0.04, 95% CI −7.69 to 7.77). Participants with a higher baseline knowledge of OA (odds ratio [OR] 1.2, 95% CI 1.0 to 1.4) and who used the internet less frequently in their daily life (OR 0.6, 95% CI 0.5 to 0.9) were more likely to use the educational eHealth tool. We found no differences between the demographics and clinical characteristics of the superficial and active users.

Conclusions

Based on the results of this study, it can be concluded that the use of an educational eHealth tool to prepare patients with hip and knee OA for the first orthopedic consultation is feasible. Our results suggest some improvements that should be made to the content of the tool to improve its usability. No clear practical implications were found to support the implementation of the educational eHealth tool in specific subgroups.

Trial Registration

Netherlands Trial Register NTR6262; https://www.trialregister.nl/trial/6262

Toward Value Based Health Care in pituitary surgery: application of a comprehensive outcome set in perioperative care

OBJECTIVE

Although widely advocated, applying Value Based Health Care (VBHC) in clinical practice is challenging. This study describes VBHC-based perioperative outcomes for patients with pituitary tumors up to 6 months postoperatively.

METHODS

A total of 103 adult patients undergoing surgery were prospectively followed. Outcomes categorized according to the framework of VHBC included survival, degree of resection, endocrine remission, visual outcome (including self-perceived functioning), recovery of pituitary function, disease burden and health-related quality of life (HRQoL) at 6 months (Tier 1); time to recovery of disease burden, HRQoL, visual function (Tier 2); permanent hypopituitarism and accompanying hormone replacement (Tier 3). Generalized estimating equations (GEEs) analysis was performed to describe outcomes over time.

RESULTS

Regarding Tier 1, there was no mortality, 72 patients (70%) had a complete resection, 31 of 45 patients (69%) with functioning tumors were in remission, 7 (12%, with preoperative deficits) had recovery of pituitary function and 45 of 47 (96%) had visual improvement. Disease burden and HRQoL improved in 36-45% at 6 months; however, there were significant differences between tumor types. Regarding Tier 2: disease burden, HRQoL and visual functioning improved within 6 weeks after surgery; however, recovery varied widely among tumor types (fastest in prolactinoma and non-functioning adenoma patients). Regarding Tier 3, 52 patients (50%) had persisting (tumor and treatment-induced) hypopituitarism.

CONCLUSIONS

Though challenging, outcomes of a surgical intervention for patients with pituitary tumors can be reflected through a VBHC-based comprehensive outcome set that can distinguish outcomes among different patient groups with respect to tumor type.

Health Care Use and Its Associated Factors 5-8 Years after Stroke

OBJECTIVES

To describe health care use and its associated factors in the chronic phase after stroke.

METHODS

Patients completed a questionnaire on health care use, 5-8 years after hospital admission for stroke. It comprised the number of visits to physicians or other health care professionals over the past 6 months (Physician-visits; Low ≤1 or High ≥2) and other health care professionals (Low = 0 or High ≥ 1). In addition the Longer-term Unmet Needs after Stroke (LUNS), Frenchay Activity Index (FAI) and Physical and Mental Component Summary Scales of the Short Form 12 (PCS and MCS) were administered. Their associations with health care use (high, low) were determined by means of logistic regression analysis, adjusted for sex and age.

RESULTS

Seventy-eight of 145 patients (54%) returned the questionnaires; mean time-since-stroke was 80.3 months (SD10.2), age-at-stroke 61.7 years (SD13.8), and 46 (59%) were male. Physician contacts concerned mainly the general practitioner (58; 79.5%). Forty-one (52.6%) and 37 (47.4%) of the patients had a high use of physician and other health professionals visits, respectively. Worse PCS scores were associated with both high use of physician and other health professionals visits (OR .931; 95%CI .877-.987 and OR .941; 95%CI .891-.993, respectively), whereas the FAI, MCS, or LUNS were not related to health care use.

CONCLUSIONS

Health care use after stroke is substantial and is related to physical aspects of health status, not to mental aspects, activities or unmet needs, suggesting a mismatch between patients' needs and care delivered.

Systematic review on the comparative effectiveness of foot orthoses in patients with rheumatoid arthritis

Background

Foot orthoses (FOs) are prescribed as an important conservative treatment option in patients with foot problems related to rheumatoid arthritis. However, a broad variation in FOs is used, both in clinical practice and in research. To date, there is no overview on the outcomes of the treatment with different kinds of FOs in patients with rheumatoid arthritis and a specific foot problem. The objectives of the present study were to summarize the comparative effectiveness of FOs in the treatment of various foot problems in patients with rheumatoid arthritis, on the primary outcomes foot function and foot pain, and the secondary outcomes physical functioning, health related quality of life, compliance, adverse events, the costs of FOs and patient satisfaction.

Methods

Studies comparing different kinds of FOs, with a presumed therapeutic effect, in the treatment of foot problems related to rheumatoid arthritis were included. A literature search was conducted in The Cochrane Central Registry for Controlled Trials (CENTRAL), PubMed, EMBASE and PEDro up to May 18th, 2018. Data was meta-analyzed, when this was not possible qualitative data analysis was performed.

Results

Ten studies were identified, with a total number of 235 patients. These studies made a comparison between different materials used (soft versus semi-rigid), types of FOs (custom-made versus ready-made; total-contact versus non-total contact), or modifications applied (metatarsal bars versus domes). Also, different techniques to construct custom-made FOs were compared (standard custom-molding techniques versus more sophisticated techniques). A medium effect for (immediate) reduction of forefoot plantar pressure was found in favor of treatment with soft FOs compared to semi-rigid FOs (SMD 0.60, 95% CI 0.07-1.14; P = 0.03; 28 participants). Other comparisons between FOs resulted in non-significant effects or inconclusive evidence for one kind of FOs over the other.

Conclusions

Foot orthoses made of soft materials may lead to more (immediate) forefoot plantar pressure reduction compared to foot orthoses constructed of semi-rigid materials. Definitive high quality RCTs, with adequate sample sizes and long-term follow-up, are needed to investigate the comparative (cost-) effectiveness of different kinds of foot orthoses for the treatment of foot problems related to rheumatoid arthritis.

Patients' pre-operative general and specific outcome expectations predict postoperative pain and function after total knee and total hip arthroplasties

Background and aims Previous studies have suggested there is an association between preoperative expectations about the outcome and outcomes of total knee and total hip arthroplasty (TKA/THA). However, expectations have been rarely examined on their clinical relevance relative to other well-known predictive factors. Furthermore expectations can be measured on a more generic level (e.g. does one expect their symptoms to improve after surgery) or on a more specific level (e.g. does one expect to be able to squat again after surgery). Aim of this study was to examine whether patients' general and specific preoperative outcome expectations predict function and pain 12-months after TKA/THA, when assessed as one of the candidate predictive variables alongside other relevant clinical and sociodemographic variables. Moreover, we explored whether a more generic or a more specific assessment of expectations would better predict outcome. Methods A prospective cohort study on consecutive TKA/THA patients, with assessments done preoperatively and 12-months postoperative. Primary outcomes were the knee injury and osteoarthritis outcome score (KOOS) and hip injury and osteoarthritis outcome score (HOOS) activities of daily living (ADL) and pain subscale scores at 12-months. The pain subscales consist of nine-(KOOS) and 10-(HOOS) items and the ADL of 17 items. Patients' preoperative outcome expectations were measured with the credibility expectancy questionnaire (CEQ), which contains three items scored on a 0-9 scale and sum score 0-27 and the Hospital for Special Surgery expectations surveys (HSS expectation surveys) for 17(TKA) or 18(THA) outcomes on 0-4 scale. Other candidate predictors: preoperative pain and function as measured with HOOS/KOOS, sex, age, education level, body mass index, Kellgren/Lawrence score, preoperative mental health and treatment credibility as measured with CEQ. Eight prediction models were constructed using multivariate linear regression analysis with a backward selection procedure. Results The 146 TKA patients included in this study had a mean age of 66.9 years (SD 9.2) and 69% was female. The 148 THA patients had a mean age 67.2 (SD 9.5) and 57% was female. Mean outcomes: postoperative HOOS-ADL 84.3 (SD 16.6), pain 88.2 (SD 15.4), KOOS-ADL 83.9 (SD 15.8) and pain 83.6 (SD 17.1). CEQ-expectancy median was in THA 23 (IQR 21;24) and TKA 23 (IQR 20;24). HSS-expectation surveys function was for THA 21.0 (18.0;24.0) and 19.0 (14.0;22.0) in TKA. Patients' outcome expectations were consistently part of the combination of variables that best predicted outcomes for both TKA/THA 1-year post-operatively. Expectations alone explained between 17.0 and 30.3% of the variance in outcomes. The CEQ expectancy subscale explained more variance of postoperative function in TKA and of function and pain in THA as compared to the HSS expectation surveys. Conclusions In planning of surgical treatment, orthopedic surgeons should take a range of variables into account of which the patient's expectations about outcome of surgery is one. The CEQ expectancy subscale predicted outcomes slightly better as the HSS expectation surveys, but differences in predictive value of the two measurements were too small to prefer between the two. Future studies are advised to replicate these findings and externally validate the models presented.

Preoperative Radiographic Osteoarthritis Severity Modifies the Effect of Preoperative Pain on Pain/Function After Total Knee Arthroplasty: Results at 1 and 2 Years Postoperatively

BACKGROUND

Osteoarthritis (OA) severity as demonstrated by preoperative radiographs and preoperative pain play an important role in the indication for total knee arthroplasty (TKA). We investigated whether preoperative radiographic evidence of OA severity modified the effect of preoperative self-reported pain on postoperative pain and function 1 and 2 years after TKA for OA.

METHODS

Data from the Longitudinal Leiden Orthopaedics Outcomes of Osteoarthritis Study (LOAS), a multicenter cohort study on outcomes after TKA, were used. OA severity was assessed radiographically with the Kellgren and Lawrence (KL) score (range, 0 to 4). Pain and function were evaluated with the Knee injury and Osteoarthritis Outcome Score (KOOS). After adjustment for body mass index (BMI), age, sex, and the Mental Component Summary scores from the Short Form-12, multivariate linear regression analyses with an interaction term between the preoperative KL score and preoperative pain were performed.

RESULTS

The study included 559 patients. The preoperative KL score was independently associated with 1-year postoperative pain and function (β = 5.4, 95% confidence interval [CI] = 1.4 to 9.4, and β = 7.7, 95% CI = 3.2 to 12.2), while preoperative pain was associated only with postoperative pain (β = 0.3, 95% CI = 0.1 to 0.6) and not with postoperative function (β = 0.2, 95% CI = -0.2 to 0.5). Comparable associations were found between 2-year postoperative pain and KL score (β = 8.0, 95% CI = 3.2 to 12.7) and preoperative pain (β = 0.5, 95% CI = 0.1 to 0.8) and between 2-year postoperative function and KL score (β = 7.7, 95% CI = 3.2 to 12.2). The study showed a trend toward the KL score modifying the effect of preoperative pain on 1-year postoperative pain (β = -0.1, 95% CI = -0.1 to 0.0) and 2-year postoperative pain (β = -0.1, 95% CI = -0.2 to 0.0) and on 1 and 2-year function (β = -0.1, 95% CI = -0.2 to 0.0 for both), with the effect of preoperative pain on postoperative pain and function seeming to become less important when there was radiographic evidence of greater preoperative OA severity.

CONCLUSIONS

Patients with less pain and higher KL grades preoperatively had better function and pain outcomes 1 and 2 years after TKA. However, the effect of preoperative pain on the postoperative outcomes seems to become less important when the patient has radiographic evidence of more severe OA. We believe that analysis of the severity of preoperative pain is an important proxy for optimal postoperative patient outcome.

LEVEL OF EVIDENCE

Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Healthcare utilization and costs among patients with non-functioning pituitary adenomas

PURPOSE

Non-functioning pituitary adenomas (NFPA) have a substantial impact on patients' health status, yet research on the extent of healthcare utilization and costs among these patients is scarce. The objective was to determine healthcare usage, associated costs, and their determinants among patients treated for an NFPA.

METHODS

In a cross-sectional study, 167 patients treated for an NFPA completed four validated questionnaires. Annual healthcare utilization and associated costs were assessed through the medical consumption questionnaire (MTA iMCQ). In addition, the Leiden Bother and Needs Questionnaire for pituitary patients (LBNQ-Pituitary), Short Form-36 (SF-36), and EuroQol (EQ-5D) were administered. Furthermore, age, sex, endocrine status, treatment, and duration of follow-up were extracted from the medical records. Associations were analyzed using logistic/linear regression.

RESULTS

Annual healthcare utilization included: consultation of an endocrinologist (95% of patients), neurosurgeon (14%), and/or ophthalmologist (58%). Fourteen percent of patients had ≥1 hospitalization(s) and 11% ≥1 emergency room visit(s). Mean overall annual healthcare costs were € 3040 (SD 6498), highest expenditures included medication (31%), inpatient care (28%), and specialist care (17%). Factors associated with higher healthcare utilization and costs were greater self-perceived disease bother and need for support, worse mental and physical health status, younger age, and living alone.

CONCLUSION

Healthcare usage and costs among patients treated for an NFPA are substantial and were associated with self-perceived health status, disease bother, and healthcare needs rather than endocrine status, treatment, or duration of follow-up. These findings suggest that targeted interventions addressing disease bother and unmet needs in the chronic phase are needed.

Frailty Questionnaire Is Not a Strong Prognostic Factor for Functional Outcomes in Hip or Knee Arthroplasty Patients

Introduction

Up to 33% and 25% of patients with end-stage hip and knee osteoarthritis (OA) are considered frail by the Groningen Frailty Indicator (GFI). This study aims to assess whether frail patients have lower functional gains after arthroplasty and to assess GFI as a tool to discriminate between good and adverse change score.

Materials and Methods

Patients with end-stage hip/knee OA scheduled for arthroplasty were recruited from the Longitudinal Leiden Orthopaedics Outcomes of Osteo-Arthritis Study. Functional outcome was measured as change score on the Hip Osteoarthritis Outcome Score/Knee Osteoarthritis Outcome Score (HOOS/KOOS), by subtracting preoperative score from 1-year postsurgery score and then dichotomized based on a cutoff of 20 points. For each HOOS/KOOS subscale, 3 models were estimated: GFI univariate (model 1), GFI and baseline score (model 2), and baseline score univariate (model 3). A receiver operating characteristic analysis was performed to assess the discriminative ability of each model.

Results

Eight hundred five patients with end-stage hip OA (31.4% frail) and 640 patients with end-stage knee OA (25.4% frail) were included. Frail patients were older, had a higher body mass index, had more comorbidities, and lived more often alone. Persons considered frail by GFI had significant lower baseline score; however, except for "function in sports and recreation" and "quality of life," change scores were similar in frail and nonfrail persons. The discriminatory value of GFI was negligible for all HOOS/KOOS subscales. Baseline score, however, was adequate to discriminate between total knee arthroplasty patients with more or less than twice the minimally clinically important difference on KOOS symptoms subscale (area under the curve = 0.802).

Discussion/Conclusion

Although frail patients with OA have lower functioning scores at baseline, the change scores on HOOS/KOOS subscales are similar for both frail and nonfrail patients. Exploring other heath assessements may improve patient-specific outcome prediction.

Work disability and its determinants in patients with pituitary tumor-related disease

INTRODUCTION

Pituitary tumors may have a considerable impact on patients' functional status, including paid employment, yet research in this area is sparse.

OBJECTIVE

To describe work disability and its determinants in patients treated for a pituitary tumor.

METHODS

Cross-sectional study including patients treated for a pituitary tumor in the working age (18-65 years), who completed five validated questionnaires assessing work disability [Short Form-Health and Labour Questionnaire, Work Role Functioning Questionnaire 2.0 (WRFQ)], health-related quality of life (HRQoL) and utility (Short Form-36, EuroQoL) and disease burden (Leiden Bother and Needs Questionnaire-Pituitary). Additional data were extracted from the medical records (age, gender, tumor type, treatment, date of diagnosis) and self-reports (marital status, education, endocrine status). Associations of disease-specific and sociodemographic characteristics, HRQoL, and disease burden with (not) having a paid job were examined through multivariate logistic regression.

RESULTS

We included 241 patients (61% female, median age 53 years, median time since diagnosis 11 years), of whom 68 (28%) were without a paid job. Patients who had acromegaly, Cushing's disease, (pan)hypopituitarism, radiotherapy, were single, less educated, lower HRQoL, and increased disease burden were more often without a paid job (p < 0.05). Among those with paid jobs, 41% reported health-related absenteeism in the previous year. The three work incapacitating problems reported by the largest proportion of patients were within the mental and social domain (WRFQ).

CONCLUSION

Work disability among patients treated for a pituitary tumor is substantial. As impact on social functioning is high, it is strongly advised to incorporate work disability during clinical guidance of patients.

Self-reported knee instability associated with pain, activity limitations, and poorer quality of life before and 1 year after total knee arthroplasty in patients with knee osteoarthritis

Information on the association of self-reported knee instability with clinical outcomes after Total Knee Arthroplasty (TKA) and 1 year follow-up is scarce. The aims were to determine (i) the course and prevalence of self-reported knee instability before and 1 year after TKA and (ii) the associations of preoperative, postoperative, and retained self-reported knee instability with pain, activity limitations, and quality of life (QoL) in patients with knee osteoarthritis. Patients undergoing primary TKA, selected from the Longitudinal Leiden Orthopaedics and Outcomes of OsteoArthritis Study, had their knee instability measured using a questionnaire. The Knee injury and Osteoarthritis Outcome Score pain, activity limitations, and QoL subscales were administered before and 1 year after surgery. Multivariable regression analyses were performed to examine associations between knee instability, pain, activity limitations, and QoL, adjusted for covariates (age, gender, comorbidities, and radiographic severity). Of the 908 included patients, 649 (71%) and 187 (21%) reported knee instability before and following TKA, respectively. Of the patients with preoperative knee instability, this perception was retained in 165 (25%) cases. Knee instability was preoperatively associated with pain (B -9.6; 95%CI: -12.4 to -6.7), activity limitations (B -7.5; 95%CI: -10.2 to -4.8), and QoL (B -4.7; 95%CI: -7.0 to -2.4) and postoperatively with pain (B -15.0; 95%CI: -18.5 to -11.6), activity limitations (B -15.1; 95%CI: -18.4 to -11.8), and QoL (B -18.7; 95%CI: -22.3 to -15.3). Retained knee instability was associated with postoperative pain (B -15.1; 95%CI: -18.9 to -11.2), activity limitations (B -14.1; 95%CI: -17.8 to -10.4), and QoL (B -18.0; 95%CI: -21.7 to -14.3). In conclusion, in clinical care, self-reported knee instability is retained postoperatively in 25% of the patients. Retained knee instability is associated with more pain, activity limitations, and poorer QoL postoperatively. © 2018 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 36:2671-2678, 2018.

Short-Term and Long-Term Outcomes of a Vocational Rehabilitation Program for Patients with Acquired Brain Injury in The Netherlands

Purpose To describe short-term and long-term work status after a vocational rehabilitation (VR) program in patients with acquired brain injury (ABI) in the Netherlands. Methods Patients with ABI who participated in a VR program between 2007 and 2010 were included in this study. The 4-month VR program included a multidisciplinary assessment, three meetings with all stakeholders and reintegration with coaching on the job. Short-term results at the end of the VR program were based on data extracted from medical records. Long-term results were determined at 3-6 years (mean 4.4 years) after the program based on patient-reported data. Outcome measures included return to work, hours at work and task adjustments. Results Fifty-eight patients were included [mean age 48 (SD 9.4) years; n = 33 male; all working before ABI]. After the intervention, 50 patients (86%) had returned to work, working on average 60% of their former hours. Working tasks were adjusted in 48 patients. At long-term follow-up 28 patients had paid work, working on average 5.3 h more than immediately after the VR program. Conclusions Directly after the intervention 86% of the patients had returned to work. After 3-6 years, 64% of these patients were still working in a paid job.

What is Important in E-health Interventions for Stroke Rehabilitation? A Survey Study among Patients, Informal Caregivers and Health Professionals

Incorporating user requirements in the design of e-rehabilitation interventions facilitates their implementation. However, insight into requirements for e-rehabilitation after stroke is lacking. This study investigated which user requirements for stroke e-rehabilitation are important to stroke patients, informal caregivers, and health professionals. The methodology consisted of a survey study amongst stroke patients, informal caregivers, and health professionals (physicians, physical therapists and occupational therapists). The survey consisted of statements about requirements regarding accessibility, usability and content of a comprehensive stroke e-health intervention (4-point Likert scale, 1=unimportant/4=important). The mean with standard deviation was the metric used to determine the importance of requirements. Patients (N=125), informal caregivers (N=43), and health professionals (N=105) completed the survey. The mean score of user requirements regarding accessibility, usability and content for stroke e-rehabilitation was 3.1 for patients, 3.4 for informal caregivers and 3.4 for health professionals. Data showed that a large number of user requirements are important and should be incorporated into the design of stroke e-rehabilitation to facilitate their implementation.

Patients' outcome expectations and their fulfilment in multidisciplinary stroke rehabilitation

BACKGROUND

Patients' expectations of the outcomes of rehabilitation may influence the outcomes and satisfaction with treatment.

OBJECTIVES

For stroke patients in multidisciplinary rehabilitation, we aimed to explore patients' outcome expectations and their fulfilment as well as determinants.

METHODS

The Stroke Cohort Outcomes of REhabilitation (SCORE) study included consecutive stroke patients admitted to an inpatient rehabilitation facility after hospitalisation. Outcome expectations were assessed at the start of rehabilitation (admission) by using the three-item Expectancy scale (sum score range 3-27) of the Credibility/Expectancy Questionnaire (CEQ). After rehabilitation, patients answered the same questions formulated in the past tense to assess fulfilment of expectations. Baseline patient characteristics were recorded and health-related quality of life (EQ-5D) was measured at baseline and after rehabilitation. The number of patients with expectations unfulfilled or fulfilled or exceeded was computed by subtracting the admission and discharge CEQ Expectancy scores. Multivariable regression analysis was used to determine the factors associated with outcome expectations and their fulfilment, estimating odds ratios (ORs) and 95% confidence intervals (CIs).

RESULTS

We included 165 patients (96 males [58.2%], mean (SD) age 60.2 years [12.7]) who completed the CEQ Expectancy instrument at admission (median score 21.6, interquartile range [IQR] 17.0-24.0); 79 completed it both at admission (median score 20.6, IQR 16.6-24.4) and follow-up (median score 20.0, IQR 16.4-22.8). For 40 (50.6%) patients, expectations of therapy were fulfilled or exceeded. No patient characteristic at admission was associated with baseline CEQ Expectancy score. Odds of expectation fulfilment were associated with low expectations at admission (OR 0.70, 95% CI 0.60-0.83) and improved EQ-5D score (OR 1.35, 95% CI 1.04-0.75).

CONCLUSIONS

In half of the stroke patients in multidisciplinary rehabilitation, expectations were fulfilled or exceeded, most likely in patients with low expectations at admission and with improved health-related quality of life. More research into the role of health professionals regarding the measurement, shaping and management of outcome expectations is needed.

Multidisciplinary recommendations for diagnosis and treatment of foot problems in people with rheumatoid arthritis

BACKGROUND

Foot problems in people with rheumatoid arthritis (RA) are highly prevalent and have a substantial impact on quality of life. Healthcare professionals from various professions can be involved in the management of these foot problems. There is currently no consensus on optimal management. Therefore, the aim of the present study was to develop multidisciplinary recommendations for the management of foot problems in people with RA in the Netherlands.

METHODS

The recommendations were based on research evidence and consensus among experts, following published strategies for the development of practice recommendations. The expert group was composed of 2 patients and 22 experienced professionals (rheumatologists, rehabilitation physicians, orthopaedic surgeons, specialized nurses, podiatrists, orthopaedic shoe technicians, pedicurists, and researchers) in the Netherlands. For each developed recommendation i) the level of evidence was determined, and ii) the level of agreement (among the expert group) was set by an anonymous voting procedure using a numeric rating scale. The mean and range of the level of agreement for each recommendation was calculated. A recommendation was approved when ≥70% of the expert group voted an NRS-agreement ≥7.

RESULTS

In total, 41 recommendations were developed. Two recommendations concerned a framework for diagnosis and treatment. Thirty-nine recommendations on foot care were developed: seven on diagnosis (including check-ups of feet and shoes and diagnostic imaging), 27 on treatment (including corticosteroid injections, foot surgery, therapeutic shoes, foot orthoses, exercise therapy, toe-orthoses and toenail-braces, treatment of toenails and skin), four on communication, and one on organisation of RA-related footcare. All recommendations were approved by the expert group. The percentage score of NRS-agreement ≥7 ranged from 80 to 100%.

CONCLUSIONS

These are the first published multidisciplinary recommendations specific to the management of foot problems in people with RA. Multidisciplinary recommendations can provide guidance in timely referrals and access to adequate footcare. More research is needed to strengthen the evidence on diagnosis and treatment of RA-related foot problems. These national recommendations may be a first step towards developing international multidisciplinary recommendations for the management of foot problems in RA.

Not Physical Activity, but Patient Beliefs and Expectations are Associated With Return to Work After Total Knee Arthroplasty

BACKGROUND

After total knee arthroplasty (TKA), 17%-60% of the patients do not or only partially return to work (RTW). Reasons for no or partial RTW remain unclear, warranting further research. Physical activity (PA) has proven beneficial effects on work participation. Therefore, we hypothesized that preoperative PA is associated with RTW after TKA.

METHODS

Working TKA patients participating in an ongoing prospective cohort study were included. Preoperatively and 1 year postoperatively, patients were asked to define their work status and PA level according to the Dutch Recommendation for Health-Enhancing PA and the Fitnorm. Multivariate logistic regression analysis was performed to assess the effect of PA on RTW, taking into account established prognostic factors for RTW among TKA patients.

RESULTS

Of 283 eligible patients, 266 (93%) completed the questionnaires sufficiently. Preoperatively, 141 patients (54%) performed moderate PA for ≥5 d/wk and 42 (16%) performed intense PA for ≥3 d/wk. Concerning RTW, 178 patients (67%) reported full RTW, 59 patients (22%) partial RTW, and 29 patients (11%) no RTW. Preoperative PA was not associated with RTW. Patients who reported that their knee symptoms were not or only partially work-related had lower odds of no RTW (odds ratio 0.37, 95% confidence interval 0.17-0.81). Also, for each additional week patients expected to be absent from work, the likelihood of no RTW increased (odds ratio 1.11, 95% confidence interval 1.03-1.18).

CONCLUSION

No association between preoperative PA and RTW after TKA was found. Patient beliefs and preoperative expectations did influence RTW and should be addressed to further improve RTW after TKA.

How to best distribute written patient education materials among patients with rheumatoid arthritis: a randomized comparison of two strategies

BACKGROUND

The aim of this randomized controlled trial was to evaluate the effect of a 'supply on demand'-distribution strategy, compared to an 'unsolicited supply'-distribution strategy, on the use of a care booklet and clinical outcomes among patients with rheumatoid arthritis (RA). In addition, differences in socio-demographic and clinical characteristics between users and non-users were explored.

METHODS

As part of regular care the care booklet was distributed among RA-patients of two hospitals in the Netherlands. 1000 patients received the care booklet by mail, whereas another 1000 received an information letter with the option to order the care booklet. Four months after distribution, a random sample of 810 patients (stratified by hospital and distribution method) received a questionnaire on the use of the booklet, social-demographic and clinical characteristics. To compare effects between the two distribution strategies and differences between users and non-users univariate and multilevel regression analyses were performed. Secondary analysis included a per-protocol analysis (excluding participants who did not order the care booklet).

RESULTS

One hundred ninety four patients in the 'unsolicited supply' and 176 patients in the 'supply on demand' group (46%) returned the questionnaire. In the 'supply on demand' group 106 (60.2%) participants ordered the care booklet. In total, no difference was found in use between the 'unsolicited supply'-group (23.2%) and the 'supply on demand'-group (21.6%) (OR 0.9 CI:0.6-1.5). However, the proportion of users among patients in the 'supply on demand'-group who ordered the booklet (35%) was significantly higher than in the 'unsolicited supply'-group (OR 1.9 CI:1.1-3.2). Regardless of distribution method, use of the care booklet was associated with being married (OR 2.4 CI:1.2-4.6), higher disease activity (mean difference 0.5 CI: 0.0-1.1), more activity limitations (mean difference 0.2 CI: 0.1-0.4), use of corticosteroids (OR 1.9 CI:1.0-3.5), perception of disease course as fluctuating (mean difference 1.4 CI:0.5-2.3) and higher educational needs (mean difference 9.7 CI: 2.9-16.6).

CONCLUSIONS

From an economic and environmental perspective a 'supply on demand'-distribution strategy could be recommended. Results of this study provide starting points to optimize further implementation strategies of a care-booklet in routine care.

TRIAL REGISTRATION

ISRCTN registry ( ISRCTN22703067 ). Retrospectively registered 27 March 2017.

Preoperative risk factors for postoperative complications in endoscopic pituitary surgery: a systematic review

BACKGROUND

The ability to preoperatively predict postoperative complication risks is valuable for individual counseling and (post)operative planning, e.g. to select low-risk patients eligible for short stay surgery or those with higher risks requiring special attention. These risks however, are not well established in pituitary surgery.

METHODS

We conducted a systematic review of associations between preoperative characteristics and postoperative complications of endoscopic transsphenoidal surgery according to the PRISMA guidelines. Risk of bias was assessed through the QUIPS tool.

RESULTS

In total 23 articles were included, containing 5491 patients (96% pituitary adenoma). There was a wide variety regarding the nature and number of risk factors, definitions, measurement and statistics employed, and overall quality of mainly retrospective studies was low. Consistent significant associations were older age for complications in general, and intraventricular extension for cerebrospinal fluid (CSF) leaks. Associations identified in some but not all studies were younger age, increased BMI, female gender, and learning curve for CSF leaks; increased tumor size for complications in general; and Rathke's cleft cysts for diabetes insipidus. Mortality (incidence rate 1%) was not addressed as a risk factor.

CONCLUSION

Based on current literature, of low to medium quality, it is not possible to comprehensively quantify risk factors for complications. Nevertheless, older age and intraventricular extension were associated with increased postoperative complications. Future research should aim at prospective data collection, reporting of outcomes, and uniformity of definitions. Only then a proper risk analysis can be performed for endoscopic pituitary surgery.