Developing an international competency and capability framework for advanced practice physiotherapy: a scoping review with narrative synthesis

INTRODUCTION

The need to address increasing numbers of people seeking care, insufficient numbers of physicians, and providing high-value and sustainable care has contributed to changing physiotherapy practice across the world, often referred to as advanced practice physiotherapy. Currently, there is no internationally standardized competency and capability framework to support advanced practice physiotherapy.

OBJECTIVES

This scoping review has two aims; 1) To identify and map out the competencies of advanced practice physiotherapy available in the literature. 2) To develop a competency and capability framework by mapping the competencies identified from the review.

DESIGN

The Arksey and O'Malley framework and the PRISMA Scoping review methodology were used. Databases searched included CINAHL Plus, MEDLINE Ovid, PubMed, and Scopus. The competency and capability framework was developed through a narrative synthesis approach.

RESULTS

Nineteen documents were included in the final review, with 13 grey literature (government reports, policy documents, thesis) and six research papers. Included publications came from the United Kingdom, Ireland, Australia, New Zealand, and Canada. The included documents covered predominantly musculoskeletal practice (n = 17). The others focused on cardiorespiratory care, incontinence and pelvic health. Through narrative synthesis, 27 competencies and capabilities were identified and grouped under seven domains.

CONCLUSION

The synthesis of this scoping review provides the first competency and capability framework for advanced practice physiotherapy that integrates competencies and capabilities from five different countries. With the expansion of advanced practice physiotherapy, the framework developed from this review is the first step towards international recognition, standardization and consistency of education and training of practitioners. CONTRIBUTION OF THE PAPER.

Exercise and Behavior: Adjuncts to Pro-Myogenic Compounds for Enhancing Mobility in Older Adults

Physical activity and exercise training exert multiple and varied beneficial effects on a wide array of human tissues, making them therapeutic modalities that can prevent and treat age-related decline in physical function. The Molecular Transducers of Physical Activity Consortium is currently working to elucidate the molecular mechanisms underlying how physical activity improves and preserves health. Exercise training, especially when task specific, is an effective intervention for improving skeletal muscle performance and physical function in everyday activities. As seen elsewhere in this supplement, its adjunctive use with pro-myogenic pharmaceuticals may prove to be synergistic in effect. Behavioral strategies aiming to promote exercise participation and sustain adherence are being considered as additional adjuncts to further improve physical function in comprehensive, multicomponent interventions. One application of this combined strategy may be to target multimodal pro-myogenic therapies in prehabilitation to optimize physical preoperative health to enhance functional recovery postsurgery. We summarize here recent progress on biological mechanisms of exercise training, behavioral approaches to exercise participation, and the role task-specific exercise plays in synergy with pharmacologic therapies with a particular focus on older adults. Physical activity and exercise training in multiple settings should serve as the baseline standard of care around which other therapeutic interventions should be considered when the goal is restoring or increasing physical function.

The sensitivity and specificity of using the McGill pain subscale for diagnosing neuropathic and non-neuropathic chronic pain in the total joint arthroplasty population

BACKGROUND

The purpose of this study was to describe the diagnostic performance of the Neuropathic Pain Subscale of McGill [NP-MPQ (SF-2)] and the Self-Administered Leeds Assessment of Neuropathic Symptoms and Signs (S-LANSS) questionnaire in differentiating people with neuropathic chronic pain post total joint arthroplasty (TJA).

METHODS

This study was a survey of a cohort of individuals who had undergone primary, unilateral total knee, or hip joint arthroplasty. The questionnaires were administered by mail. The time interval from operation to the completion of the postal survey varied from 1.5 to 3.5 years post-surgery. Receiver Operating Characteristic (ROC) analysis was used to assess the overall diagnostic power and determine the optimal threshold value of the NP-MPQ (SF-2) in identification of neuropathic pain.

RESULTS

S-LANSS identified 19 subjects (28%) as having neuropathic pain (NP), while NP-MPQ (SF-2) subscale identified 29 (43%). When using the S-LANSS as the reference standard, a Receiver Operating Characteristic (ROC) analysis for NP-MPQ (SF-2) had an area under the curve of 0.89 (95% CI: 0.82, 0.97); a cut off score of 0.91 NP-MPQ (SF-2) maximized sensitivity (89.5%) and specificity (75.0%). Correlation between the measures was moderate (r = 0.56; 95% CI: 0.40, 0.68).

CONCLUSION

These finding suggest some conceptual overlap but some variability in diagnosis of NP which may relate to scale-tapping into different dimensions of the pain experience, or the different scoring metrics.

Patient appropriateness for total knee arthroplasty and predicted probability of a good outcome

OBJECTIVES

One-fifth of total knee arthroplasty (TKA) recipients experience a suboptimal outcome. Incorporation of patients' preferences in TKA assessment may improve outcomes. We determined the discriminant ability of preoperative measures of TKA need, readiness/willingness and expectations for a good TKA outcome.

METHODS

In patients with knee osteoarthritis (OA) undergoing primary TKA, we preoperatively assessed TKA need (Western Ontario-McMaster Universities OA Index (WOMAC) Pain Score and Knee injury and Osteoarthritis Outcome Score (KOOS) function, arthritis coping), health status, readiness (Patient Acceptable Symptom State, depressive symptoms), willingness (definitely yes-yes/no) and expectations (outcomes deemed 'very important'). A good outcome was defined as symptom improvement (met Outcome Measures in Rheumatology and Osteoarthritis Research Society International (OMERACT-OARSI) responder criteria) and satisfaction with results 1 year post TKA. Using logistic regression, we assessed independent outcome predictors, model discrimination (area under the receiver operating characteristic curve, AUC) and the predicted probability of a good outcome for different need, readiness/willingness and expectations scenarios.

RESULTS

Of 1,053 TKA recipients (mean age 66.9 years (SD 8.8); 58.6% women), 78.1% achieved a good outcome. With TKA need alone (WOMAC pain subscale, KOOS physical function short-form), model discrimination was good (AUC 0.67, 95% CI 0.63 to 0.71). Inclusion of readiness/willingness, depressive symptoms and expectations regarding kneeling, stair climbing, well-being and performing recreational activities improved discrimination (p=0.01; optimism corrected AUC 0.70, 0.66-0.74). The predicted probability of a good outcome ranged from 44.4% (33.9-55.5) to 92.4% (88.4-95.1) depending on level of TKA need, readiness/willingness, depressive symptoms and surgical expectations.

CONCLUSIONS

Although external validation is required, our findings suggest that incorporation of patients' TKA readiness, willingness and expectations in TKA decision-making may improve the proportion of recipients that experience a good outcome.

Developing a core competency and capability framework for advanced practice physiotherapy: A qualitative study

INTRODUCTION

There is an urgent need to develop an international competency and capability framework to support standardization of education and roles in advanced practice physiotherapy (APP). This need arose due to the rapid growth of the APP model of care, implemented out of necessity in the absence of agreement as to the competencies and capabilities or formal education required for the roles. This study explores the views and perceptions of practitioners and key stakeholders on a draft competency and capability framework for advanced practice physiotherapists.

OBJECTIVES

The purpose of this study was to: 1) gather feedback from key stakeholders (advanced practice physiotherapists, researchers, and leaders) on a draft competency and capability framework and 2) use that feedback to revise and improve the draft framework.

DESIGN

Qualitative study using a series of four multi-national online focus groups. Thematic analysis was conducted according to Braun and Clarke.

RESULTS

Sixteen participants from the United Kingdom, Ireland, Canada, Australia, and New Zealand participated in the study. Five themes were generated after data analysis: clinical expert, experienced communicator, strong leader, collaborator, and knowledge creator). A modified competency and capability framework was developed based on feedback from the focus groups and input from subject matter experts (SMEs).

CONCLUSION

This study provides a modified core competency and capability framework comprising 24 competencies grouped under six domains. This study is a step toward international standardization of advanced practice physiotherapy based on a commonly agreed framework for the education and training of advanced practice physiotherapists.

Does obesity affect patient-reported outcomes following total knee arthroplasty?

Background

There is an existing perception that obesity has a negative impact on complications following total knee arthroplasty (TKA). However, data on the impact of obesity levels on patient-reported outcomes (PROMs) is sparse. We investigated the association between different obesity classes with PROMs among patients who underwent TKA.

Methods

We performed retrospective secondary analyses on data extracted from the total joint replacement data repository (Alberta, Canada) managed by the Alberta Bone and Joint Health Institute (ABJHI). Patients had WOMAC and EQ5D scores measured at baseline in addition to 3 and/or 12 months following TKA. Patients were stratified according to the World Health Organization (WHO) classification, into five body mass index (BMI) groups of normal, overweight, BMI class I, BMI class II, and BMI class III. The association between BMI and mean changes in WOMAC subscales (pain, function, and stiffness) and EQ-5D-5L index over the time intervals of baseline to 3 months and 3 to 12 months following TKA was assessed. Linear mixed-effects models were used, and the models were adjusted for age, sex, length of surgery, comorbidities, year of surgery, and geographical zone where the surgery was performed.

Results

Mean age was 65.5 years (SD = 8.7). Postoperatively, there was a significant improvement (p < 0.001) in WOMAC subscales of patient-reported pain, function, and stiffness, as well as EQ-5D-5L regardless of BMI group. Although, patients in BMI class II and class III reported significantly improved pain 3 months after TKA compared to those with normal BMI, all BMI groups attained similar level of pain reduction at 12 months after TKA. The greatest improvement in all WOMAC subscales, as well as EQ5D index, occurred between baseline and 3 months (adjusted p < 0.0001).

Conclusion

The findings indicate that patients reported improved pain, function, and stiffness across all BMI groups following TKA. Patients with BMI classified as obese reported similar benefits to those with BMI classified as normal weight. These results may help health care providers to discuss expectations regarding the TKA recovery in terms of pain, function, and quality of life improvements with their TKA candidates.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-022-04997-4.

Advanced practice in physiotherapy: a global survey

INTRODUCTION

Advanced practice in physiotherapy represents a development in the practice of physiotherapy and has developed in different ways around the world. There is growing evidence to support advanced physiotherapy practice. In May 2019, the member organisations adopted the first World Physiotherapy policy on advanced practice in physiotherapy. However, to date, there is no evidence on the nature and extent of this practice globally.

OBJECTIVES

To investigate the extent to which advanced practice is present within the global physiotherapy community, to document the titles used, to describe the pathway to become an advanced physiotherapy practitioner and to investigate the barriers and facilitators to the development of the roles.

DESIGN

An online cross-sectional survey was sent to the various national associations of the World Physiotherapy.

PARTICIPANTS

Participants were the member organisations of World Physiotherapy.

INSTRUMENT

The survey comprised 14 questions. The questions were developed based on a review of the evidence around advanced practice and in-depth discussions with the expert group set up by World Physiotherapy.

RESULTS

A total of 82/112 MOs responded to the survey representing a 73% response rate. Fourteen respondents (14/82, 17%) indicated that they had formal roles in their country/territory. The terms specialist and advanced physiotherapy practitioner were often used interchangeably and were a source of confusion. Seventy-nine (11/14, 79%) percent stated that most advanced physiotherapy practitioners have a combination of clinical practice and a Master's or Doctoral degree. The major facilitators to the development and sustainability of the role were the research evidence, advocacy by the professional organisation, the need to reduce cost and the support received by the advanced physiotherapy practitioners from their employers.

CONCLUSION

The outcomes of this study provide a clearer understanding of how member organisations of World Physiotherapy defined advanced practice in physiotherapy and what titles are used. It provides insights into the barriers and facilitators to the development of advanced practice in physiotherapy.

Competing Risks Methods Are Recommended for Estimating the Cumulative Incidence of Revision Arthroplasty for Health Care Planning Purposes

Cumulative incidence of revision provides a measure of the failure rate of joint replacements and can be used to project demand for revisions. The most commonly applied survival analysis method (Kaplan-Meier [KM]) does not account for competing risks (eg, death). The authors compared the cumulative incidence function (CIF), a competing risks method, with the KM method through application to population-based cohorts. They measured time to revision, death, or censoring for unilateral total hip arthroplasty (THA; n=12,496) and total knee arthroplasty (TKA; n=19,172) cohorts in administrative databases in Alberta and TKAs (n=80,177) in the Swedish Knee Arthroplasty Register. The authors compared relative differences between the KM and CIF. They fitted Cox, Fine and Gray, and Royston and Parmar regression models and compared coefficients, standard errors, and P values. On sensitivity analysis, the authors included staged bilateral operations. Kaplan-Meier estimates exceeded the CIF at each time point. The magnitude of overestimation increased with follow-up time and was greatest for the Swedish cohort. At 5 years, relative differences between KM and CIF estimates for the Alberta THA and TKA and Swedish TKA cohorts were 1.8%, 2.3%, and 3.8%, respectively. These differences increased to 3.1%, 5.8%, and 8.2%, respectively, at 9 years, reaching 39.1% at 20 years (Swedish cohort). On sensitivity analysis (including staged bilateral operations), the Fine and Gray subdistribution hazard ratio differed from the Cox and Royston and Parmar hazard ratios. When the frequency of competing risks is high, competing risks methods are recommended to obtain accurate cumulative incidence estimates for informing health care planning and decision making. [Orthopedics. 2021;44(4):e549-e555.].

Prevalence of Persistent Pain of the Neuropathic Subtype after Total Hip or Knee Arthroplasty

Purpose: This study aimed to (1) estimate the point prevalence of persistent postoperative pain (PPP) identified using the Self-Administered Leeds Assessment of Neuropathic Symptoms and Signs (S-LANSS) after unilateral primary total hip arthroplasty (THA) and total knee arthroplasty (TKA) using data from a registry of total joint arthroplasty (TJA) patients in Ontario, (2) estimate the effect of PPP on function, (3) estimate the prevalence of neuropathic pain (NP) features among patients with persistent pain, (4) determine participant characteristics in order to estimate the potential predictors of NP classification among individuals with persistent pain after TJA, (5) estimate the extent to which the estimates of prevalence depended on the measure used (i.e., S-LANSS vs. NP sub-scale of the Short-Form McGill Pain Questionnaire 2 [NP-SF-MPQ-2]), and (6) determine the difference in characteristics between those with and without NP. Method: This was a prospective follow-up study of a historical cohort of individuals who had undergone primary unilateral THA or TKA. Persistent pain was operationally defined as pain rated as 3 or more (out of 5) on the Oxford Pain Questionnaire 6 months or 1 year after THA or TKA. Participants with persistent pain completed the S-LANSS and the NP-SF-MPQ-2. Results: A total of 1,143 participants were identified as having had a TJA, 148 (13%) of whom had PPP. A total of 67 recipients completed the S-LANSS and the NP-SF-MPQ-2. Of these, an NP subtype was identified among 19 (28%; those with an S-LANSS score ≥ 12) to 29 (43%; those with an NP-SF-MPQ-2 score ≥ 0.91). Individuals with persistent pain of the NP subtype after TJA reported severe pain intensity and higher disability levels 1.5–3.5 years after surgery compared with those without persistent pain. Conclusions: A significant proportion of patients have persistent pain post-unilateral THA or TKA.

Associations Between Self-Reported Weight History and Sarcopenic Obesity in Adults with Knee Osteoarthritis

OBJECTIVE

The purpose of this study was to examine associations between self-reported weight history and sarcopenic obesity in adults with advanced knee osteoarthritis (OA).

METHODS

Self-reported weight history was collected from n = 151 adults (58.9% female) with knee OA and BMI ≥30 kg/m² in a cross-sectional study. Body composition was assessed using dual-energy x-ray absorptiometry. Sarcopenic obesity was defined as appendicular skeletal muscle mass, adjusted by BMI, <0.51 kg/m² in females and <0.79 kg/m² in males; prevalence was 27.2%. Weight gain in the preceding year, weight gain ≥5% of body weight in the past decade, and multiple weight cycling events in life-span (loss of ≥10 lb [4.5 kg] with regain ≥3 times) were examined using logistic regression (adjusted by age, sex, and %fat mass), with the dependent variable of sarcopenic obesity presence.

RESULTS

Weight gain in the preceding year was associated with sarcopenic obesity (odds ratio [OR]: 2.45, 95% CI: 1.02-5.87). No associations were found with weight gain in the past decade (OR: 1.04, 95% CI: 0.43-2.5) or weight cycling (OR: 0.86, 95% CI: 0.37-2.01).

CONCLUSIONS

In adults with obesity and advanced knee OA, self-reported weight gain in the preceding year was associated with sarcopenic obesity. This patient population may benefit from recommendations that prioritize prevention of weight gain.

The Relationship between Patient-Reported Readiness for Total Knee Arthroplasty and Likelihood of a Good Outcome at One Year

OBJECTIVE

To determine the relationship between patients' pre-operative readiness for total knee arthroplasty (TKA) and surgical outcome at one-year.

METHODS

This prospective cohort study recruited knee osteoarthritis (OA) patients aged 30+ years referred for TKA at two hip/knee surgery centers in Alberta, Canada. Those who received primary, unilateral TKA completed questionnaires pre-TKA to assess WOMAC-pain, KOOS-physical function, Perceived Arthritis Coping Efficacy, General Self-Efficacy, PHQ-8, BMI, comorbidities and TKA readiness (Patient Acceptable Symptom State; willingness to undergo TKA), and one-year post-TKA to assess outcomes. A good TKA outcome was defined as improved knee symptoms (OARSI-OMERACT responder criteria) AND overall satisfaction with results. Poisson regression with robust error estimation was used to estimate relative risk of a good outcome for exposures, before and after controlling for covariates.

RESULTS

Of 1,272 TKA recipients assessed at one year, 1,053 with data for our outcome were included (mean age 66.9 years (SD 8.8); 58.6% female). Most (87.8%) were definitely willing to undergo TKA and had 'unacceptable' knee symptoms (79.7%). 78.1% achieved a good TKA outcome. Controlling for pre-TKA OA-related disability, arthritis coping efficacy, comorbid hip symptoms and depressed mood, definite willingness to undergo TKA and unacceptable knee symptoms were associated with greater likelihood of a good TKA outcome (adjusted RRs 1.18, 95% CI 1.04-1.35, and 1.14, 95% CI 1.02-1.27, respectively).

CONCLUSION

Among TKA recipients for knee OA, patients' psychological readiness and willingness for TKA were associated greater likelihood of a good outcome. Incorporation of these factors in TKA decision-making may enhance patient outcomes and appropriate use of TKA.

Clinical screening and identification of sarcopenic obesity in adults with advanced knee osteoarthritis

BACKGROUND AND AIMS

Sarcopenic obesity (defined as low muscle mass and strength with high adiposity) requires attention in adults with advanced knee osteoarthritis (OA) due to implications on treatment outcomes. This study aimed to identify muscle function measures and patient characteristics associated with the presence of low muscle mass that could be used to screen and detect sarcopenic obesity in patients with knee OA in the clinical setting.

METHODS

Cross-sectional study of patients with knee OA and a body mass index (BMI) ≥30 kg/m². Body composition was measured in n = 151 patients (59% female, mean age 65.1 ± 7.9 years) using dual-energy x-ray absorptiometry. Appendicular skeletal muscle mass (ASM) adjusted by BMI and below established sex-specific cut-points was used to differentiate low muscle mass. Muscle function was assessed by 4-m gait speed, 6 min walk test, and maximal grip strength (absolute, and relative, adjusted by BMI). Logistic regression was used to assess the relationship between muscle function measures, patient characteristics, and low muscle mass. Receiver operating characteristic curves and area under the curve (AUC) were used to examine the final model and identify potential clinical cut-points.

RESULTS

Sex and relative grip strength were associated with low muscle mass (AUC 0.774, p < 0.001). Cut-points for low relative grip strength (<0.65 kg/m² in females and <1.1 kg/m² in males) were distinguished and used in combination with low muscle mass to screen and identify sarcopenic obesity. Patients with both low relative grip strength and low muscle mass (sarcopenic obesity) had impaired mobility and quality of life.

CONCLUSION

Relative grip strength shows promise as a clinical screening measure for sarcopenic obesity in patients with knee OA.

Do Quebec Physiotherapists Follow Evidence-Based Guidelines for Treating Knee Osteoarthritis?

Purpose: The aim of this study was to document the types of treatment that Quebec physiotherapists use for knee osteoarthritis (OA), to assess whether treatment choices are consistent with current practice guidelines, and to explore the factors associated with using certain treatments. Method: Physiotherapists in Quebec answered a cross-sectional survey that was sent through licensing bodies and social media contacts. The respondents were asked which treatments they would use for a typical case of knee OA. We used descriptive statistics to determine the proportions of physiotherapists who chose each treatment and explored the associations between the use of treatments and demographic factors. Results: A total of 195 Quebec physiotherapists participated in this study, 74.9% of whom were women. The most common treatment choices were mobility exercises (96.4%), followed by education (93.8%), strengthening exercises (85.1%), thermotherapy and cryotherapy (72.3%), manual therapy (53.3%), and electrotherapy (42.1%). Selecting either manual or electrotherapy was significantly associated with working in private practice. Conclusions: The great majority of physiotherapists included mobility and strengthening exercises, both of which are the recommended approaches for treating knee OA. Physiotherapists in private practice were more likely to select manual therapy and electrotherapy.

Implementing models of care for musculoskeletal conditions in health systems to support value-based care

Models of Care (MoCs), and their local Models of Service Delivery, for people with musculoskeletal conditions are becoming an acceptable way of supporting effective implementation of value-based care. MoCs can support the quadruple aim of value-based care through providing people with musculoskeletal disease improved access to health services, better health outcomes and satisfactory experience of their healthcare; ensure the health professionals involved are experiencing satisfaction in delivering such care and health system resources are better utilised. Implementation of MoCs is relevant at the levels of clinical practice (micro), service delivery organisations (meso) and health system (macro) levels. The development, implementation and evaluation of MoCs has evolved over the last decade to more purposively engage people with lived experience of their condition, to operationalise the Chronic Care Model and to employ innovative solutions. This paper explores how MoCs have evolved and are supporting the delivery of value-based care in health systems.

Sarcopenia Definition: The Position Statements of the Sarcopenia Definition and Outcomes Consortium

OBJECTIVES

To develop an evidence-based definition of sarcopenia that can facilitate identification of older adults at risk for clinically relevant outcomes (eg, self-reported mobility limitation, falls, fractures, and mortality), the Sarcopenia Definition and Outcomes Consortium (SDOC) crafted a set of position statements informed by a literature review and SDOC's analyses of eight epidemiologic studies, six randomized clinical trials, four cohort studies of special populations, and two nationally representative population-based studies.

METHODS

Thirteen position statements related to the putative components of a sarcopenia definition, informed by the SDOC analyses and literature synthesis, were reviewed by an independent international expert panel (panel) iteratively and voted on by the panel during the Sarcopenia Position Statement Conference. Four position statements related to grip strength, three to lean mass derived from dual-energy x-ray absorptiometry (DXA), and four to gait speed; two were summary statements.

RESULTS

The SDOC analyses identified grip strength, either absolute or scaled to measures of body size, as an important discriminator of slowness. Both low grip strength and low usual gait speed independently predicted falls, self-reported mobility limitation, hip fractures, and mortality in community-dwelling older adults. Lean mass measured by DXA was not associated with incident adverse health-related outcomes in community-dwelling older adults with or without adjustment for body size.

CONCLUSION

The panel agreed that both weakness defined by low grip strength and slowness defined by low usual gait speed should be included in the definition of sarcopenia. These position statements offer a rational basis for an evidence-based definition of sarcopenia. The analyses that informed these position statements are summarized in this article and discussed in accompanying articles in this issue of the journal. J Am Geriatr Soc 68:1410-1418, 2020.

Establishing the Link Between Lean Mass and Grip Strength Cut Points With Mobility Disability and Other Health Outcomes: Proceedings of the Sarcopenia Definition and Outcomes Consortium Conference

BACKGROUND

Lack of consensus on how to diagnose sarcopenia has limited the ability to diagnose this condition and hindered drug development. The Sarcopenia Definitions and Outcomes Consortium (SDOC) was formed to develop evidence-based diagnostic cut points for lean mass and/or muscle strength that identify people at increased risk of mobility disability. We describe here the proceedings of a meeting of SDOC and other experts to discuss strategic considerations in the development of evidence-based sarcopenia definition.

METHODS

Presentations and panel discussions reviewed the usefulness of sarcopenia as a biomarker, the analytical approach used by SDOC to establish cut points, and preliminary findings, and provided strategic direction to develop an evidence-based definition of sarcopenia.

RESULTS

The SDOC assembled data from eight epidemiological cohorts consisting of 18,831 participants, clinical populations from 10 randomized trials and observational studies, and 2 nationally representative cohorts. In preliminary assessments, grip strength or grip strength divided by body mass index was identified as discriminators of risk for mobility disability (walking speed <0.8 m/s), whereas dual-energy X-ray absorptiometry-derived lean mass measures were not good discriminators of mobility disability. Candidate definitions based on grip strength variables were associated with increased risk of mortality, falls, mobility disability, and instrumental activities of daily living disability. The prevalence of low grip strength increased with age. The attendees recommended the establishment of an International Expert Panel to review a series of position statements on sarcopenia definition that are informed by the findings of the SDOC analyses and synthesis of literature.

CONCLUSIONS

International consensus on an evidence-based definition of sarcopenia is needed. Grip strength-absolute or adjusted for body mass index-is an important discriminator of mobility disability and other endpoints. Additional research is needed to develop a predictive risk model that takes into account sarcopenia components as well as age, sex, race, and comorbidities.

Low back pain and radiographic severity as predictors in hip osteoarthritis patients receiving steroid injection therapy

INTRODUCTION

We investigated the effects of lower back pain (LBP) on measures of pain, disability, and function in highly symptomatic hip OA patients receiving intra-articular steroid injection (IASI) therapy. We also investigated the effect of radiographic severity of hip OA for comparison to LBP.

METHODS

97 consenting subjects with symptomatic hip OA presenting for IASI were evaluated at baseline, assessed over an 8-week period, and followed at least 1 year later for new arthroplasty. At baseline and 8 weeks follow-up patient demographics, presence/absence of back pain, physical function tests, a single anteroposterior pelvis x-ray, and subjective scores of pain, stiffness and function (VAS and WOMAC) were collected. We also followed which subjects proceeded to obtain total hip arthroplasty in the examined hip.

RESULTS

Cohorts with LBP reported significantly worse scores for all of VAS pain and WOMAC questionnaires but showed no difference in ROM and were not more likely to proceed to arthroplasty. Cohorts with severe radiographic OA had significantly worsened scores for stiffness (χ² = 6.74, p = 0.009), decreased ROM (p < 0.01), and were more likely to proceed to arthroplasty (χ² = 9.79, p = 0.044).

DISCUSSION

Back pain has a substantial effect on clinical parameters relevant to assessment of severity of hip OA, especially self-reported pain and function. This finding highlights LBP as a significant confounding factor in hip OA patient assessments and will inform future studies to determine the most effective treatment strategies for hip OA patients.

Prevalence of sarcopenic obesity in adults with end-stage knee osteoarthritis

OBJECTIVE

To identify the prevalence of sarcopenic obesity, a phenotype of low muscle mass and high adiposity, in adults with end-stage knee osteoarthritis (OA). Various diagnostic criteria, including assessment of muscle/fat mass, muscle strength and physical function, were used to identify patients with and without sarcopenic obesity, and to compare outcomes of pain, function and quality of life.

DESIGN

Cross-sectional clinical study including adults with a body mass index (BMI) ≥30 kg/m² and knee OA. Body composition was measured by dual-energy X-ray absorptiometry (DXA). Assessments included gait speed, handgrip strength, six minute walk test, and self-reported pain, physical function, and health-related quality of life using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and EuroQol Foundation (EQ-5D).

RESULTS

151 adults (59% female) aged 65.1 ± 7.9 years, mean BMI 37.1 ± 5.5 kg/m², were included. Prevalence of sarcopenic obesity using diagnostic cut-offs of appendicular skeletal muscle mass (ASM) relevant to height², weight and BMI varied from 1.3% (95% confidence interval (CI): 0.2-4.7%) to 14.6% (9.4-21.2%) and 27.2% (20.2-35%), respectively. A combined diagnostic approach including low ASM with either low strength or low function yielded a prevalence of 8.6% (4.7-14.3%). Sarcopenic obesity influenced walking speed, endurance, strength, and patient-reported difficulty with self-care activities, regardless of diagnostic approach.

CONCLUSION

Prevalence of sarcopenic obesity varied depending on diagnostic criteria. Given the impact of this condition and OA on physical function, we suggest a combined diagnostic approach be used to clarify expected prevalence and enable early clinical identification and management of sarcopenic obesity in patients with knee OA.

Use of Recommended Non-surgical Knee Osteoarthritis Management in Patients prior to Total Knee Arthroplasty: A Cross-sectional Study

OBJECTIVE

Our aim was to assess prior use of core recommended non-surgical treatment among patients with knee osteoarthritis (OA) scheduled for total knee arthroplasty (TKA), and to assess potential patient-level correlates of underuse, if found.

METHODS

This was a cross-sectional study of patients undergoing TKA for primary knee OA at 2 provincial central intake hip and knee clinics in Alberta, Canada. Standardized questionnaires assessed sociodemographic characteristics, social support, coexisting medical conditions, OA symptoms and coping, and previous non-surgical management. Multivariable logistic regression was used to assess the patient-level variables independently associated with receipt of recommended non-surgical knee OA treatment, defined as prior use of pharmacotherapy for pain, rehabilitation strategies (exercise or physiotherapy), and weight loss if overweight or obese (body mass index ≥ 25 kg/m²).

RESULTS

There were 1273 patients included: mean age 66.9 years (SD 8.7), 39.9% male, and 44.1% had less than post-secondary education. Recommended non-surgical knee OA treatment had been used by 59.7% of patients. In multivariable modeling, the odds of having received recommended non-surgical knee OA treatment were significantly and independently lower among individuals who were older (OR 0.97, 95% CI 0.95-0.99), male (OR 0.33, 0.25-0.45), and who lacked post-secondary education (OR 0.70, 0.53-0.93).

CONCLUSION

In a large cross-sectional analysis of knee OA patients scheduled for TKA, 40% of individuals reported having not received core recommended non-surgical treatments. Older individuals, men, and those with less education had lower odds of having used recommended non-surgical OA treatments.

Large variability found in musculoskeletal physiotherapy scope of practice throughout WCPT and IFOMPT affiliated countries: An international survey

BACKGROUND

Advanced practice physiotherapy (APP) rights are part of the evolution of the Physical Therapy profession. To date, no study has investigated musculoskeletal APP rights within the World Confederation for Physical Therapy (WCPT).

OBJECTIVE

To investigate musculoskeletal APP rights for physical therapists worldwide and examine the relationship between level of education (entry and post-professional) and direct access for countries that are vs. are not members of the International Federation of Orthopaedic Manipulative Physical Therapists (IFOMPT).

DESIGN

Cross-sectional study with descriptive and exploratory online surveys.

METHODS

An electronic survey-based descriptive and exploratory investigation was conducted. We assessed variability between WCPT member organizations descriptively and the strength of the relationships among the number and types of APP rights with: (1) country affiliation to IFOMPT; (2) entry-level professional degree; (3) post-professional training; and (4) direct access.

RESULTS

Some countries reported having the right to practice all 20 APP rights while others reported no APP rights. Countries with IFOMPT member organization countries displayed fair correlation (r_s = .48, p < .03) between entry-level physical therapy degrees and number of APP rights. IFOMPT member organization countries were less likely to require post-professional training for direct access and manipulation.

CONCLUSION

APP rights for countries with direct access were significantly higher than for countries without direct access. IFOMPT member organizations demonstrated higher APP rights prevalence and were less likely to require post-professional training to obtain the right to direct access and perform manipulation.

Can effusion-synovitis measured on ultrasound or MRI predict response to intra-articular steroid injection in hip osteoarthritis?

OBJECTIVES

Intra-articular steroid injection (IASI) is an effective therapy for hip osteoarthritis (OA), but carries risks and provides significant pain relief to only two thirds of patients. We attempted to predict response to IASI in hip OA patients using baseline clinical, ultrasound, and MRI data.

METHODS

Observational study of 97 subjects with symptomatic hip OA presenting for IASI. At baseline and 8 weeks we obtained hip MRI, grayscale and Doppler ultrasound, clinical range of motion (ROM), timed-up and go test (TUG) scores, and self-reported Western Ontario and McMaster Universities Osteoarthritis (WOMAC) pain, stiffness, and function scores. Bone-capsule distance (BCD) measurements of inflammation on hip ultrasound and MRI were measured at three locations: the proximal-most uncovered portion of the femoral head, the superficial-most (apex) portion of the femoral head, and the largest fluid pocket at the femoral neck.

RESULTS

Ultrasound and MRI BCD correlated with each other significantly and strongly at the apex and neck. Power Doppler findings did not correlate significantly with any other imaging indices. Eight weeks post-injection, WOMAC pain, function, and stiffness scores significantly improved and TUG time improved nearly to the level of significance, but there were no significant changes in ultrasound, MRI, or Doppler indices. Baseline variables were not significantly different between responder and nonresponder WOMAC pain or TUG time cohorts.

CONCLUSION

Basic measures of inflammation on ultrasound and MRI are highly related to each other, but provide little insight into patient function and pain after IASI. Other mechanisms to explain improvement in patient status after IASI are likely at work.

The voice of patients in system redesign: A case study of redesigning a centralized system for intake of referrals from primary care to rheumatologists for patients with suspected rheumatoid arthritis

BACKGROUND

The published literature demands examples of health-care systems designed with the active engagement of patients to explore the application of this complex phenomenon in practice.

METHODS

This case study explored how the voice of patients was incorporated into the process of redesigning an element of the health-care system, a centralized system for intake of referrals from primary care to rheumatologists for patients with suspected rheumatoid arthritis (RA)-centralized intake. The phenomenon of patient engagement using "patient and community engagement researchers" (PaCERs) in research and the process of redesigning centralized intake were selected as the case. In-depth evaluation of the case was undertaken through the triangulation of findings from the document review and participants' reflection on the case.

RESULTS

In this case, patients and PaCERs participated in multiple activities including an initial meeting of key stakeholders to develop the project vision; a patient-to-patient PaCERs study to gather perspectives of patients with RA on the challenges they face in accessing and navigating the health-care system, and what they see as key elements of an effective system that would be responsive to their needs; the development of an evaluation framework for future centralized intake; and the choice of candidate centralized intake strategies to be evaluated.

CONCLUSIONS

The described feasible multistep approach to active patient engagement in health-care system redesign contributes to an understanding of the application of this complex phenomenon in practice. Therefore, the manuscript serves as one more step towards a patient-centred health-care system that is redesigned with active patient engagement.

Neuropathic Pain after Shoulder Arthroplasty: Prevalence, Impact on Physical and Mental Function, and Demographic Determinants

Purpose: The objectives of this survey study were to provide an estimate of the prevalence of neuropathic pain (NP) and to explore the cross-sectional and longitudinal group differences postoperatively. Method: A cohort of consecutive patients who had undergone total shoulder arthroplasty (TSA), reverse shoulder arthroplasty (RSA), or humeral head replacement (HHR) were surveyed within an average of 3.8 years after surgery. Questionnaires completed at the time of the survey were the Self-Administered Leeds Assessment of Neuropathic Symptoms and Signs (S-LANSS) pain scale, the visual analogue scale (VAS) for pain, the Western Ontario Osteoarthritis of the Shoulder (WOOS) index, the Patient Health Questionnaire-9 (PHQ-9), and a satisfaction questionnaire. Results: Of the 141 candidates who were invited to participate in the study, 115 patients participated (85 TSA, 21 HHR, and 9 RSA), for an 82% response rate. Five patients (4%) met the criteria for NP, of whom one had a loosening of the prosthesis and required further surgery. Having NP was associated with greater pain (VAS; p=0.001), greater depression (PHQ-9; p=0.001), more disability (WOOS; p=0.030), and less satisfaction with the surgery (p=0.014). There was no relationship between the presence of NP and patients' age, sex, preoperative pain, range of motion results, or WOOS scores (p>0.05). Conclusions: Persistent pain of neuropathic origin is not common after shoulder arthroplasty, but it is a significant contributor to poor mental and physical well-being and thus warrants further research.

The impact of sarcopenic obesity on knee and hip osteoarthritis: a scoping review

BACKGROUND

The progressive, debilitating nature of knee and hip osteoarthritis can result in severe, persistent pain and disability, potentially leading to a need for total joint arthroplasty (TJA) in end-stage osteoarthritis. TJA in adults with obesity is associated with increased surgical risk and prolonged recovery, yet classifying obesity only using body mass index (BMI) precludes distinction of obesity phenotypes and their impact on surgical risk and recovery. The sarcopenic obesity phenotype, characterized by high adiposity and low skeletal muscle mass, is associated with higher infection rates, poorer function, and slower recovery after surgery in other clinical populations, but not thoroughly investigated in osteoarthritis. The rising prevalence and impact of this phenotype demands further attention in osteoarthritis treatment models of care, particularly as osteoarthritis-related pain, disability, and current treatment practices may inadvertently be influencing its development.

METHODS

A scoping review was used to examine the extent of evidence of sarcopenic obesity in adults with hip or knee osteoarthritis. Medline, CINAHL, Web of Science and EMBASE were systematically searched from inception to December 2017 with keywords and subject headings related to obesity, sarcopenia and osteoarthritis.

RESULTS

Eleven studies met inclusion criteria, with indications that muscle weakness, low skeletal muscle mass or sarcopenia are present alongside obesity in this population, potentially impacting therapeutic outcomes, and TJA surgical risk and recovery.

CONCLUSIONS

Consideration of sarcopenic obesity should be included in osteoarthritis patient assessments.

Association between MRI-defined osteoarthritis, pain, function and strength 3–10 years following knee joint injury in youth sport

Background

Youth and young adults who participate in sport have an increased risk of knee injury and subsequent osteoarthritis. Improved understanding of the relationship between structural and clinical outcomes postinjury could inform targeted osteoarthritis prevention interventions. This secondary analysis examines the association between MRI-defined osteoarthritis and self-reported and functional outcomes, 3–10 years following youth sport-related knee injury in comparison to healthy controls.

Methods

Participants included a subsample (n=146) of the Alberta Youth Prevention of Early Osteoarthritis cohort: specifically, 73 individuals with 3–10years history of sport-related intra-articular knee injury and 73 age-matched, sex-matched and sport-matched controls with completed MRI studies. Outcomes included: MRI-defined osteoarthritis, radiographic osteoarthritis, Knee Injury and Osteoarthritis Outcome Score, Intermittent and Constant Osteoarthritis Pain, knee extensor/flexor strength, triple-hop and Y-balance test. Descriptive statistics and univariate logistic regression were used to compare those with and without MRI-defined osteoarthritis. Associations between MRI-defined osteoarthritis and each outcome were assessed using multivariable linear regression considering the influence of injury history, sex, body mass index and time since injury.

Results

Participant median age was 23 years (range 15–27), and 63% were female. MRI-defined osteoarthritis varied by injury history, injury type and surgical history and was not isolated to participants with ACL and/or meniscal injuries. Those with a previous knee injury had 10-fold (95% CI 2.3 to 42.8) greater odds of MRI-defined osteoarthritis than uninjured participants. MRI-defined osteoarthritis was independently significantly associated with quality of life, but not symptoms, strength or function.

Summary

MRI-detected structural changes 3– 10 years following youth sport-related knee injury may not dictate clinical symptomatology, strength or function but may influence quality of life.

Reduced knee adduction moments for management of knee osteoarthritis:: A three month phase I/II randomized controlled trial

Wedged insoles are believed to be of clinical benefit to individuals with knee osteoarthritis by reducing the knee adduction moment (KAM) during gait. However, previous clinical trials have not specifically controlled for KAM reduction at baseline, thus it is unknown if reduced KAMs actually confer a clinical benefit. Forty-eight participants with medial knee osteoarthritis were randomly assigned to either a control group where no footwear intervention was given, or a wedged insole group where KAM reduction was confirmed at baseline. KAMs, Knee Injury and Osteoarthritis Outcome Score (KOOS) and Physical Activity Scale for the Elderly (PASE) scores were measured at baseline. KOOS and PASE surveys were re-administered at three months follow-up. The wedged insole group did not experience a statistically significant or clinically meaningful change in KOOS pain over three months (p=0.173). Furthermore, there was no association between change in KAM magnitude and change in KOOS pain over three months within the wedged insole group (R²=0.02, p=0.595). Improvement in KOOS pain for the wedged insole group was associated with worse baseline pain, and a change in PASE score over the three month study (R²=0.57, p=0.007). As an exploratory comparison, there was no significant difference in change in KOOS pain (p=0.49) between the insole and control group over three months. These results suggest that reduced KAMs do not appear to provide any clinical benefit compared to no intervention over a follow-up period of three months. ClinicalTrials.gov ID Number: NCT02067208.

Impact of Platelet-Rich Plasma on Arthroscopic Repair of Small- to Medium-Sized Rotator Cuff Tears: A Randomized Controlled Trial

Background:

Increased interest in using platelet-rich plasma (PRP) as an augment to rotator cuff repair warrants further investigation, particularly in smaller rotator cuff tears.

Purpose:

To examine the effectiveness of PRP application in improving perioperative pain and function and promoting healing at 6 months after arthroscopic repair of small- or medium-sized rotator cuff tears.

Study Design:

Randomized controlled trial; Level of evidence, 1.

Methods:

This was a double-blinded randomized controlled trial of patients undergoing arthroscopic repair of partial- or full-thickness rotator cuff tears of up to 3 cm who were observed for 6 months. Patients were randomized to either repair and PRP application (study group) or repair only (control group) groups. The patient-oriented outcome measures utilized were the visual analog scale (VAS), the Short Western Ontario Rotator Cuff Index (ShortWORC), the American Shoulder and Elbow Surgeons (ASES) form, and the Constant-Murley Score (CMS). Range of motion (ROM) and inflammatory and coagulation markers were measured before and after surgery. Magnetic resonance imaging was used at 6 months to assess retear and fatty infiltration rate.

Results:

Eighty-two patients (41 males) with a mean age of 59 ± 8 years were enrolled; 41 patients were included in each group. Both the PRP and control groups showed a significant improvement in their pain level based on the VAS within the first 30 days (P < .0001), with the PRP group reporting less pain than the control group (P = .012), which was clinically significantly different from days 8 through 11. The PRP group reported taking less painkillers (P = .026) than the control group within the first 30 days. All outcome measure scores and ROM improved significantly after surgery (P < .0001), with no between-group differences. No differences were observed between groups in inflammatory or coagulation marker test results (P > .05), retear (14% vs 18% full retear; P = .44), or fatty infiltration rate (P = .08).

Conclusion:

The PRP biological augmentation for repair of small- to medium-sized rotator cuff tears has a short-term effect on perioperative pain without any significant impact on patient-oriented outcome measures or structural integrity of the repair compared with control group.

Clinical Decision Support Tools for Selecting Interventions for Patients with Disabling Musculoskeletal Disorders: A Scoping Review

Purpose We aimed to identify and inventory clinical decision support (CDS) tools for helping front-line staff select interventions for patients with musculoskeletal (MSK) disorders. Methods We used Arksey and O'Malley's scoping review framework which progresses through five stages: (1) identifying the research question; (2) identifying relevant studies; (3) selecting studies for analysis; (4) charting the data; and (5) collating, summarizing and reporting results. We considered computer-based, and other available tools, such as algorithms, care pathways, rules and models. Since this research crosses multiple disciplines, we searched health care, computing science and business databases. Results Our search resulted in 4605 manuscripts. Titles and abstracts were screened for relevance. The reliability of the screening process was high with an average percentage of agreement of 92.3 %. Of the located articles, 123 were considered relevant. Within this literature, there were 43 CDS tools located. These were classified into 3 main areas: computer-based tools/questionnaires (n = 8, 19 %), treatment algorithms/models (n = 14, 33 %), and clinical prediction rules/classification systems (n = 21, 49 %). Each of these areas and the associated evidence are described. The state of evidentiary support for CDS tools is still preliminary and lacks external validation, head-to-head comparisons, or evidence of generalizability across different populations and settings. Conclusions CDS tools, especially those employing rapidly advancing computer technologies, are under development and of potential interest to health care providers, case management organizations and funders of care. Based on the results of this scoping review, we conclude that these tools, models and systems should be subjected to further validation before they can be recommended for large-scale implementation for managing patients with MSK disorders.

Predictive value of the DASH tool for predicting return to work of injured workers with musculoskeletal disorders of the upper extremity

OBJECTIVES

To determine whether the Disabilities of the Arm, Shoulder, and Hand (DASH) tool added to the predictive ability of established prognostic factors, including patient demographic and clinical outcomes, to predict return to work (RTW) in injured workers with musculoskeletal (MSK) disorders of the upper extremity.

METHODS

A retrospective cohort study using a population-based database from the Workers' Compensation Board of Alberta (WCB-Alberta) that focused on claimants with upper extremity injuries was used. Besides the DASH, potential predictors included demographic, occupational, clinical and health usage variables. Outcome was receipt of compensation benefits after 3 months. To identify RTW predictors, a purposeful logistic modelling strategy was used. A series of receiver operating curve analyses were performed to determine which model provided the best discriminative ability.

RESULTS

The sample included 3036 claimants with upper extremity injuries. The final model for predicting RTW included the total DASH score in addition to other established predictors. The area under the curve for this model was 0.77, which is interpreted as fair discrimination. This model was statistically significantly different than the model of established predictors alone (p<0.001). When comparing the DASH total score versus DASH item 23, a non-significant difference was obtained between the models (p=0.34).

CONCLUSIONS

The DASH tool together with other established predictors significantly helped predict RTW after 3 months in participants with upper extremity MSK disorders. An appealing result for clinicians and busy researchers is that DASH item 23 has equal predictive ability to the total DASH score.

An investigation of the validity of the Work Assessment Triage Tool clinical decision support tool for selecting optimal rehabilitation interventions for workers with musculoskeletal injuries

OBJECTIVE

To evaluate the concurrent validity of a clinical decision support tool (Work Assessment Triage Tool (WATT)) developed to select rehabilitation treatments for injured workers with musculoskeletal conditions.

DESIGN

Methodological study with cross-sectional and prospective components.

SETTING

Data were obtained from the Workers' Compensation Board of Alberta rehabilitation facility in Edmonton, Canada.

SUBJECTS

A total of 432 workers' compensation claimants evaluated between November 2011 and June 2012.

MAIN MEASURES

Percentage agreement between the Work Assessment Triage Tool and clinician recommendations was used to determine concurrent validity. In claimants returning to work, frequencies of matching were calculated and compared between clinician and Work Assessment Triage Tool recommendations and the actual programs undertaken by claimants. The frequency of each intervention recommended by clinicians, Work Assessment Triage Tool, and case managers were also calculated and compared.

RESULTS

Percentage agreement between clinician and Work Assessment Triage Tool recommendations was poor (19%) to moderate (46%) and Kappa = 0.37 (95% CI -0.02, 0.76). The Work Assessment Triage Tool did not improve upon clinician recommendations as only 14 out of 31 claimants returning to work had programs that contradicted clinician recommendations, but were consistent with Work Assessment Triage Tool recommendations. Clinicians and case managers were inclined to recommend functional restoration, physical therapy, or no rehabilitation while the Work Assessment Triage Tool recommended additional evidence-based interventions, such as workplace-based interventions.

CONCLUSIONS

Our findings do not provide evidence of concurrent validity for the Work Assessment Triage Tool compared with clinician recommendations. Based on these results, we cannot recommend further implementation of the Work Assessment Triage Tool. However, the Work Assessment Triage Tool appeared more likely than clinicians to recommend interventions supported by evidence; thus warranting further research.

Reduced knee joint loading with lateral and medial wedge insoles for management of knee osteoarthritis: a protocol for a randomized controlled trial

Background

Knee osteoarthritis (OA) progression has been linked to increased peak external knee adduction moments (KAMs). Although some trials have attempted to reduce pain and improve function in OA by reducing KAMs with a wedged footwear insole intervention, KAM reduction has not been specifically controlled for in trial designs, potentially explaining the mixed results seen in the literature. Therefore, the primary purpose of this trial is to identify the effects of reduced KAMs on knee OA pain and function.

Methods/design

Forty-six patients with radiographically confirmed diagnosis medial knee OA will be recruited for this 3 month randomized controlled trial. Recruitment will be from Alberta and surrounding areas. Eligibility criteria include being between the ages of 40 and 85 years, have knee OA primarily localized to the medial tibiofemoral compartment, based on the American College of Rheumatology diagnostic criteria and be classified as having a Kellgren-Lawrence grade of 1 to 3. Patients will visit the laboratory at baseline for testing that includes dual x-ray absorptiometry, biomechanical testing, and surveys (KOOS, PASE activity scale, UCLA activity scale, comfort visual analog scale). At baseline, patients will be randomized to either a wedged insole group to reduce KAMs, or a waitlist control group where no intervention is provided. The survey tests will be repeated at 3 months, and response to wedged insoles over 3 months will be evaluated.

Discussion

This study represents the first step in systematically evaluating the effects of reduced KAMs on knee OA management by using a patient-specific wedged insole prescription procedure rather than providing the same insole to all patients. The results of this trial will provide indications as to whether reduced KAMs are an effective strategy for knee OA management, and whether a personalized approach to footwear insole prescription is warranted.

Trial registration

NCT02067208.

Electronic supplementary material

The online version of this article (doi:10.1186/1471-2474-15-405) contains supplementary material, which is available to authorized users.

The effect of pressure pain sensitivity and patient factors on self-reported pain-disability in patients with chronic neck pain

The study was conducted to estimate the extent to which pressure pain sensitivity (PPS) and patient factors predict pain-related disability in patients with neck pain (NP), and to determine if PPS differs by gender. Forty-four participants with a moderate level of chronic NP were recruited for this cross sectional study. All participants were asked to complete self-reported assessments of pain, disability and comorbidity and then underwent PPS testing at 4-selected body locations. Pearson`s r w was computed to explore relationships between the PPS measures and the self-reported assessments. Regression models were built to identify predictors of pain and disability. An independent sample t-test was done to identify gender-related differences in PPS, pain-disability and comorbidity. In this study, greater PPS (threshold and tolerance) was significantly correlated to lower pain-disability (r = -.30 to -.53, p≤0.05). Age was not correlated with pain or disability but comorbidity was (r= 0.42-.43, p≤0.01). PPS at the 4-selected body locations was able to explain neck disability (R²=25-28%). Comorbidity was the strongest predictor of neck disability (R² =30%) and pain (R²=25%). Significant mean differences for gender were found in PPS, disability and comorbidity, but not in pain intensity or rating. This study suggests that PPS may play a role in outcome measures of pain and disability but between-subject comparisons should consider gender and comorbidity issues.

Functional outcomes post-radial head arthroplasty: a systematic review of literature

BACKGROUND

The present study was conducted to determine the quality and content of research on the functional outcomes and complications post-metal radial head arthroplasty (RHAP).

METHODS

A comprehensive search of medical databases for studies reporting on functional outcomes of patients undergoing metallic RHAP was conducted. The Structured Effectiveness Quality Evaluation Scale (SEQES) was used to evaluate quality of the studies.

RESULTS

We identified 21 Sackett's Level IV studies reporting on 391 radial heads. The mean duration of follow-up was 47.2 months and the mean (SD) age of patients was 48.4 years (6.9 years). The male to female ratio was found to be 1.05 : 1 and the dominant arm was involved in 54% of patients. When functional outcomes achieved post-RHAP were compared with normative scores, the comparison suggested that RHAP has good to excellent functional outcomes in short- to mid-term follow-up. The weighted mean (SD) Mayo Elbow Performance Score was 85.8 (4.1) (95% confidence interval 85.3 to 86.3). Incidences of implant removal (3.06%) and revision (2.22%) were found to be low.

CONCLUSIONS

There is consistent low-quality evidence of positive functional outcomes following RHAP. The heterogeneity of type of implant, patient characteristics and outcome measures used, along with an inadequate reporting of study details, restrict any definitive conclusions being made.

CanWell: meeting the psychosocial and exercise needs of cancer survivors by translating evidence into practice

BACKGROUND

As more evidence emerges to support the incorporation of exercise for cancer survivors to positively affect physical, emotional, and social health, it is imperative that health-care providers use current knowledge to develop evidence-based exercise programs for these patients. Our purpose is to describe the development, implementation, and effectiveness of the CanWell program, an evidence-based, community and partnership-based, exercise, and education program for all people with cancer.

METHODS

Exercise and cancer research was reviewed, summarized, and utilized to develop CanWell. A 12-week, supervised, community-based, exercise, and education program established in collaboration between an acute care hospital, academic center, and a not-for-profit YMCA facility. CanWell participants completed physical and health-related quality of life measures prior to initiating the program and repeated them at 6 and 12 weeks.

RESULTS

Following the exercise program, participants reported significant improvements in health-related quality of life, recorded distance ambulated during a 6-min walk test, and total minutes on a treadmill recorded using the standardized exponential exercise protocol treadmill test. Furthermore, no increases in disease burden were identified using the Edmonton Symptom Assessment System. In addition, no exercise related injuries were reported by CanWell participants.

CONCLUSIONS

As the body of evidence supporting the incorporation of exercise as a standard of care for cancer survivors, it is imperative that care providers use current knowledge to provide opportunities for their patients to exercise in effective exercise programs. CanWell is an example on how collaboration between hospital, university, and community institutions can be used to move research into practice and meet the needs of cancer survivors.

The FGFR4-G388R single-nucleotide polymorphism alters pancreatic neuroendocrine tumor progression and response to mTOR inhibition therapy

Pancreatic neuroendocrine tumors (pNET), also known as islet cell tumors, exhibit a wide range of biologic behaviors ranging from long dormancy to rapid progression. Currently, there are few molecular biomarkers that can be used to predict recurrence/metastasis or response to therapy. This study examined the predictive and prognostic value of a single nucleotide polymorphism substituting an arginine (R) for glycine (G) in codon 388 of the FGFR4 transmembrane domain. We established the FGFR4 genotype of 71 patients with pNETs and correlated genotype with biologic behavior. We created an in vivo model of pNET with BON1 cells and transfected them with either FGFR4-G388 or FGFR4-R388 to determine the mechanism of action and to examine response to the mTOR inhibitor everolimus. We then validated the predictive results of experimental studies in a group of patients treated with everolimus. FGFR4-R388 is associated with more aggressive clinical behavior in patients with pNETs with a statistically significant higher risk of advanced tumor stage and liver metastasis. Using an orthotopic mouse xenograft model, we show that FGFR4-R388 promotes tumor progression by increasing intraperitoneal spread and metastatic growth within the liver. Unlike FGFR4-G388, FGFR4-R388 BON1 tumors exhibited diminished responsiveness to everolimus. Concordantly, there was a statistically significant reduction in response to everolimus in patients with FGFR4-R388. Our findings highlight the importance of the FGFR4 allele in pNET progression and identify a predictive marker of potential therapeutic importance in this disease.

Comparing the responsiveness of the assessment of motor and process skills and the functional independence measure

BACKGROUND

Selecting and utilizing appropriate assessments to evaluate outcomes is an important aspect of evidence-based occupational therapy practice. The Functional Independence Measure (FIM), to which occupational therapists contribute motor and cognitive scores, is currently the only required assessment for evaluating change from admission to discharge on an inpatient rehabilitation unit. However, occupational therapists are also using the motor and process scales from the Assessment of Motor and Process Skills (AMPS) to assess clients and evaluate change.

PURPOSE

To compare responsiveness of the AMPS and the FIM on an inpatient rehabilitation unit.

METHODS

A retrospective chart review of AMPS measures and FIM scores at admission and discharge was undertaken. Standardized response means and effect sizes were calculated to estimate responsiveness.

FINDINGS

No significant difference was found in the ability of the AMPS motor and FIM motor scales to detect change. The AMPS process scale was more responsive to change than the FIM cognitive scale.

IMPLICATIONS

Using the AMPS as an assessment to evaluate outcomes allows practitioners to detect changes that may not be detected through the exclusive use of the FIM.

Interprofessional collaboration and turf wars how prevalent are hidden attitudes?

PURPOSE

Interprofessional collaboration in health care is believed to enhance patient outcomes. However, where professions have overlapping scopes of practice (eg, chiropractors and physical therapists), "turf wars" can hinder effective collaboration. Deep-rooted beliefs, identified as implicit attitudes, provide a potential explanation. Even with positive explicit attitudes toward a social group, negative stereotypes may be influential. Previous studies on interprofessional attitudes have mostly used qualitative research methodologies. This study used quantitative methods to evaluate explicit and implicit attitudes of physical therapy students toward chiropractic.

METHODS

A paper-and-pencil instrument was developed and administered to 49 individuals (students and faculty) associated with a Canadian University master's entry-level physical therapy program after approval by the Research Ethics Board. The instrument evaluated explicit and implicit attitudes toward the chiropractic profession. Implicit attitudes were determined by comparing response times of chiropractic paired with positive versus negative descriptors.

RESULTS

Mean time to complete a word association task was significantly longer (t = 4.75, p =.00) when chiropractic was associated with positive rather than negative words. Explicit and implicit attitudes were not correlated (r = 0.13, p =.38).

CONCLUSIONS

While little explicit bias existed, individuals associated with a master's entry-level physical therapy program appeared to have a significant negative implicit bias toward chiropractic.

Strategies Aimed at Preventing Chronic Post-surgical Pain: Comprehensive Perioperative Pain Management after Total Joint Replacement Surgery

PURPOSE

Chronic post-surgical pain (CPSP) is a frequent outcome of musculoskeletal surgery. Physiotherapists often treat patients with pain before and after musculoskeletal surgery. The purposes of this paper are (1) to raise awareness of the nature, mechanisms, and significance of CPSP; and (2) to highlight the necessity for an inter-professional team to understand and address its complexity. Using total joint replacement surgeries as a model, we provide a review of pain mechanisms and pain management strategies.

SUMMARY OF KEY POINTS

By understanding the mechanisms by which pain alters the body's normal physiological responses to surgery, clinicians selectively target pain in post-surgical patients through the use of multi-modal management strategies. Clinicians should not assume that patients receiving multiple medications have a problem with pain. Rather, the modern-day approach is to manage pain using preventive strategies, with the aims of reducing the intensity of acute postoperative pain and minimizing the development of CPSP.

CONCLUSIONS

The roles of biological, surgical, psychosocial, and patient-related risk factors in the transition to pain chronicity require further investigation if we are to better understand their relationships with pain. Measuring pain intensity and analgesic use is not sufficient. Proper evaluation and management of risk factors for CPSP require inter-professional teams to characterize a patient's experience of postoperative pain and to examine pain arising during functional activities.

Shoulder muscle endurance: the development of a standardized and reliable protocol

Background

Shoulder muscle fatigue has been proposed as a possible link to explain the association between repetitive arm use and the development of rotator cuff disorders. To our knowledge, no standardized clinical endurance protocol has been developed to evaluate the effects of muscle fatigue on shoulder function. Such a test could improve clinical examination of individuals with shoulder disorders. Therefore, the purpose of this study was to establish a reliable protocol for objective assessment of shoulder muscle endurance.

Methods

An endurance protocol was developed on a stationary dynamometer (Biodex System 3). The endurance protocol was performed in isotonic mode with the resistance set at 50% of each subject's peak torque as measured for shoulder external (ER) and internal rotation (IR). Each subject performed 60 continuous repetitions of IR/ER rotation. The endurance protocol was performed by 36 healthy individuals on two separate occasions at least two days apart. Maximal isometric shoulder strength tests were performed before and after the fatigue protocol to evaluate the effects of the endurance protocol and its reliability. Paired t-tests were used to evaluate the reduction in shoulder strength due to the protocol, while intraclass correlation coefficients (ICC) and minimal detectable change (MDC) were used to evaluate its reliability.

Results

Maximal isometric strength was significantly decreased after the endurance protocol (P < 0.001). The total work performed during the last third of the protocol was significantly less than the first third of the protocol (P < 0.05). The test-retest reliability of the post-fatigue strength measures was excellent (ICC >0.84).

Conclusions

Changes in muscular performance observed during and after the muscular endurance protocol suggests that the protocol did result in muscular fatigue. Furthermore, this study established that the resultant effects of fatigue of the proposed isotonic protocol were reproducible over time. The protocol was performed without difficulty by all volunteers and took less than 10 minutes to perform, suggesting that it might be feasible for clinical practice. This protocol could be used to induce local muscular fatigue in order to evaluate the effects of fatigue on shoulder kinematics or to evaluate changes in shoulder muscle endurance following rehabilitation.

A scoping review of strategies for the prevention of hip fracture in elderly nursing home residents

BACKGROUND

Elderly nursing home residents are at increased risk of hip fracture; however, the efficacy of fracture prevention strategies in this population is unclear.

OBJECTIVE

We performed a scoping review of randomized controlled trials of interventions tested in the long-term care (LTC) setting, examining hip fracture outcomes.

METHODS

We searched for citations in 6 respective electronic searches, supplemented by hand searches. Two reviewers independently reviewed all citations and full-text papers; consensus was achieved on final inclusion. Data was abstracted in duplicate.

FINDINGS

We reviewed 22,349 abstracts or citations and 949 full-text papers. Data from 20 trials were included: 7--vitamin D (n = 12,875 participants), 2--sunlight exposure (n = 522), 1--alendronate (n = 327), 1--fluoride (n = 460), 4--exercise or multimodal interventions (n = 8,165), and 5--hip protectors (n = 2,594). Vitamin D, particularly vitamin D(3) > or = 800 IU orally daily, reduced hip fracture risk. Hip protectors reduced hip fractures in included studies, although a recent large study not meeting inclusion criteria was negative. Fluoride and sunlight exposure did not significantly reduce hip fractures. Falls were reduced in three studies of exercise or multimodal interventions, with one study suggesting reduced hip fractures in a secondary analysis. A staff education and risk assessment strategy did not significantly reduce falls or hip fractures. In a study underpowered for fracture outcomes, alendronate did not significantly reduce hip fractures in LTC.

CONCLUSIONS

The intervention with the strongest evidence for reduction of hip fractures in LTC is Vitamin D supplementation; more research on other interventions is needed.

Using hierarchical linear modeling to explore predictors of pain after total hip and knee arthroplasty as a consequence of osteoarthritis

Hierarchical linear modeling was used to establish differences in, and the average pattern of, recovery of the pain subscale of the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and 2 composite performance-specific measures of pain as well as to determine if significant individual variations exist in the growth curves for each measure. Predictors of postoperative pain were also of interest. One hundred forty-seven patients undergoing unilateral primary hip or knee arthroplasty completed 4 performance measures-self-paced 40-m walk, timed up and go, stair test, and 6-minute walk-and the WOMAC prearthroplasty and at multiple points in time between 2 and 27 weeks postarthroplasty. Although patients reported different levels of postoperative pain initially, similar recovery patterns were noted. Predictive variables were found to be site of joint arthroplasty and WOMAC prearthroplasty pain scores for the WOMAC pain subscale, the site of joint arthroplasty and sex for the first composite pain score, and sex for the second composite.

A systematic review of the psychometric properties of the Constant-Murley score

HYPOTHESIS

The purpose of this study was to conduct a systematic review of the psychometric evidence relating to Constant-Murley score.

MATERIALS AND METHODS

A search of 3 databases (Medline, CINAHL, and EMBASE) and a manual search yielded 35 relevant publications. Pairs of raters used structured tools to analyze these articles, through critical appraisal and data extraction. A descriptive synthesis of the psychometric evidence was then performed.

RESULTS

Quality ratings of 23% of the studies reviewed reached a level of 75% or higher. Studies evaluating the content validity of the Constant-Murley score suggest that the description in the original publication is insufficient to accomplish standardization between centers and evaluators. Despite this limitation, the Constant-Murley score correlates strongly (>or= 0.70) with shoulder-specific questionnaires, reaches acceptable benchmarks (rho > 0.80) for its reliability coefficients, and is responsive (effect sizes and standardized response mean > 0.80) for detecting improvement after intervention in a variety of shoulder pathologies.

DISCUSSION

This systematic review provides evidence to support the use of the Constant-Murley score for specific clinical and research applications but underscores the need for greater standardization and precaution when interpreting scores. Methods to improve standardization and measurement precision are needed. Responsiveness has been shown to be excellent, but some properties still need be evaluated, particularly those related to the absolute errors of measurement and minimal clinically important difference.

CONCLUSION

Given the widespread acceptance for usage of the Constant-Murley score in clinical studies and early indications that the measure is responsive, studies defining more rigid standardization of the tools/procedures are needed.

LEVEL OF EVIDENCE

Level 1.

Measuring shoulder function: a systematic review of four questionnaires

OBJECTIVE

To conduct a systematic review of the quality and content of the psychometric evidence relating to 4 shoulder disability scales: the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire, the Shoulder Pain and Disability Index (SPADI), the American Shoulder and Elbow Surgeons (ASES) score, and the Simple Shoulder Test (SST).

METHODS

We conducted a structured search using 3 databases (Medline, CINAHL, EMBase). In total, 71 published primary studies were analyzed. A pair of raters conducted data extraction and critical appraisal using structured tools. A descriptive synthesis was performed.

RESULTS

Quality ratings of 55% of the studies reviewed reached a level of > or =75%. Most studies suggest that all 4 questionnaires have excellent reliability (intraclass correlation coefficient > or =0.90). The 4 questionnaires are strongly correlated (r >0.70) with each other and with a number of similar indices, and the questionnaires were able to differentiate between different populations and disability levels. The minimal detectable change (MDC) is approximately 9.4 for the ASES, 10.5 for the DASH, and 18 for the SPADI; the minimal clinically important difference (MCID) is approximately 6.4 for the ASES and 10.2 for the DASH, and ranges between 8 and 13 for the SPADI. MDC and MCID have not been defined for the SST.

CONCLUSION

The psychometric properties of the ASES, DASH, and SPADI have been shown to be acceptable for clinical use. Conversely, some properties of the SST still need be evaluated, particularly the absolute errors of measurement. Overall, validation studies have focused on less clinically relevant properties (construct validity or group reliability) than estimates of MDC and MCID.

Measurement properties of performance-specific pain ratings of patients awaiting total joint arthroplasty as a consequence of osteoarthritis

PURPOSE

To estimate the test-retest reliability of the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain sub-scale and performance-specific assessments of pain, as well as the association between these measures for patients awaiting primary total hip or knee arthroplasty as a consequence of osteoarthritis.

METHODS

A total of 164 patients awaiting unilateral primary hip or knee arthroplasty completed four performance measures (self-paced walk, timed up and go, stair test, six-minute walk) and the WOMAC. Scores for 22 of these patients provided test-retest reliability data. Estimates of test-retest reliability (Type 2,1 intraclass correlation coefficient [ICC] and standard error of measurement [SEM]) and the association between measures were examined.

RESULTS

ICC values for individual performance-specific pain ratings were between 0.70 and 0.86; SEM values were between 0.97 and 1.33 pain points. ICC estimates for the four-item performance pain ratings and the WOMAC pain sub-scale were 0.82 and 0.57 respectively. The correlation between the sum of the pain scores for the four performance measures and the WOMAC pain sub-scale was 0.62.

CONCLUSION

Reliability estimates for the performance-specific assessments of pain using the numeric pain rating scale were consistent with values reported for patients with a spectrum of musculoskeletal conditions. The reliability estimate for the WOMAC pain sub-scale was lower than typically reported in the literature. The level of association between the WOMAC pain sub-scale and the various performance-specific pain scales suggests that the scores can be used interchangeably when applied to groups but not for individual patients.

Measurement properties of the WOMAC LK 3.1 pain scale

OBJECTIVE

The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) is applied extensively to patients with osteoarthritis of the hip or knee. Previous work has challenged the validity of its physical function scale however an extensive evaluation of its pain scale has not been reported. Our purpose was to estimate internal consistency, factorial validity, test-retest reliability, and the standard error of measurement (SEM) of the WOMAC LK 3.1 pain scale.

METHOD

Four hundred and seventy-four patients with osteoarthritis of the hip or knee awaiting arthroplasty were administered the WOMAC. Estimates of internal consistency (coefficient alpha), factorial validity (confirmatory factor analysis), and the SEM based on internal consistency (SEM(IC)) were obtained. Test-retest reliability [Type 2,1 intraclass correlation coefficients (ICC)] and a corresponding SEM(TRT) were estimated on a subsample of 36 patients.

RESULTS

Our estimates were: internal consistency alpha=0.84; SEM(IC)=1.48; Type 2,1 ICC=0.77; SEM(TRT)=1.69. Confirmatory factor analysis failed to support a single factor structure of the pain scale with uncorrelated error terms. Two comparable models provided excellent fit: (1) a model with correlated error terms between the walking and stairs items, and between night and sit items (chi2=0.18, P=0.98); (2) a two factor model with walking and stairs items loading on one factor, night and sit items loading on a second factor, and the standing item loading on both factors (chi2=0.18, P=0.98).

CONCLUSION

Our examination of the factorial structure of the WOMAC pain scale failed to support a single factor and internal consistency analysis yielded a coefficient less than optimal for individual patient use. An alternate strategy to summing the five-item responses when considering individual patient application would be to interpret item responses separately or to sum only those items which display homogeneity.

Performance measures provide assessments of pain and function in people with advanced osteoarthritis of the hip or knee

BACKGROUND AND PURPOSE

Pain and physical function are core outcome measures for people with osteoarthritis, and self-report questionnaires have been the preferred assessment method. There is evidence suggesting that self-reports of physical function represent what people experience when performing activities rather than their ability to perform activities. The purpose of this study was to examine the factorial validity of performance-specific assessments of pain and function.

SUBJECTS

The sample consisted of 177 participants who had osteoarthritis of the hip (n=81) or knee (n=96) and who were awaiting total joint arthroplasty.

METHODS

Through a cross-sectional design, participants performed 4 performance activities (self-paced walk test, stair test, Timed "Up & Go" Test, and Six-Minute Walk Test).

OUTCOMES

were time or distance (function) and pain ratings obtained immediately after each activity. The authors conceptualized 2 correlated factors, with pain items loading uniquely on 1 factor and functional items loading on the second factor, and uncorrelated error terms. Confirmatory factor analysis was applied.

RESULTS

Initial analysis yielded results consistent with the conceptualized model in this study with the exception of a nonzero correlation between the stair pain and function error terms. Dropping the stair test provided results consistent with the conceptualized model.

DISCUSSION AND CONCLUSION

Given the limitations of self-report alone as a method of obtaining reasonably distinct assessments of pain and function, the extent to which performance-specific assessments could accomplish this goal was examined in this study. It was found that collectively the walk test, Timed "Up & Go" Test, and Six-Minute Walk Test yielded 2 factors consistent with the health concepts of pain and function. The authors believe that the application of these tests may provide clinicians and clinical researchers with more distinct impressions of pain and function that complement information from self-report measures.