Factors associated with pain and functional impairment five years after total knee arthroplasty: a prospective observational study.

BACKGROUND: Few studies have evaluated the associations between preoperative factors and pain and physical function outcomes after total knee arthroplasty (TKA) from a mid-term perspective. Identification of such factors is important for optimizing outcomes following surgery. Thus, we examined the associations between selected preoperative factors and moderate to severe pain and pain-related functional impairment as measured using the Brief Pain Inventory (BPI), five years after TKA in patients with knee osteoarthritis. METHODS: In this prospective observational study, all patients scheduled for primary unilateral TKA for osteoarthritis were consecutively recruited. Preoperative factors identified from previous meta-analyses were included to assess their associations with pain severity and pain-related functional impairment five years after TKA. Pain severity was the primary outcome, while pain-related functional impairment was the secondary outcome. The BPI was used to evaluate outcomes five years post-TKA. Statistically significant factors from univariate regressions were entered into a multiple logistic regression model to identify those with the strongest associations with pain severity or pain-related functional impairment five years after TKA. RESULTS: A total of 136 patients were included, with a mean age of 67.7 years (SD 9.2) and a majority being female (68%). More severe preoperative pain (OR = 1.34, 95% CI [1.03 to 1.74]), more painful sites (OR = 1.28., 95% CI [1.01 to 1.63]), and more severe anxiety symptoms (OR = 1.14., 95% CI [1.01 to 1.28]) were associated with increased likelihood of moderate to severe pain five years after TKA surgery, while more severe osteoarthritis (OR = 0.13, 95% CI [0.03 to 0.61]) was associated with reduced likelihood of moderate to severe pain five years after TKA. More severe anxiety symptoms (OR = 1.25, 95% CI [1.08 to 1.46]) were also associated with increased likelihood of moderate to severe pain-related functional impairment five years after surgery, while male sex (OR = 0.23, 95% CI [0.05 to 0.98]) was associated with reduced likelihood of pain-related functional impairment five years after surgery. CONCLUSION: The identified preoperative factors should be included in larger prognostic studies evaluating the associations between preoperative factors and mid-term pain severity and physical function outcomes after TKA surgery.

A comparison of the prevalence of dry mouth and other symptoms using two different versions of the Edmonton Symptom Assessment System on an inpatient palliative care unit.

BACKGROUND: Symptom assessment is key to effective symptom management and palliative care for patients with advanced cancer. Symptom prevalence and severity estimates vary widely, possibly dependent on the assessment tool used. Are symptoms specifically asked about or must the patients add them as additional symptoms? This study compared the prevalence and severity of patient-reported symptoms in two different versions of a multi-symptom assessment tool. In one version, three symptoms dry mouth, constipation, sleep problems were among those systematically assessed, while in the other, these symptoms had to be added as an "Other problem". METHODS: This retrospective cross-sectional study included adult patients with advanced cancer at an inpatient palliative care unit. Data were collected from two versions of the Edmonton Symptom Assessment System (ESAS): modified (ESAS-m) listed 11 symptoms and revised (ESAS-r) listed 9 and allowed patients to add one "Other problem". Seven similar symptoms were listed in both versions. RESULTS: In 2013, 184 patients completed ESAS-m, and in 2017, 156 completed ESAS-r. Prevalence and severity of symptoms listed in both versions did not differ. In ESAS-m, 83% reported dry mouth, 73% constipation, and 71% sleep problems, but on ESAS-r, these symptoms were reported by only 3%, 15% and < 1%, respectively. Although ESAS-r severity scores for these three symptoms were higher than on ESAS-m, differences did not reach statistical significance. CONCLUSION: We identified significant differences in patient symptom reporting based on whether symptoms like dry mouth, obstipation and sleep problems were specifically assessed or had to be added by patients as an "Other problem".

Is alcohol and psychoactive medication use associated with excess hospital length-of-stay and admission frequency? A cross-sectional, observational study.

BACKGROUND: Hospital length-of-stay and admission frequency are commonly used indicators of disease burden and health resource expenditures. However, the impact of psychoactive prescription medication use and harmful alcohol consumption on both the duration and frequency of hospital admissions is under-explored. METHODS: We conducted an analysis of data gathered from 2872 patients admitted to the Emergency Department at Lovisenberg Diaconal Hospital in Oslo, Norway. Psychoactive medicines (benzodiazepines, opioids, and z-hypnotics) were detected via liquid chromatography-mass spectrometry analysis of whole blood, while alcohol consumption was self-reported through the Alcohol Use Disorder Identification Test-4 (AUDIT-4). Using logistic regression, we examined associations with our primary outcomes, which were excess length-of-stay and admission frequency, defined as exceeding the sample median of 3.0 days and 0.2 admissions per year, respectively. RESULTS: Compared to the absence of psychoactive medication, and after adjusting for age, gender, malignant disease, pre-existing substance use disorder and admission due to intoxication, the detection of two or more psychoactive medicines was associated with both excess length-of-stay (odds ratio [OR], 1.60; 95% confidence interval [CI], 1.20 to 2.14) and yearly hospitalization rate (OR, 3.72; 95% CI, 2.64 to 5.23). This association persisted when increasing the definition for excess length-of-stay to 4 and 5 days and to 1.0 and 1.5 admissions per year for admission frequency. Harmful alcohol consumption (AUDIT-4 scores of 9 to 16) was not associated with excess length-of-stay, but with excess admission frequency when defined as more than 1.0 admission per year when compared to scores of 4 to 6 (OR, 2.68; 95% CI, 1.58 to 4.57). CONCLUSIONS: Psychoactive medication use is associated with both excess length-of-stay and increased antecedent admission frequency, while harmful alcohol consumption may be associated with the latter. The utility of our findings as a causal factor should be explored through intervention-based study designs.

Development and evaluation of the Norwegian Fatigue Characteristics and Interference Measure (FCIM) for stroke survivors: cognitive interviews and Rasch analysis.

PURPOSE: There is need for a comprehensive measure of post-stroke fatigue with sound measurement properties. This study aimed to develop the Norwegian Fatigue Characteristics and Interference Measure (FCIM) and assess its content validity, structural validity, and internal consistency. METHOD: This study consisted of three steps: (1) an expert panel developed version 1.0 of the Norwegian FCIM, (2) its content validity was assessed in cognitive interviews with stroke patients (N = 15), (3) a convenience sample of stroke patients (N = 169) completed an online questionnaire with the FCIM, Fatigue Severity Scale, and sociodemographic information; validity and reliability were assessed using Rasch analysis. RESULTS: FCIM version 1.0 included a 10-item characteristics subscale, a 20-item interference subscale, and two pre-stroke fatigue items. The cognitive interviews revealed content validity issues, resulting in two interference items being removed and five items being flagged but retained for Rasch analysis (version 2.0). Rasch analysis led to removal of four items from the characteristics subscale and six more from the interference subscale. The final six-item characteristics subscale and 12-item interference subscale (version 3.0) both showed adequate fit to the Rasch model with indications of unidimensionality and local independence. The interference subscale had a high person separation index. No significant differential item function (DIF) was found in relation to gender, but one item demonstrated DIF in relation to age. CONCLUSION: The cognitive interviews and Rasch analysis demonstrated that the Norwegian version of the FCIM has high content validity, structural validity, and internal consistency. Future research should assess its construct validity, reliability, and responsiveness.

Validation of a short version of the Lee fatigue scale in adults living in Norway: a cross-sectional population survey.

BACKGROUND: Due to the nature of fatigue, a brief reliable measure of fatigue severity is needed. Thus, the aim of our study was to evaluate a short version of the Lee Fatigue Scale (LFS) in the Norwegian general population. METHODS: This cross-sectional survey consists of a representative sample from the Norwegian population drawn by The National Population Register in Norway. The study is part of a larger study (NORPOP) aimed at collecting normative data from several questionnaires focused on health in adults living in Norway. Registered citizens between 18 and 94 years of age were randomly selected stratified by age, sex and geographic region. Of the 4971 respondents eligible for the study, 1792 (36%) responded to the survey. In addition to age and sex, we collected responses on a 5-item version of the LFS measuring current fatige severity. The psychometric properties focusing on internal structure and precision of the LFS items were analyzed by a Rasch rating scale model. RESULTS: Complete LFS scores for analyses were available for 1767 adults. Women had higher LFS-scores than men, and adults < 55 years old had higher scores than older respondents. Our analysis of the LFS showed that the average category on each item advanced monotonically. Two of the five items demonstrated misfit, while the three other items demonstrated goodness-of-fit to the model and uni-dimensionality. Items #1 and #4 (tired and fatigue respectively) showed differential item functioning (DIF) by sex, but no items showed DIFs in relation to age. The separation index of the LFS 3-item scale showed that the sample could be separated into three different groups according to the respondents' fatigue levels. The LFS-3 raw scores correlated strongly with the Rasch measure from the three items. The core dimensions in these individual items were very similarly expressed in the Norwegian language version and this may be a threat to the cultural-related or language validity of a short version of the LFS using these particular items. CONCLUSIONS: The study provides validation of a short LFS 3-item version for estimating fatigue in the general population.

"I am accustomed to something in my body causing pain": a qualitative study of knee replacement non-improvers' stories of previous painful and stressful experiences.

BACKGROUND: Approximately 20% of total knee arthroplasty patients experience persistent postsurgical pain one year after surgery. No qualitative studies have explored previous stories of painful or stressful life experiences in patients experiencing persistent postsurgical pain after total knee replacement. This study aimed to explore stories of previous painful or stressful experiences in life in a cohort of patients that reported no improvement in pain one year after total knee arthroplasty. METHODS: The study employed an explorative-descriptive qualitative design. Data was collected through semi-structured interviews five to seven years after surgery, with patients who reported no improvement in pain-related interference with walking 12 months after total knee replacement. The data was analyzed using qualitative content analysis. RESULTS: The sample consisted of 13 women and 10 men with a median age of 67 years at the time of surgery. Prior to surgery, six reported having at least one chronic illness and 16 reported having two or more painful sites. Two main themes were identified in the data analysis: Painful years - the burden of living with long lasting pain, and the burden of living with psychological distress. CONCLUSIONS: The participants had severe longlasting knee pain as well as longlasting pain in other locations, in addition to experiences of psychologically stressful life events before surgery. Health personnel needs to address the experience and perception of pain and psychological struggles, and how it influences patients' everyday life including sleeping routines, work- and family life as well as to identify possible vulnerability for persistent postsurgical pain. Identifying and assessing the challenges enables personalized care and support, such as advice on pain management, cognitive support, guided rehabilitation, and coping strategies both pre-and post-surgery.

Three patterns of symptom communication between patients and clinicians in the intensive care unit: A fieldwork study.

AIM: To describe different patterns of communication aimed at preventing, identifying and managing symptoms between mechanically ventilated patients and clinicians in the intensive care unit. DESIGN: We conducted a fieldwork study with triangulation of participant observation and individual interviews. METHODS: Participant observation of nine patients and 50 clinicians: nurses, physiotherapists and physicians. Subsequent individual face-to-face interviews with nine of the clinicians, and six of the patients after they had regained their ability to speak and breathe spontaneously, were fully alert and felt well enough to sit through the interview. FINDINGS: Symptom communication was found to be an integral part of patient care. We identified three communication patterns: (1) proactive symptom communication, (2) reactive symptom communication and (3) lack of symptom communication. The three patterns co-existed in the cases and the first two complemented each other. The third pattern represents inadequate management of symptom distress. CONCLUSION: Recognition of symptoms in non-speaking intensive care patients is an important skill for clinicians. Our study uncovered three patterns of symptom communication, two of which promoted symptom management. The third pattern suggested that clinicians did not always acknowledge the symptom distress. IMPLICATIONS FOR PATIENT CARE: Proactive and reactive symptom assessment of non-speaking patients require patient verification when possible. Improved symptom prevention, identification and management require a combination of sound clinical judgement and attentiveness towards symptoms, implementation and use of relevant assessment tools, and implementation and skill building in augmentative and alternative communication. IMPACT: This study addressed the challenges of symptom communication between mechanically ventilated patients and clinicians in the intensive care unit. Our findings may have an impact on patients and clinicians concerned with symptom management in intensive care units. REPORTING METHOD: We used the consolidated criteria for reporting qualitative research. PATIENT CONTRIBUTION: A user representative was involved in the design of the study.

Identification and susceptibility testing of oral candidiasis in advanced cancer patients.

BACKGROUND: Patients with advanced cancer are prone to develop different opportunistic oral infection due to anti-cancer treatment or the malignancies themselves. Studies of oral fungal samples show an increased prevalence of non-Candida albicans species in mixed oral infections with Candida albicans. Non-C. albicans and C. albicans are associated with varying degrees of resistance to azoles, which may have implications for treatment. This study aimed to assess the diversity and antifungal susceptibility of Candida species detected in the oral cavity. METHODS: An observational study with microbiological analysis was conducted. Clinical fungal isolates were collected from patients in a hospice unit in 2014-2016. Isolates were re-grown on chromID® Candida plates in 2020. Single colony of each species was re-cultivated and prepared for biochemical identification with a VITEK2® system and verified by gene sequencing. Etest was performed on RPMI agar, and the antifungals fluconazole, amphotericin B, anidulafungin and nystatin were applied. RESULTS: Fifty-six isolates from 45 patients were identified. Seven different Candida species and one Saccharomyces species were detected. The results of biochemical identification were confirmed with sequencing analysis. Thirty-six patients had mono infection, and nine out of 45 patients had 2-3 different species detected. Of C. albicans strains, 39 out of 40 were susceptible to fluconazole. Two non-C. albicans species were resistant to fluconazole, one to amphotericin B and three to anidulafungin. CONCLUSION: C. albicans was the predominant species, with a high susceptibility to antifungal agents. Different Candida species occur in both mono and mixed infections. Identification and susceptibility testing may therefore lead to more effective treatment and may prevent the development of resistance among patients with advanced cancer. TRAIL REGISTRATION: The study Oral Health in Advanced Cancer was registered at ClinicalTrials.gov (#NCT02067572) in 20/02/2014.

Unidentified communication challenges in the intensive care unit: A qualitative study using multiple triangulations.

BACKGROUND: Communication in the intensive care unit is challenged by patients' inability to speak owing to intubation, treatment, and illness. Research has focused on the use of communication tools or techniques, characteristics of the communication between patients and clinicians, and their experiences of communication challenges. However, few studies have combined the perspectives of patients, family members, and clinicians. We explored communication from different angles and investigated challenges that cannot be explained by ineffective use of aids and communication techniques. OBJECTIVES: The aim of this study was to explore communication between patients, family members, and nurses and to investigate previously unidentified communication challenges. METHODS: This study used a case-oriented design with multiple triangulations. It was conducted in two general intensive care units at a Norwegian university hospital. Participant observations were conducted on nine mechanically ventilated patients while communicating with family members and healthcare personnel. Following the observations, individual interviews were conducted with six patients, six family members, and nine healthcare personnel. FINDINGS: Communication often seemed uncomplicated at the time of observations, but information from the interviews revealed another picture. We demonstrate what participants emphasised differently when they discussed their experiences, revealing a discrepancy in perceived importance in the situation. Family members had an important role in interpreting signs from the patient, uncovering challenges that would have been unknown to the nurses otherwise. CONCLUSIONS: This study illustrates how communication challenges in the intensive care unit may not be perceptible to an observer or to all of the participants involved at the time of the communication. Nurses need to be aware of these communication challenges and realise that the patient might face issues that cannot be easily solved without extensive involvement of the patient, family, and nurses, and perhaps not even until a later stage in the patient's recovery process.

Many Patients With Persistent Pain 1 Year After TKA Report Improvement by 5 to 7 Years: A Mixed-methods Study.

BACKGROUND: Approximately 20% of patients report pain 12 months after TKA. No studies have investigated patients' experiences of living with persistent postsurgical pain 5 to 7 years after TKA by combining a qualitative and quantitative methodology. QUESTION/PURPOSE: In a mixed-methods study, we explored patients' experiences of living with persistent pain up to 7 years after primary TKA. We asked: In a subgroup analysis of patients who reported persistent pain 1 year after TKA surgery, how do patients live with persistent pain at the 5- to 7-year postoperative timepoint? METHODS: This follow-up study was part of a longitudinal study of pain, symptoms, and health-related quality of life in patients who underwent TKA for osteoarthritis. The present study targeted a subgroup of patients (22% [45 of 202]) identified in the longitudinal study who reported no improvement in pain interference with walking at 12 months after surgery. Inclusion criteria were: all 31 patients in this subgroup who attended their 5-year follow-up at the hospital and lived within a 2-hour drive from the hospital. Eight patients declined or were unable to participate due to illness or death. Hence, the final sample consisted of 23 patients (13 women and 10 men). The participants' mean age at surgery was 66 ± 10 years. There were no differences in sociodemographic baseline data between the 23 included and the 22 excluded participants. A mixed-methods approach was employed, in which the quantitative data were followed up and investigated with qualitative interviews. Instruments used were the Brief Pain Inventory preoperatively, 12 months, and 5 years after surgery, as well as a semistructured interview guide. The individual interviews were conducted at one timepoint 5 to 7 years postsurgery to capture how pain was experienced at that timepoint. The interviews were audiorecorded, transcribed, and analyzed using qualitative content analysis. Meaning units were identified, condensed, and sorted into subthemes that were interpreted and abstracted into themes, guided by the research question. With a small sample, the quantitative analysis focused on descriptive statistics and nonparametric statistics when comparing demographics of included and nonincluded patients. In addition, two multivariate mixed models for repeated measures were employed to estimate within-patient and between-patient variations as well as to assess the effect of time on the pain outcomes. RESULTS: Pain with walking decreased from 12 months to 5 years postoperatively (estimated mean score 7 versus 4, difference of means -3 [95% CI -5 to -2]; p < 0.001). Pain with daily activity decreased from 12 months to 5 years postoperatively (estimated mean score 6 versus 3, difference of means -3 [95% CI -4 to -1]; p < 0.001). Pain intensity (average pain) decreased from 12 months to 5 years postoperatively (estimated mean score 5 versus 4, difference of means -1 [95% CI -3 to 0]; p = 0.03). The results are presented as point estimates rounded up to whole numbers. The qualitative data analysis yielded three themes: persistent limitations after TKA, regained wellness over time, and complexity in physical challenges. Intermittent pain with certain movements resulted in limitations with some activities in everyday life and seemed to persist beyond 5 years. Multiple painful body sites and presence of comorbidities seemed to interfere with regained wellness over time. CONCLUSION: In this subgroup of patients experiencing postsurgical persistent pain 12 months after primary TKA, persistent postsurgical pain still limited certain activities for the participants, although pain seemed to be less influential in their everyday lives after 5 years to 7 years. Clinicians may use these findings to inform and guide patients with delayed improvements in pain into more realistic expectations for recovery, rehabilitation, and strategies for coping with pain and impaired function. However, it is imperative to rule out other reasons for pain in patients reporting pain 12 months and longer after surgery and to be attentive of possible changes in pain over time. LEVEL OF EVIDENCE: Level III, therapeutic study.

A mouth rinse based on a tea solution of Salvia officinalis for oral discomfort in palliative cancer care: a randomized controlled trial.

BACKGROUND: Few clinical studies evaluate interventions to reduce oral discomfort among patients in palliative care. AIM: This study examines the efficacy of a Salvia officinalis (SO) based herbal mouth rinse compared to conventional normal saline (NS) in order to improve oral health. DESIGN: A block-randomized controlled trial. Data were collected before and after a 4-day intervention with either SO (n=44) or NS (n=44). Numerical rating scales (NRS, 0-10) and 12 items from the European Organisation for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire-Oral Health 17 (EORTC QLQ-OH17) measured patient-reported oral symptoms. An oral examination was performed before and after the intervention. SETTING/PARTICIPANTS: This study included adult patients with late-stage cancer in an inpatient hospice unit. RESULTS: Of the 88 patients included (mean age=63.9 years, SD=10.6), 73 (83%) completed the study. At baseline, 78% reported dry mouth on the EORTC QLQ-OH17, and 80% rated dry mouth ≥4 on the NRS. Total oral health scores based on the 12 EORTC QLQ-OH17 items improved similarly in both groups (p<0.001). However, dry mouth ratings on both the EORTC QLQ-OH17 (p=0.036) and NRS (p=0.045) improved more in the SO group than in the NS group. Plaque on the teeth improved in both the SO (p=0.008) and NS (p=0.018) groups, but plaque on the tongue and erythema only improved with NS. CONCLUSIONS: This study did not detect an overall significant difference between SO and NS. Both mouth rinses improved oral health parameters, indicating that systematic assessment and oral care may reduce oral discomfort. TRIAL REGISTRATION: NCT02067572.

The Association between the Alcohol Biomarker Phosphatidylethanol (PEth) and Self-Reported Alcohol Consumption among Russian and Norwegian Medical Patients.

AIMS: Valid measures to identify harmful alcohol use are important. Alcohol Use Disorders Identification Test (AUDIT) is a validated questionnaire used to self-report harmful drinking in several cultures and settings. Phosphatidylethanol 16:0/18:1 (PEth) is a direct alcohol biomarker measuring alcohol consumption levels. The aim of this study was to investigate how PEth levels correlate with AUDIT-QF and weekly grams of alcohol consumed among patients in two urban hospitals. In addition, we wanted to investigate the predictive value of PEth in identifying harmful alcohol use as defined by AUDIT-QF and weekly grams of alcohol cutoffs. METHODS: A cross-sectional study comprising acute medically ill patients with measurable PEth levels (≥0.030 µM) admitted to two urban hospitals in Oslo, Norway (N = 931) and Moscow, Russia (N = 953) was conducted using PEth concentrations in whole blood, sociodemographic data and AUDIT-QF questionnaires. RESULTS: PEth levels from patients with measurable PEth were found to be positively correlated with AUDIT-QF scores, with PEth cutpoints of 0.128 µM (Oslo) and 0.270 µM (Moscow) providing optimal discrimination for harmful alcohol use defined by AUDIT-QF (the difference between cities probably reflecting different national drinking patterns in QF). When converting AUDIT-QF into weekly grams of alcohol consumed, the predictive value of PEth improved, with optimal PEth cutpoints of 0.327 (Oslo) and 0.396 (Moscow) µM discriminating between harmful and non-harmful alcohol use as defined in grams (≥350 grams/week). CONCLUSIONS: By using PEth levels and converting AUDIT-QF into weekly grams of alcohol it was possible to get an improved rapid and sensitive determination of harmful alcohol use among hospitalized patients.

Development of an internet-delivered cognitive behavioral therapy program for use in combination with exercise therapy and education by patients at increased risk of chronic pain following total knee arthroplasty.

BACKGROUND: Approximately 20% of patients experience chronic pain after total knee arthroplasty (TKA). Due to the growing number of TKA procedures, this will affect an increasing number of people worldwide. Catastrophic thinking, dysfunctional illness perception, poor mental health, anxiety and depression characterize these non-improvers, and indicate that these patients may need individualized treatment using a treatment approach based on the bio-psycho-social health model. The present study developed an internet-delivered cognitive behavioral therapy (iCBT) program to be combined with exercise therapy and education for patients with knee osteoarthritis (OA) at increased risk of chronic pain after TKA. METHODS: The development process followed the first two phases of the UK Medical Research Council framework for complex interventions. In the development phase, the first prototype of the iCBT program was developed based on literature review, established iCBT programs and multidisciplinary workshops. The feasibility phase consisted of testing the program, interviewing users, condensing the program, and tailoring it to the patient group. A physiotherapist manual was developed and adapted to physiotherapists who will serve as mentors. RESULTS: The development process resulted in an iCBT program consisting of 10 modules with educational texts, videos and exercises related to relevant topics such as goalsetting, stress and pain, lifestyle, automatic thoughts, mindfulness, selective attention, worry and rumination. A physiotherapist manual was developed to guide the physiotherapists in supporting the patients through the program and to optimize adherence to the program. CONCLUSIONS: The iCBT program is tailored to patients at risk of chronic pain following TKA, and may be useful as a supplement to surgery and/or exercise therapy. A multicentre RCT will evaluate the iCBT program in combination with an exercise therapy and education program. This novel intervention may be a valuable contribution to the treatment of OA patients at risk of chronic pain after TKA. TRIAL REGISTRATION: The RCT is pre-registered at ClinicalTrials.gov: NCT03771430 11/12/2018.

The effectiveness of exercise therapy and education plus cognitive behavioral therapy, alone or in combination with total knee arthroplasty in patients with knee osteoarthritis - study protocol for the MultiKnee trial.

BACKGROUND: One in five patients report chronic pain following total knee arthroplasty (TKA) and are considered non-improvers. Psychological interventions such as cognitive behavioral therapy (CBT), combined with exercise therapy and education may contribute to reduced pain an improved function both for patients with OA or after TKA surgery, but the evidence for the effectiveness of such interventions is scarce. This randomized controlled trial with three arms will compare the clinical effectiveness of patient education and exercise therapy combined with internet-delivered CBT (iCBT), evaluated either as a non-surgical treatment choice or in combination with TKA, in comparison to usual treatment with TKA in patients with knee OA who are considered candidates for TKA surgery. METHODS: The study, conducted in three orthopaedic centers in Norway will include 282 patients between ages 18 and 80, eligible for TKA. Patients will be randomized to receive the exercise therapy + iCBT, either alone or in combination with TKA, or to a control group who will undergo conventional TKA and usual care physiotherapy following surgery. The exercise therapy will include 24 one hour sessions over 12 weeks led by a physiotherapist. The iCBT program will be delivered in ten modules. The physiotherapists will receive theoretical and practical training to advise and mentor the patients during the iCBT program. The primary outcome will be change from baseline to 12 months on the pain sub-scale from the Knee Injury and Osteoarthritis Outcome Score (KOOS). Secondary outcomes include the remaining 4 sub-scales from the KOOS (symptoms, function in daily living, function in sports and recreation, and knee-related quality of life), EQ-5D-5L, the Pain Catastrophizing Scale, the 30-s sit-to-stand test, 40-m walking test and ActiGraph activity measures. A cost-utility analysis will be performed using QALYs derived from the EQ-5D-5L and registry data. DISCUSSION: This is the first randomized controlled trial to investigate the effectiveness of exercise therapy and iCBT with or without TKA, to optimize outcomes for TKA patients. Findings from this trial will contribute to evidence-based personalized treatment recommendations for a large proportion of OA patients who currently lack an effective treatment option. TRIAL REGISTRATION: Clinicaltrials.gov : NCT03771430 . Registered: Dec 11, 2018.

Psychometric properties of a short version of Lee Fatigue Scale used as a generic PROM in persons with stroke or osteoarthritis: assessment using a Rasch analysis approach.

BACKGROUND: Fatigue is a common symptom associated with a wide range of diseases and needs to be more thoroughly studied. To minimise patient burden and to enhance response rates in research studies, patient-reported outcome measures (PROM) need to be as short as possible, without sacrificing reliability and validity. It is also important to have a generic measure that can be used for comparisons across different patient populations. Thus, the aim of this secondary analysis was to evaluate the psychometric properties of the Norwegian 5-item version of the Lee Fatigue Scale (LFS) in two distinct patient populations. METHODS: The sample was obtained from two different Norwegian studies and included patients 4-6 weeks after stroke (n = 322) and patients with osteoarthritis on a waiting list for total knee arthroplasty (n = 203). Fatigue severity was rated by five items from the Norwegian version of the LFS, rating each item on a numeric rating scale from 1 to 10. Rasch analysis was used to evaluate the psychometric properties of the 5-item scale across the two patient samples. RESULTS: Three of the five LFS items ("tired", "fatigued" and "worn out") showed acceptable internal scale validity as they met the set criterion for goodness-of-fit after removal of two items with unacceptable goodness-of-fit to the Rasch model. The 3-item LFS explained 81.6% of the variance, demonstrated acceptable unidimensionality, could separate the fatigue responses into three distinct severity groups and had no differential functioning with regard to disease group. The 3-item version of the LFS had a higher separation index and better internal consistency reliability than the 5-item version. CONCLUSIONS: A 3-item version of the LFS demonstrated acceptable psychometric properties in two distinct samples of patients, suggesting it may be useful as a brief generic measure of fatigue severity. TRIAL REGISTRATION: Clinicaltrials.gov: NCT02338869; registered 10/04/2014 (stroke study).

A literature review of factors associated with fatigue after stroke and a proposal for a framework for clinical utility.

OBJECTIVE: Post-stroke fatigue (PSF) is a common and often disabling consequence of stroke, considered to be a complex multidimensional phenomenon. The present review sought to identify studies examining associations between PSF and at least one factor, with the objective of identifying factors that should be investigated in patients with PSF. METHOD: A search for research investigating PSF was conducted through PubMed, CINAHL and Psychinfo databases (19 October 2017), and included studies in English published during the last 15 years, with more than 10 stroke participants (>18 years old), fatigue assessed with quantitative measurements, and reported relationship with one or more associated factor/-s. RESULTS: Overall, 281 papers were identified of which 34 were included in the final review. Demographics (gender, age), emotional health (depression, anxiety, coping strategy, and locus of control), clinical factors (sleep, pain, stroke characteristics, biological and immunological factors), social factors (social support, disabilities and functionality in daily life) and cognitive functions were found to be associated with PSF. A new framework is discussed, incorporating modifiability of PSF-related factors to heighten the clinical utility. CONCLUSIONS: Post-stroke fatigue is multidimensional phenomena with complex aetiology. Further studies are needed to investigate whether treating associated modifiable factors also can decrease PSF.

More Severe Radiographic Osteoarthritis Is Associated With Increased Improvement in Patients' Health State Following a Total Knee Arthroplasty.

BACKGROUND: To assess whether preoperative radiological severity of osteoarthritis (OA) is related to the level of improvement in patients' health state measured 1 year after total knee arthroplasty (TKA). METHODS: Radiographic severity of OA was graded using the Kellgren-Lawrence (KL) classification. Two independent observers were blinded to patients' outcome scores. Health-related quality of life was measured using EQ-5D-3L preoperatively and at 12-month follow-up. The 5 dimensions of the EQ-5D were converted into a health state index score. The association between KL grade and improvement in health state score was analyzed using multiple linear regression. RESULTS: Among 156 consecutive patients (68% females, mean age 69 years) who underwent primary TKA, 3 knees (2%) were classified as KL grade 2, 115 as KL grade 3 (74%), and 38 as KL grade 4 (24%). Follow-up rate was 77%. There was substantial intra-rater and inter-rater agreement (Cohen's kappa = 0.80 and 0.79). Most patients (64%) had clinically significant improvement in their health state score 1 year after TKA. However, after adjusting for relevant covariates, patients with severe OA (KL grade 4) were found to have significantly more improvement in their health state score than patients with mild or moderate OA (KL grade 2 or 3, respectively). Separate analysis of the 5 EQ-5D dimensions showed that the KL group differences were most evident in the "usual activities" and "pain/discomfort" dimensions. CONCLUSION: Patients with severe OA have significantly more improvement in their usual activities and pain/discomfort 1 year after TKA than patients with less severe OA.

Self-rated global health in the Norwegian general population.

BACKGROUND: Prevalence studies are needed to assess the distribution of diseases. However, in a contrasting health promotion perspective, self-rated health is in itself an important field of study. This study investigated self-rated global health in the general population in Norway. METHODS: As part of a national survey, a two-item measure of global health (score range 0-100) was administered to a general population sample, and 1776 of 4961 eligible participants (response rate 36%) responded. Group comparisons were conducted using independent t-tests and one-way analyses of variance, whereas factors associated with global health was investigated with linear regression analysis. RESULTS: In the adjusted analyses, better global health was associated with higher age (ß = 0.13, p <  0.001), having higher education (ß = 0.10, p <  0.001), being employed (ß = 0.21, p <  0.001), and living with a spouse or partner (ß = 0.05, p <  0.05). CONCLUSIONS: While global health was similar for men and women in the Norwegian general population, other sociodemographic variables were linked with global health. In particular, the link between employment and self-rated global health was strong. The findings are considered representative for the Norwegian population.

General self-efficacy in the Norwegian population: Differences and similarities between sociodemographic groups.

Aims: General self-efficacy (GSE) refers to optimistic self-beliefs of being able to perform and control behaviors, and is linked with various physical and mental health outcomes. Measures of self-efficacy are commonly used in health research with clinical populations, but are less explored in relationship to sociodemographic characteristics in general populations. This study investigated GSE in relation to sociodemographic characteristics in the general population in Norway. Methods: As part of a larger national survey, the GSE scale was administered to a general population sample, and 1787 out of 4961 eligible participants (response rate 36%) completed the scale. Group comparisons were conducted using independent t-tests and one-way analyses of variance. Linear regression analysis was used to examine factors independently associated with GSE. Results: GSE was lower for older compared to younger participants (p < 0.001). It was higher for men compared to women (p < 0.001), higher for those with higher levels of education compared to those with lower levels (p < 0.001) and higher for those in work compared to their counterparts (p < 0.001). Controlling for all variables, male gender and employment were independently associated with higher GSE. Age moderated the associations between gender and employment on one hand, and GSE on the other. The association between being male and having higher GSE was more pronounced in younger age, as was the association between being employed and having higher GSE. Conclusions: Male gender and being employed were related to higher GSE among persons in the general population in Norway, and these associations were stronger among persons of younger age. The findings are considered fairly representative for the Norwegian population.

Effectiveness of nursing interventions for breathlessness in people with chronic obstructive pulmonary disease: A systematic review and meta-analysis.

AIM: To critically review and synthesize the findings of studies that evaluated the effectiveness of nursing interventions for improving breathlessness in adults with chronic obstructive pulmonary disease. BACKGROUND: Systematic reviews of nursing interventions for breathlessness in people with chronic obstructive pulmonary disease have not been specifically addressed. DESIGN: Systematic review with meta-analysis. DATA SOURCES: A systematic search of Medline, CINAHL, PsycINFO and Embase was performed for studies published between January 2000 and June 2017. REVIEW METHODS: Risk of bias, data extraction and meta-analysis were conducted using Cochrane methodology. The quality of evidence was assessed using the GRADE approach. RESULTS: Twenty papers were included. A meta-analysis of interventions performed at home, including two trials, showed a significant effect in favour of experimental groups for the symptom score of the St. George Respiratory Questionnaire compared with controls. A meta-analysis of interventions performed in clinics with home follow-up showed a significant effect in favour of experimental groups for the mastery and fatigue scores of the Chronic Respiratory Questionnaire compared with controls. In this category of intervention, an additional meta-analysis showed a significant effect in favour of experimental groups for the symptom, activity and total scores of the St. George Respiratory Questionnaire compared with controls. The quality of evidence was assessed to be very low to moderate. CONCLUSION: The results are equivocal as to whether nursing interventions performed at home and nursing interventions performed in hospital with follow-up improve breathlessness in people with chronic obstructive pulmonary disease.