Development of a Multimodal, Physiotherapist-Led, Vocational Intervention for People with Inflammatory Arthritis and Reduced Work Ability: A Mixed-Methods Design Study.

PURPOSE: Work ability of people with rheumatoid arthritis (RA) and axial spondyloarthritis (axSpA) is reduced, but underexamined as a clinical treatment target. The evidence on vocational interventions indicates that delivery by a single healthcare professional (HCP) may be beneficial. Physiotherapist (PT)-led interventions have potential because PTs are most commonly consulted by RA/axSpA patients in the Netherlands. The aim was to develop a PT-led, vocational intervention for people with RA/axSpA and reduced work ability. METHODS: Mixed-methods design based on the Medical Research Council (MRC) framework for developing and evaluating complex interventions, combining a rapid literature review and six group meetings with: patient representatives (n = 6 and 10), PTs (n = 12), (occupational) HCPs (n = 9), researchers (n = 6) and a feasibility test in patients (n = 4) and PTs (n = 4). RESULTS: An intervention was developed and evaluated. Patient representatives emphasized the importance of PTs' expertise in rheumatic diseases and work ability. The potential for PTs to support patients was confirmed by PTs and HCPs. The feasibility test confirmed adequate feasibility and underlined necessity of training PTs in delivery. The final intervention comprised work-focussed modalities integrated into conventional PT treatment (10-21 sessions over 12 months), including a personalized work-roadmap to guide patients to other professionals, exercise therapy, patient education and optional modalities. CONCLUSION: A mixed-methods design with stakeholder involvement produced a PT-led, vocational intervention for people with RA/axSpA and reduced work ability, tested for feasibility and ready for effectiveness evaluation.

Identification of relevant ICF (International Classification of Functioning, Disability and Health) categories in lymphedema patients: A cross-sectional study.

BACKGROUND: To describe functioning and health of lymphedema patients and to identify their most common problems using the International Classification of Functioning, Disability and Health (ICF) as part of the preparatory studies for the development of ICF Core Sets for lymphedema. METHODS: Cross-sectional study in a population of lymphedema patients (n = 200), undergoing treatment in a Dutch lymphedema-specialized hospital. The second-level categories of the ICF were used to collect information on patients' problems in daily functioning. RESULTS: The mean age of the study group was 56 years (22-84). In total 78.5% of the patients were female. The most frequent mentioned items were: In the Body Functions component: muscle power and mobility of joints, in the Activities and Participation component: doing housework, and changing and maintaining a body position, in the Environmental Factors: Health professionals, who can act as both facilitators and barriers. Interestingly, patients assessed their health more positively than health professionals do. CONCLUSION: By using the ICF, a considerable part of the broad spectrum of problems in functioning of lymphedema patients was reported.

Development of consensus International Classification of Functioning, Disability and Health (ICF) core sets for lymphedema.

To understand the challenges of patients with lymphedema it is important to describe functioning and to measure the effectiveness of treatment in changing functioning. The International Classification of Functioning, Disability and Health (ICF) offers an international framework to classify functioning of persons in their personal environment. ICF Core Sets are lists of selected ICF categories concerning those important aspects of functioning that are most likely to be affected by a specific health problem or disease. These Core Sets make it easier and faster to describe and communicate the patient's problems and to define treatment goals. Furthermore, they are available to health care providers of all professions, researchers, health insurance companies and policy-makers. The objective of this document is to present the outcomes of a consensus conference held to determine the first versions of the ICF Core Sets for lymphedema. Frequency rankings were made of the ICF categories derived from four preparatory studies, being: a) a systematic review; b) a qualitative study; c) an expert survey; and d) a cross-sectional study. By means of working group discussions and plenary sessions, a final consensus on ICF categories was achieved and Comprehensive and Brief Core Sets for lymphedema for the upper limb, lower limb, and midline lymphedema were defined. These ICF Core Sets contain different items in each region. Future validation of these Core Sets for health professions and for countries is needed.

Effect evaluation of a self-management program for dutch workers with a chronic somatic disease: a randomized controlled trial.

PURPOSE: The objective of this study is to investigate the effect of a Self-Management Program for workers with a chronic disease. This program is based on the Chronic Disease Self-Management Program of Stanford University, modified for workers with a chronic somatic disease. METHODS: In a randomized controlled trial, the effectiveness of a Self-Management Program was evaluated. Participants were randomly assigned to the experimental group (n = 57) and the control group (n = 47). The experimental group received an intervention, the control group received care as usual. Primary outcome measures were self-efficacy at work and the attitude towards self-management at work. Secondary outcomes were the SF-12 health survey questionnaire, job satisfaction and intention to change job. The results were measured at baseline, after the intervention and 8 months after the intervention. RESULTS: The attitude towards self-management at work (enjoyment) improved after 8 months for the intervention group (p = 0.030). No other outcome variable differed significantly. As an interaction effect, it was found that low educated workers developed a better physical health quality (SF-12) in the intervention group compared with the control group. The attitude towards self-management at work (importance) improved in the intervention group for older and female workers and the attitude toward enjoying self-management at work improved for female workers only. CONCLUSION: The results show that low educated workers, older workers and women benefit significantly more from the training than higher educated workers, younger workers and men.

Effectiveness and cost-effectiveness of a multimodal, physiotherapist-led, vocational intervention in people with inflammatory arthritis: study protocol of the Physiotherapy WORKs trial.

BACKGROUND: Although reduced work ability is a substantial problem among people with inflammatory arthritis (IA), work ability is an underexposed area in clinical practice. Evidence on vocational interventions in IA is limited, but favourable results of delivery by a physiotherapist (PT) warrant the need for further research. Therefore, we aim to evaluate the (cost-)effectiveness of a multimodal, PT-led, vocational intervention in (self-)employed people with IA compared to usual care. METHODS: This randomized controlled trial will include 140 people with rheumatoid arthritis (RA) or axial spondyloarthritis (axSpA) who are (self-)employed and have reduced work ability (Work Ability Index - Single Item Scale (WAS) ≤ 7/10) and/or RA/axSpA related sick leave (≤ 6 months). Participants will be randomized 1:1 to the intervention or control condition (usual care). The intervention, delivered by primary care PTs, will be personalized to each patient, consisting of 10 to 21 sessions over 12 months. The intervention will be multimodal, comprising of 1) exercise therapy and a physical activity plan, 2) education/self-management support, 3) work-roadmap to guide participants in finding relevant other care, with optionally 4) online self-management course and 5) workplace examination. Assessments will be performed at baseline and after 3, 6, and 12 months. The primary outcome measure of effectiveness is work ability, as measured with the WAS at 12 months. For the cost-effectiveness analysis, the EuroQol (EQ-5D-5L), self-reported healthcare use, sick leave and productivity while at work will be used to estimate the trial based cost-utility from a societal perspective. A process evaluation, including assessments of adherence and treatment fidelity, will be undertaken using the registrations of the PTs and semi-structured interviews at 12 months follow-up in a random sample of the intervention group. DISCUSSION: The results of this study will provide insights in the (cost-)effectiveness of a multimodal, PT-led, vocational intervention in people with IA and a reduced work ability. TRIAL REGISTRATION: This study is registered in the International Clinical Trial Registry Platform (ICTRP) under number NL9343.

Functional morphology of the M. gastrocnemius medialis of the rat during growth.

Length-force relations, both active and passive, and twitch contraction characteristics were quantified for left medial gastrocnemius muscles of four young, four adult, and four old male Wistar rats. Muscle and bundle optimum length and muscle weight were also determined and subsequently used for calculation of a number of morphological characteristics of the muscles. Fiber optimum length was derived from muscle bundle optimum length. Generally, physiological characteristics remained constant during growth. There was no change either in active tension at muscle optimum length or in active working range relative to fiber optimum length, relative passive fiber stiffness, active force relative to passive force at optimum length, twitch contraction time and twitch half relaxation time at optimum length. A number of morphological changes, however, did take place in the medial gastrocnemius muscle during growth. Fiber optimum length increased but only by about 2 mm from youth to old age, whereas muscle optimum length increased by approximately 14 mm, presumably owing to extensive hypertrophy of the muscle fibers during growth. The priority for force of the medial gastrocnemius muscle (defined as the quotient of physiological cross-sectional area of a muscle and the cubed root of its volume, a measure independent of architecture and dimensions of muscles) increased during growth. This increase indicates that during growth the muscle shifts relatively more towards force generation than towards excursion generation. These findings are discussed in view of existing scaling theories.

The international classification of impairments, disabilities and handicaps in leprosy-control projects.

The use of a uniform language, which includes definitions of terms, is very important in the field of health care. It is important to have a common language for educational, research and communication purposes. Classifications can play a major role in the development of uniform reporting and registration systems. The purpose of this article is to familiarize leprosy workers with two classifications that are in common use in health care, a classification of diseases and a classification used to describe the overall health status of a person, and to relate the 3 terms that are used in the latter classification, impairments, disabilities and handicaps, to leprosy.

Intraobserver and interobserver reliability of assessments of impairments and disabilities.

BACKGROUND AND PURPOSE: The purpose of this study was to evaluate the interobserver and intraobserver reliability of assessments of impairments and disabilities. SUBJECTS AND METHODS: One physical therapist's assessments were examined for intraobserver reliability. Judgments of two pairs of therapists were used to examine interobserver reliability. Reliability was assessed by Cohen's kappa. RESULTS: Of the 42 impairments and disabilities assessed by the physical therapist in the intraobserver reliability study, kappa values could be calculated for 33 items. For 31 items (94%), kappa values ranged from .40 to .91, and 2 items (6%) had kappa values of less than .40. To determine interobserver reliability, 37 items were assessed in one practice. Kappa values could be calculated for 34 items, with 30 items (88%) having kappa values ranging from .41 to .80 and 4 items (12%) showing "poor" agreement. In the second practice, 47 items were assessed for interobserver reliability. Kappa values could be calculated for 40 items, with 11 items (27.5%) having kappa values ranging from .41 to .84. Poor agreement was shown for the remaining 29 items (72.5%). CONCLUSION AND DISCUSSION: Assessments of impairments and disabilities are potentially reliable. The differences between practices of the interobserver reliability study can be explained by the fact that one of the therapists did not receive training in the use of the assessment form. More generalizable conclusions will require further study with more subjects and therapists.

Impairments and disabilities--the difference: proposal for adjustment of the International Classification of Impairments, Disabilities, and Handicaps.

In this article, a proposal for adjustment of the Classification of Impairments and the Classification of Disabilities of the International Classification of Impairments, Disabilities, and Handicaps is presented. This proposal is a result of a project conducted by the Dutch National Institute for Research and Postgraduate Education in Physical Therapy. The project was executed in collaboration with the professional national organizations of five health professions: occupational therapy, chiropody, Cesar therapy (exercise therapy), Mensendieck therapy (exercise therapy), and physical therapy. The proposal includes reformulated definitions of impairment and disability, an inventory of the impairments and disabilities that are relevant for the health professions that participated in the project, a description of the domain of the Classification of Impairments and the Classification of Disabilities, a new subdivision for both classifications in chapters, and a set of "types of characteristics" and "characteristics" that subdivide the different chapters of the two classifications.

The need for revision of the ICIDH: an example--problems in gait.

In this article a proposal is formulated for adjustment of the Classification of Impairments and the Classification of Disabilities of the International Classification of Impairments, Disabilities, and Handicaps (ICIDH). This proposal is a product of a project from the Dutch National Institute of Research and Postgraduate Education in Physical Therapy. This project is conducted in close cooperation with the professional national organizations of five health professions. To give an indication of the kind of changes proposed, the disabilities and impairments necessary for classifying the complaints, the examination findings, the treatment goals and the treatment results in patients with gait problems are discussed.

Reflection on the definition of impairment and disability as defined by the World Health Organization.

The International Classification of Impairments, Disabilities, and Handicaps (ICIDH) is gaining wide acceptance inside and outside the field of rehabilitation medicine. Impairment and disability are concepts which are often used interchangeably or defined differently. The World Health Organization (WHO) has defined impairment and disability in the ICIDH. In this article an analysis is made of these definitions and the characteristics that are given for the definitions. Based on this analysis, modifications for the definitions and characteristics of impairment and disability are suggested.

Towards a new ICIDH. International Classification of Impairments, Disabilities and Handicaps.

In 1995 a special issue of Disability and Rehabilitation was published on the use of the International Classification of Impairments, Disabilities and Handicaps (ICIDH) which was issued by WHO in 1980. Since 1995 a lot of energy has been spent by WHO and other organizations aiming at the development of a new and improved ICIDH. In 1997, a draft ICIDH-2 (Beta-1 version) was circulated by WHO in order to be tested in the field. This paper informs the reader about the content of the draft ICIDH, the revision process planning and some Dutch comments relating to the actual draft.

Coding of meaningful concepts in lymphedema-specific questionnaires with the ICF.

PURPOSE: To identify and quantify the meaningful concepts within questionnaires focusing on lymphedema using the International Classification of Functioning, Disability and Health (ICF). METHODS: Electronic searches of Medline, EMBASE, CINAHL, CENtral and Pedro (2005-2010) were conducted. The concepts in the questionnaires were retrieved from the included studies and linked to the ICF. RESULTS: Of the 2381 abstracts retrieved, 136 studies were included. The study population suffered from lymphedema in the upper limb (65%), in the lower limb (25%), in the midline (3%) and in combinations of these areas (7%). In total, 12 lymphedema-specific questionnaires were found (nine for the upper limb, two for the lower limb and one for lymphedema in general). A total of 301 concepts were extracted from the questionnaires, of which 271 (90%) could be linked to the ICF. There were 45 two-level ICF categories linked to concepts in ≥2 questionnaires; 13 in Body Functions, 6 in Body Structures, 16 in Activities and Participation and 10 in Environmental Factors. The most frequently measured categories were "Structure of upper extremity", "Immunological system functions", "Looking after one's health", "Sensation of pain", "Touch functions", "Dressing" and "Health services, systems and policies". CONCLUSION: The ICF provides a valuable reference to identify concepts in questionnaires focusing on individuals with lymphedema. Implications for Rehabilitation Lymphedema is a chronic condition and the problems in physical functioning related to lymphedema can result in distress and loss of quality of life. ICF Core Sets for lymphedema consist of a lymphedema-specific selection of ICF categories, which makes it easier to implement the use of the ICF in medical and allied health care. ICF Core Sets for lymphedema can act as a framework for more unity in questionnaires concerning consequences of lymphedema. Part of the development process of ICF Core Sets for lymphedema is the linking of items from lymphedema-specific clinical questionnaires to ICF codes. The ICF codes most frequently used to link the items in the reviewed questionnaires were "Structure of upper extremity", "Immunological system functions", "Looking after one's health", "Sensation of pain", "Touch functions", "Dressing" and "Health services, systems and policies".

Impairments and disabilities in hand therapy: the necessity of a uniform terminology for communication and research purposes.

Uniformity in the use of professional language is very important in the field of medicine. Impairments and disabilities are terms that are often used interchangeably. To health professionals analyzing a patient's health problem, formulating treatment goals, or writing questionnaires and protocols, the International Classification of Impairments, Disabilities, and Handicaps (ICIDH) offers a conceptual framework that has a great potential to remedy improper use of terms and that can enhance communication. The purpose of this article is twofold: (1) to familiarize the hand therapist with the ICIDH and (2) to present some proposals for a revision of the ICIDH that will make the classification structurally more practical and thereby will facilitate its use.

Growth of medial gastrocnemius muscle and Achilles tendon in Wistar rats.

Dimensions, architecture, material properties and functional characteristics of medial gastrocnemius muscles and Achilles tendons of young and old Wistar rats were compared. Dimensions associated with length of the leg segment grow isometric with it. Muscle belly transsectional dimensions, volume of muscle tissue and associated functional indices increase out of proportion either with the dimensions of the limb segment or the weight of the animal. As the properties of the contractile tissue remain the same and relative proportions of tissue components alter, changes in architecture result. These are not reflected in transsection of the tendon. Functional characteristics of the muscle tendon complex can be explained by architectural or dimensional-peculiarities emerging in the complex by growth processes of which the main is that the muscle belly of this pennated muscle grows in length mainly by increments in girth of the muscle fibers proper.

Mechanical properties of passive rat muscle during sinusoidal stretching.

The dynamic passive response of the left gastrocnemius medialis muscle of thirty male Wistar rats was studied as a function of muscle dimensions and absolute and relative amount of connective tissue. Values of the absolute active and passive length-force curves (active force, passive force, active working range) correlated well (coefficients of correlation in a range of 0.62-0.92) with morphological variables (such as muscle optimum length, mean muscle fibre optimum length, physiological cross section, muscle weight and amount of intramuscular connective tissue). To eliminate dimensional effects the active and passive length-force curves were normalized taking maximal active twitch force and muscle optimum length as reference values (100%). The width of the normalized active length-force curve (relative active working range) was correlated negatively with muscle weight, muscle optimum length and physiological cross section. Relative amount of connective tissue and passive tension at optimum length (both independent of muscle dimensions) were positively correlated, indicating that passive muscles are stiffer when relative amount of intramuscular connective tissue is higher. Sinusoidal movements with several amplitudes and frequencies of movement were imposed on the passive gastrocnemius medialis muscle over a range of muscle lengths. In accordance with the approximately exponential increase of static passive muscle force with length, muscle length has a large influence on the shape and magnitude of the hysteresis diagrams resulting from sinusoidal movements: the value of all variables selected increases approximately exponentially with muscle length with the exception of the value of loss tangent, a factor indicating the amount of energy dissipated during each cycle relative to the amount of energy stored and released elastically. Velocity of movement has only minor influence on variables of the hysteresis diagrams as is shown by changing the frequency of movement. As loss tangent and relative amount of connective tissue did not vary with muscle dimensions in the muscles studied, it is likely that material properties of the components causing passive resistance were similar in these muscles.

Passive resistance of the human knee: the effect of remobilization.

Changes of circumferential dimensions and passive resistance of the human knee caused by immobilization, were studied during remobilization. Patients immobilized with a long leg cast after tibial fractures or ligamentous injuries were studied immediately after removal of the cast and after mean periods of 18, 36 and 81 days of remobilization. Immobilization resulted in a decrease of circumferential dimensions. The difference in mid-thigh circumference between the immobilized and the unaffected leg was still present after 81 days of remobilization both for the patients with tibial fractures and for the remobilization both for the patients with tibial fractures and for the patients with ligamentous lesions. An increase of midpatellar circumference was present exclusively in the patients with ligamentous lesions at all four testing dates, indicating that this is an effect of the ligamentous lesion and not of immobilization per se. Variables of the hysteresis diagrams, resulting from sinusoidal movement of the knee at a range of knee angles, were used to quantify passive resistance of the knee in the flexion-extension plane (the muscles crossing the knee are inactive). Variables related to the elastic storage and release of energy, and variables related to energy dissipation were discerned. During remobilization the increased resistance to flexion (shown by the variables related to the elastic storage of energy), as found immediately after removal of the cast, disappears and the resistance becomes identical to the resistance of the unaffected leg. This may indicate a rapid readaptation of the length of ventral structures (shortened due to immobilization in a shortened position) to almost normal values.(ABSTRACT TRUNCATED AT 250 WORDS)

Passive resistance of the human knee: the effect of immobilization.

The effects of immobilization on both the circumferential dimensions of the lower limb, and the passive resistance of the knee to sinusoidal motion in the flexion-extension plane, were studied in patients immobilized after tibial fractures or ligamentous injuries of the knee. Immobilization resulted in a decrease of circumferential dimensions of the lower limb, indicating atrophy of thigh and calf musculature. The equilibrium angle of the knee, i.e. the angle at which the net passive moment equals zero, approached the angle of the knee during immobilization. At knee angles of 60 degrees (the maximal angle imposed on the immobilized knee) and 45 degrees, the resistance was increased, and at angles of 30 degrees and 15 degrees, the resistance was decreased. The passive resistances at +/- 22.5, 15 and 7.5 degrees relative to the equilibrium angle were all increased. A simple model, taking into account changes in the length of muscles at the anterior and posterior side of the knee, explains changes in passive resistance. The duration of immobilization for patients with ligamentous injuries of the knee was less than 50% of that for patients with tibial fractures, whose ankle joint was not immobilized, both resulted in a smaller muscular atrophy for patients with ligamentous injuries. Differences in passive resistance between unaffected and immobilized legs were the same in both groups of patients. Changes in passive resistance in the immobilized leg for those with ligamentous injury are probably not the effect of immobilization alone but the combined effect of immobilization and ligamentous lesions.

Vector diagrams in the evaluation of human gait.

From recordings of reaction forces on the feet in the vertical (z) and horizontal for-aft (x) direction during walking, x-z vector-diagrams (VDG) are constructed for the purpose of clinical use in the evaluation of gait. Such use presupposes the existence of reference values. The parameters of VDG, ie, the maximal coordinates of the vectors, are dependent on weight, speed of walking, age, step length, and physical condition. A requirement of studies on reference values is that these variables as well as height are accounted for. VDG were applied to evaluation of gait of hemiplegic subjects: slow speeds, alterations in the functions of the limbs and irregularities due to instability were noted.