Foot and ankle characteristics associated with falls in adults with established rheumatoid arthritis: a cross-sectional study.

BACKGROUND: People with rheumatoid arthritis (RA) have an increased risk of falls. The foot is a common site of pathology in RA and foot problems are reported in up to 90% of patients with established disease. The aim of this study was to determine whether foot and ankle characteristics are associated with falls in people with RA. METHODS: Adults with RA were recruited from rheumatology outpatient clinics in Auckland, New Zealand. Participants reported whether they had fallen in the preceding year, and the number of falls. Clinical characteristics, common fall risk factors, and foot and ankle variables were measured. Univariate parametric and non-parametric analysis compared fallers and non-fallers on all variables to determine significant differences. Logistic regression analysis identified variables independently associated with falls. RESULTS: Two hundred and one participants were prospectively recruited. At least one fall in the preceding 12-months was reported by 119 (59%) participants. Univariate analysis showed that fallers had significantly longer mean disease duration, more co-morbid conditions, an increase in lower limb tender joints, higher midfoot peak plantar pressures and were more likely to have a history of vascular disease than non-fallers. Fallers also reported greater difficulty with activities of daily living, increased fear of falling and greater self-reported foot impairment. Logistic regression analysis revealed that increased midfoot peak plantar pressures (odds ratio (OR) 1.12 [for each 20 kPa increase], 95% confidence interval (CI) 1.00-1.25), self-reported foot impairment (OR 1.17 [for each three point increase], 95% CI 1.05-1.31) and history of vascular disease (OR 3.22, 95% CI 1.17-8.88) were independently associated with a fall in the preceding 12 months. CONCLUSIONS: Elevated midfoot peak plantar pressures, self-reported foot impairment and vascular disease are associated with falls in people with RA. Assessment of foot deformity, foot function and self-reported foot impairment may be of benefit when considering falls prevention strategies in people with RA. TRIAL REGISTRATION: Australia New Zealand Clinical Trial Registry (trial ACTRN12612000597897).

Can the Pain Attitudes and Beliefs Scales be adapted for use in the context of osteoarthritis with general practitioners and physiotherapists?

BACKGROUND: Conservative, first-line treatments (exercise, education and weight-loss if appropriate) for hip and knee joint osteoarthritis are underused despite the known benefits. Clinicians' beliefs can affect the advice and education given to patients, in turn, this can influence the uptake of treatment. In New Zealand, most conservative OA management is prescribed by general practitioners (GPs; primary care physicians) and physiotherapists. Few questionnaires have been designed to measure GPs' and physiotherapists' osteoarthritis-related health, illness and treatment beliefs. This study aimed to identify if a questionnaire about low back pain beliefs, the Pain Attitudes and Beliefs Scale for Physiotherapists (PABS-PT), can be adapted to assess GP and physiotherapists' beliefs about osteoarthritis. METHODS: This study used a cross-sectional observational design. Data were collected anonymously from GPs and physiotherapists using an online survey. The survey included a study-specific demographic and occupational characteristics questionnaire and the PABS-PT questionnaire adapted for osteoarthritis. All data were analysed using descriptive statistics, and the PABS-PT data underwent principal factor analysis. RESULTS: In total, 295 clinicians (87 GPs, 208 physiotherapists) participated in this study. The principal factor analysis identified two factors or subscales (categorised as biomedical and behavioural), with a Cronbach's alpha of 0.84 and 0.44, respectively. CONCLUSIONS: The biomedical subscale of the PABS-PT appears appropriate for adaptation for use in the context of osteoarthritis, but the low internal consistency of the behavioural subscale suggests this subscale is not currently suitable. Future research should consider the inclusion of additional items to the behavioural subscale to improve internal consistency or look to develop a new, osteoarthritis-specific questionnaire. TRIAL REGISTRATION: This trial was part of the primary author's PhD, which began in 2012 and therefore this study was not registered.

Exploring the use of ultrasound imaging by physiotherapists: An international survey.

BACKGROUND: National surveys in New Zealand, Australia and the United Kingdom suggest ultrasound imaging (USI) use by physiotherapists is increasing. However, concerns exist regarding clarity for scopes of practice, and availability and standardisation of training. OBJECTIVES: To investigate physiotherapists' understanding of scopes of practice for the use of USI; clarify the professional contexts, clinical uses and levels of training; and identify barriers preventing physiotherapists' USI use. DESIGN: A cross-sectional, observational survey. METHODS: An Internet-based survey, offered in 20 different languages, was used including items covering five domains: (1) demographic and professional characteristics; (2) knowledge of scope of practice; (3) USI use; (4) USI training content and duration; and (5) perceived barriers to physiotherapists' use of USI. RESULTS: 1307 registered physiotherapists from 49 countries responded; 30% were unsure of the scope of practice for physiotherapists' USI use. 38% of participants were users of USI, reporting varied contexts and clinical uses, reflected in the broader categories of: (i) biofeedback; (ii) diagnosis; (iii) assessment; (iv) injection guidance; (v) research; (vi) and teaching. The training users received varied, with formal training more comprehensive. 62% were non-users, the most common barrier was lack of training (76%). CONCLUSION: These findings suggest physiotherapists' USI use is increasing in various contexts; however, there is uncertainty regarding scopes of practice. There are discrepancies in training offered, with a lack of training the most common barrier to physiotherapists' use of USI. International guidelines, including a USI training framework, are needed to support the consistent and sustainable use of USI in physiotherapy.

The effectiveness of web-based patient education and action and coping plans as an adjunct to patient treatment in physiotherapy: A randomized controlled trial.

Objective: The study investigated: (1) the effect of combining web-based patient education (WBPE) with action and coping plans on patients' adherence to physiotherapy and their subsequent functional outcomes; and (2) the participants' satisfaction with the WBPE program. Methods: One hundred and eight participants enrolled in this 8-week two group randomized controlled trial. They were allocated to either the WBPE planning group or the attention-control group. The WBPE group made action and coping plans and were familiarized with their web-based program. The attention control group was given access to a web-based neutral information program about shoulder injuries and physiotherapy rehabilitation. Throughout the 8-week study physiotherapists measured the participants' clinic-based adherence and participants recorded their home-based adherence using a self-report diary. Functional outcomes for all participants were measured at the beginning and end of the study. Participants provided feedback about their respective websites. Results: The intervention group had a significantly higher clinic based adherence than the control group (p < 0.04). Both groups had a significant improvement in shoulder function but there was no significant difference between them. Participants in the intervention group were highly satisfied with the WBPE program. The preferred delivery of physiotherapy by 87% of the intervention group was a combination of face-to-face appointments and WBPE. Control participants indicated that they would have appreciated information about shoulder exercises and the shoulder complex in their program. Discussion: The WBPE program was an effective adjunct to physiotherapy in terms of patient satisfaction and clinic-based treatment adherence.

Validation of a comprehensive measure of clinic-based adherence for physiotherapy patients.

OBJECTIVE: To validate the Rehabilitation Adherence Measure for Athletic Training (RAdMAT) for use in clinic-based physiotherapy. DESIGN AND PROCEDURE: Single group, prospective study conducted over the course of the participants' rehabilitation. Clinic-based adherence was measured by participant attendance at physiotherapy appointments, the 16-item RAdMAT (three subscales) and the three-item SIRAS questionnaire. The SIRAS was evaluated after each physiotherapy treatment and the RAdMAT either at the completion of their treatment or at end of the eight week study period. Both questionnaires were completed by the physiotherapist. PARTICIPANTS: 108 participants with soft tissue injuries of the shoulder. RESULTS: The percentage of adherence for the three different adherence measures was high ranging from 89% to 95%. Large significant correlations were found between the SIRAS and the RAdMAT total score, and the RAdMAT factor 1; and amongst the RAdMAT total and its three subscales. Medium strength correlations existed between the SIRAS and the other two RAdMAT subscales. Small significant correlations occurred between percentage of attendance, and RAdMAT factors 2 and 3. CONCLUSION: The strength of the correlations between the RAdMAT and the SIRAS provide evidence for the RAdMAT and its three subscales comprising a valid and comprehensive assessment tool for measuring patient adherence to clinic-based physiotherapy. Registered with the Australian New Zealand Clinical Trials Registry (ACTRN12612000611820).

Exploring the clinical use of ultrasound imaging: A survey of physiotherapists in New Zealand.

BACKGROUND: In New Zealand ultrasound imaging (USI) is being used increasingly by physiotherapists. To fully understand the extent to which physiotherapists in New Zealand are using USI, it is necessary to evaluate not only the context of its clinical use but also the barriers preventing its uptake. OBJECTIVES: To examine the field and scope of use of USI, the type and content of training and the barriers restricting physiotherapists from using the technique. DESIGN: Cross-sectional observational design utilising an Internet-based electronic survey. METHOD: An electronic survey built on the design of previous research with guidance from an expert review panel. Participants were included if they were New Zealand registered physiotherapists. RESULTS: Of the 465 participants who responded, 433 were eligible to complete the survey. There were 415 participants who completed the survey, 24% who said they used USI whilst 76% did not. For those using USI, the uses were varied including those within a rehabilitative paradigm (i.e. biofeedback; 52%) and also diagnostic (49%). USI training was also varied ranging from formal to informal. The main barriers preventing physiotherapists from using USI were lack of training, access to equipment, and equipment expense. CONCLUSIONS: The participants reported a variety of clinical uses of USI and levels of training. A better understanding of the clinical uses and benefits of USI would enhance both training and clinical uptake. With the identification of barriers limiting physiotherapists' use of USI, ways to overcome these in New Zealand can now be explored further.

Home-based physical therapy intervention with adherence-enhancing strategies versus clinic-based management for patients with ankle sprains.

BACKGROUND AND PURPOSE: To some extent, favorable treatment outcomes for physical therapy intervention programs depend on patients attending their clinic appointments and adhering to the program requirements. Previous studies have found less-than-optimal levels of clinic attendance, and a viable option might be physical therapy intervention programs with a large component of home treatment. This study investigated the effects of a standard physical therapy intervention program--delivered primarily at either the clinic or home--on ankle function, rehabilitation adherence, and motivation in patients with ankle sprains. SUBJECTS: Forty-seven people with acute ankle sprains who were about to start a course of physical therapy intervention participated in the study. METHODS: Using a prospective design, subjects were randomly assigned to either a clinic intervention group or a home intervention group. Ankle function and motivation were measured before and after rehabilitation, and adherence to the clinic- and home-based programs was measured throughout the study. RESULTS: The groups had similar scores for post-treatment ankle function, adherence, and motivation. The home intervention group had a significantly higher percentage of attendance at clinic appointments and better physical therapy intervention program completion rate. DISCUSSION AND CONCLUSION: Home-based physical therapy intervention appears to be a viable option for patients with sprained ankles.

Are Foot and Ankle Characteristics Associated With Falls in People With Rheumatoid Arthritis? A Prospective Study.

OBJECTIVE: To determine whether foot and ankle characteristics are associated with falls in people with rheumatoid arthritis (RA). METHODS: A total of 201 adults with RA were recruited from rheumatology outpatient clinics in Auckland, New Zealand. Clinical characteristics, common fall risk factors, and foot and ankle variables were measured. Participants were prospectively studied for 12 months to record the occurrence of falls using falls diaries. Logistic regression analysis identified baseline variables that were independent predictors of falls over the 12 months. RESULTS: Eighty-four participants (42%) fell at least once and 39 (19%) experienced multiple (>1) falls over the 12-month followup period. In logistic regression analysis, including age and significant baseline variables in bivariate analysis but not baseline fall history, presence of foot or ankle tender joints (odds ratio [OR] 1.95, P = 0.034) and psychotropic medication (OR 2.35, P = 0.025) were independent predictors of prospective falls. However, when baseline fall history was included in the analysis, psychotropic medication (OR 2.34, P = 0.025) and baseline fall history (over the preceding 12 months) (OR 2.27, P = 0.008) were independent predictors of prospective falls. CONCLUSION: Foot and ankle characteristics are not associated with falls in people with RA, independent of prior falls. Inquiry about prior falls and psychotropic medications may assist in identifying patients with RA who are at high risk of future falls.

The incidence and risk factors for falls in adults with rheumatoid arthritis: a systematic review.

OBJECTIVE: To conduct a systematic review of the incidence and risk factors for falls in people with rheumatoid arthritis (RA). METHODS: A search was conducted of the electronic databases AMED, CINAHL, MEDLINE, Scopus and The Cochrane Library. Study participants were adults with RA. Outcome measures were falls experienced in the preceding 6-12 months or prospective falls over a 12-month period. Articles were scored for quality using a modified version of the Downs and Black Quality Index Tool. RESULTS: Nine articles were included with mean (range) quality scores 72% (43-93%). The quality assessment revealed inconsistency in falls data attainment. Falls incidence ranged from 10% to 50% and was independent of age, gender or RA disease duration. History of a prior fall (odds ratio (OR) = 3.6 and 9.8) and increasing number of medications (OR = 1.4 and 2.1) were consistently associated with falls in RA. Number of co-morbid conditions, swollen and tender lower extremity joints, anti-depressants, anti-hypertensives, psychotropics, pain intensity and static balance were also identified as significant fall risk factors in at least one study. However, the evidence was limited to a single study or conflicted with other studies. CONCLUSION: In studies of falls in people with RA, there is a wide range in reported falls incidence, which may be due to inconsistency in falls data attainment. Numerous potential fall risk factors have been evaluated, producing limited or conflicting evidence. It is recommended that future studies follow previous consensus guidelines for collecting and reporting falls data.

An application of the health action process approach to physiotherapy rehabilitation adherence.

This study tested the utility of an extended version of the health action process approach (HAPA) to explain the attitudinal and behavioural processes contributing to rehabilitation adherence and ultimately rehabilitation outcomes in physiotherapy patients. The HAPA focuses on self-efficacy, action and coping planning and their relationships to behavioural intentions and actual behaviour. A one group prospective design was employed in which 20 participants with soft tissue injuries of the shoulder were followed for the first four weeks of their clinic- and home-based physiotherapy. Participants enrolled in the study after their first physiotherapy clinic appointment, at which time they completed questionnaires measuring the motivational HAPA constructs and shoulder function. Action and coping plans were then made with assistance of the researcher. Adherence behaviours were measured throughout the study, and at the end the volitional stage HAPA constructs, action self-efficacy and shoulder function were assessed. Moderate to strong correlations occurred between the self-efficacies and behavioural intentions, behavioural intentions and adherence behaviours, and adherence behaviours and post-study shoulder function. These findings support the extension of the HAPA model to include the functional outcomes for soft tissue injuries of the shoulder. Its true value will nevertheless only be realized in a longer duration study with a larger sample size.

The effects of sandals on postural stability in patients with rheumatoid arthritis: an exploratory study.

BACKGROUND: Rheumatoid arthritis results in postural instability, pain and functional limitations. As rheumatoid arthritis progresses, localised forefoot deformities such as hallux valgus and clawing of the lesser toes occur, leading to a high proportion of people with rheumatoid arthritis wearing sandals. Sandals may affect postural stability due to poor motion control. The aim was to assess two different open-toe sandals on postural stability in people with rheumatoid arthritis. METHODS: Twenty women with rheumatoid arthritis were assessed in quiet standing under four conditions: (1) open-back sandal; (2) closed-back sandal; (3) own footwear and (4) bare feet. Postural stability was assessed as postural sway in the anterior-posterior and medial-lateral directions, with eyes open and eyes closed, using a pressure mat. Repeated measures analysis of variance tested the interaction effect of the footwear and eye conditions on anterior-posterior and medial-lateral sway. FINDINGS: In eyes-open, there was no significant difference in anterior-posterior sway (P=.169) and medial-lateral sway (P=.325) for footwear conditions. In eyes-closed testing, compared with barefoot conditions, increased anterior-posterior sway was observed with participants' footwear (P<.0001), the open-back sandal (P=.005), and the closed-back sandal (P=.017). With eyes closed, increased anterior-posterior sway was also observed with the participants' footwear compared with the closed-back sandal (P=.041). Increased medial-lateral sway was observed with the closed-back sandal compared with bare feet (P=.014). INTERPRETATION: Sandals may be detrimental to older women with well-established rheumatoid arthritis when eyes are closed. Further investigation is needed to evaluate the effect of sandals on dynamic tasks.

Reliability of the TekScan MatScan® system for the measurement of postural stability in older people with rheumatoid arthritis.

BACKGROUND: Postural stability can be measured in clinical and research settings using portable plantar pressure systems. People with rheumatoid arthritis (RA) have decreased postural stability compared to non-RA populations and impaired postural stability is associated with falls in people with RA. The purpose of this study was therefore to investigate the reliability of the TekScan MatScan® system in assessing postural stability in people with RA. METHODS: Twenty three participants with RA, mean (SD) age 69.74 (10.1) years, were assessed in barefoot double-limb quiet standing, with eyes open and eyes closed, for antero-posterior and medio-lateral postural sway values. Three repetitions, at a sampling frequency of 40 Hz, were recorded for each test condition to obtain a mean value. Measurements were repeated one hour later. Intraclass correlation coefficients (ICC) with 95% confidence intervals (CI) were calculated to determine between-session reliability. Measurement error was assessed through the calculation of the standard error of the measurement (SEM) and the smallest real difference (SRD). RESULTS: The system displayed good to excellent reliability for antero-posterior and medio-lateral sway, with eyes open and closed, as indicated by ICC values ranging from 0.84 to 0.92. Measurement error, as evidenced by the SEM, ranged from 1.27 to 2.35 mm. The degree of change required to exceed the expected trial to trial variability was relatively high, compared to mean values, with SRD ranging from 3.08 to 5.71 mm. CONCLUSIONS: The portability and ease of use of the TekScan MatScan® makes it a useful tool for the measurement of postural stability in clinical and research settings. The TekScan MatScan® system can reliably measure double-limb quiet standing in older people, aged 60 to 80 years, with RA.

A test of an adherence-enhancing adjunct to physiotherapy steeped in the protection motivation theory.

The primary aim of this study was to test the effect of a Protection Motivation Theory (PMT)-based patient education intervention on physiotherapy patients' beliefs about their injury and physiotherapy, intentions to adhere, rehabilitation adherence, and ankle function. A secondary aim was to explore the relationships between the patients' injury and physiotherapy beliefs, intentions, adherence behaviours, and ankle function. A randomized controlled trial was undertaken in New Zealand; 71 people with ankle sprains were allocated to either PMT present video information or two control groups (non-PMT information about ankle sprains and no formal information) before commencing their course of physiotherapy. The two information groups watched a video about ankle sprains and physiotherapy before answering the Beliefs about Ankle Sprains and Physiotherapy Scale and behavioural intentions questionnaires that measured the PMT constructs. Adherence was assessed at each treatment and ankle function was measured before and after the physiotherapy program. After viewing the video, the PMT present information group's beliefs about severity, vulnerability, and response efficacy were significantly higher than the other two groups. The groups did not differ significantly on their self-efficacy, intentions, rehabilitation adherence, and post-physiotherapy program ankle function. Significant correlations existed between the patients' PMT-based beliefs and intentions, intentions and adherence, and adherence and post-physiotherapy ankle function. With the exception of self-efficacy, the findings indicate that persuasive information grounded in PMT does enhance physiotherapy patients' beliefs about their injury and treatment.

The evaluation of walking footwear on postural stability in healthy older adults: an exploratory study.

BACKGROUND: It has been proposed that walking footwear enhances postural stability in healthy older adults. The aim of the study is to evaluate differences between two different types of athletic footwear in relation to postural stability in healthy older adults. METHODS: A convenience sample of 21 healthy older adults with mean (SD) of 74 (5) years was recruited. Postural stability was measured using a force plate for anterior-posterior (AP) and mediolateral (ML) centre of pressure excursion for 30s with eyes closed and open using two different types of athletic footwear. Each participant performed three repetitions of bipedal standing. Two-way analysis of variance tested the interaction effect of the footwear and eye conditions on anterior-posterior (AP) and mediolateral (ML) postural sway. FINDINGS: There was no significant footwear-eye condition interaction for anterior-posterior(AP) postural sway but there were significant main effects for both the footwear and eye conditions (P<0.05). The significant main effects for the footwear conditions occurred between barefeet and the two shoe conditions, but not between the two shoe conditions. For mediolateral (ML) postural sway there was no significant interaction effect and no main effects for the footwear and eye conditions (P>0.05). INTERPRETATION: The results suggest that older adults demonstrate an initial destabilisation effect which could possibly be of benefit to functional ability but the long-term effects of ability of athletic footwear to enhance postural stability requires further investigation.

The lower-limb tasks questionnaire: an assessment of validity, reliability, responsiveness, and minimal important differences.

OBJECTIVES: To develop a questionnaire that focuses only on physical tasks related to lower-limb function and, within that questionnaire, to explore the psychometric properties of a series of questions that are related specifically to activities of daily living (ADLs) and a series of activities more often associated with recreation. DESIGN: Inception cohort. SETTING: Private practice. PARTICIPANTS: Data were primarily from patients who had experienced a lower-limb injury that would typically involve rehabilitation up to 6 weeks. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Through 5 studies, the following psychometric qualities were evaluated: content and factor validity, construct and concurrent validity, test-retest reliability (intraclass correlation coefficient [ICC], typical error), responsiveness (effect size, standardized response mean, Guyatt's responsiveness statistic), and the minimum important difference (distribution, anchor-based approaches). RESULTS: Factor analysis supported the theoretical perspective that ADLs and recreational activities can be treated as different domains within the construct of function. Internal consistency was high (Cronbach alpha: ADLs, .91; recreational activities, .95) and the 2 domains explained a moderate level of the response variance (61%). In the ADL domain, 7 tasks had greater than 80% of participants regarding them as having some importance. For recreational activities, 6 tasks had 79% or more of participants regarding them as having some importance. Both domains were moderately correlated to actual performance of tasks (r = .62, r = .72), and to other questionnaires used for lower-limb injuries (r range, .51-.86). The floor and ceiling effects of the domains followed an expected pattern that could be related to the loading forces experienced on the injured limb during activities. The reliability of the 2 domains was high (ICCs >.95), and the Bland-Altman plots showed that the distribution of error across the range of scores was random with low bias scores (<1.0 point). Typical error scores were 2 points for each domain. All measures of responsiveness were high (1.2-6.7). Measures of the minimal important difference varied (3-10 points) according to the methodologic approach used. CONCLUSIONS: The questionnaire possesses good factor structure and composition, relates well with other measures of function, differentiates patients with regard to certain characteristics or processes known to occur after injury, shows high levels of reliability and responsiveness, and shows evidence of good minimal important difference scores. The findings support the use of the questionnaire in both clinical scenarios and in research.

New Zealand resident Tongan peoples' health and illness beliefs and utilisation of the health care system.

This study investigated the perceptions of health and illness, and the utilisation of the health care system, over the last five years, of Tongan people who reside in New Zealand. A descriptive qualitative approach was used, with the study being implemented by networking with representatives of the Tongan community and health care workers. Twenty adult Tongan people volunteered and were given the interview questions in advance. The individual face to face semi-structured interviews took approximately 30 to 45 minutes. Participants verified the transcription of their interviews. Answers were analysed by identifying themes in response to each interview question. Most participants considered health to be a state of physical, mental, social and spiritual well being. Illness beliefs were predominantly either a biological malfunction of the body, or a breakdown of the holistic state of well being. All participants had used the western orthodox medical system, with the general practitioner being consulted more than other services. A high level of satisfaction was expressed with this service. Traditional Tongan healing was utilised by about half the participants, and most were happy with its outcomes. A lesser number of participants had used alternative health care, but the levels of satisfaction with it were mixed.