The effect of age on the pressure pain threshold of asymptomatic ankles and knees in young individuals with haemophilia.

INTRODUCTION: Despite adequate medical treatment, many young adults with haemophilia develop joint alterations-especially in ankles and knees. Undetected over years, subtle structural changes cause subclinical symptoms, before problems become obvious. To objectify these silent pressure pains, the pressure pain threshold (PPT) can be measured by algometry. AIM: The aim was to investigate and compare the effect of age on PPTs in asymptomatic ankles and knees between boys and young adults with haemophilia and age-matched controls, in order to gain better knowledge about the alteration of the periarticular structures with increasing age. MATERIAL AND METHODS: Nineteen persons with haemophilia (PwH; severe or moderate; 8-30 years) and 19 age-matched controls with 'healthy' ankles and knees were recruited. Asymptomatic joints with a Haemophilia Joint Health Score = 0 were included. The PPT was measured on four periarticular points per joint, and the data were analysed with a linear mixed model. RESULTS: The PPT of the control group increased with age, whereas the PPT of the PwH decreased. The difference in age effect per year in kPa between PwH and controls was as follows: ß [95%-CI]: -15.41 [-31.63; 0.79]. Although the result was not statistically significant (p = .08), a clear tendency was shown. CONCLUSION: The results suggest that subclinical alterations in the periarticular structures of these joints may evolve unnoticed over time. However, further research is warranted to determine whether this observed trend is confirmed in a larger sample and at what age the PPT begins to decrease in PwH compared to controls.

Does the Conservative Non-pharmacological Management of Knee Osteoarthritis in Switzerland Reflect the Clinical Guidelines? A Survey Among General Practitioners, Rheumatologists, and Orthopaedic Surgeons.

Introduction: The International Guidelines recommend exercise, education and weight management (if appropriate) as the first-line conservative treatment for patients with knee osteoarthritis (OA) to enhance their self-management. The aim of this study was to investigate the current state of conservative non-pharmacological management of patients with knee OA in Switzerland and to explore the perceived barriers and facilitators to the application of the guideline recommendations. Materials and methods: Eleven semi-structured interviews with selected general practitioners (GPs), rheumatologists and orthopaedic surgeons were performed. Based on these results, an online survey was developed and sent to the members of three scientific medical societies. Questions addressed the frequency of diagnostic measures, treatment options, reasons for referral to exercise and also barriers and facilitators. Results: A total of 234 members responded. They indicated that patients normally present due to pain (n = 222, 98.2%) and functional limitations of the knee (n = 151, 66.8%). In addition to clinical assessment, X-ray (n = 214, 95.5%) and MRI (n = 70, 31.3%) were the most frequently used diagnostic measures. Treatment options usually involved patient education for diagnosis (n = 223, 98.6%) and suitable activities (n = 217, 96%), pharmacological treatment (n = 203, 89.8%) and referral to physiotherapy (n = 188, 83.2%). The participants estimated that they had referred 54% of their patients with knee OA for a specific exercise. The referral to exercise was driven by "patient expectation/high level of suffering" (n = 73, 37.1%) and their "own clinical experience" (n = 49, 24.9%). The specialists rated the most important barriers to referral to exercise as "disinterest of patient" (n = 88, 46.3%) and "physically active patient" (n = 59, 31.1%). As the most important facilitators, they rated "importance to mention exercise despite the short time of consultation" (n = 170, 89.4%) and "insufficiently physically active patient" (n = 165, 86.9%). Discussion: A substantial evidence-performance gap in the management of patients with knee OA appears to exist in Switzerland. For the systematic referral to exercise as the first-line intervention, it might be useful for medical doctors to suggest a structured exercise programme to patients with knee OA, rather than just advising general exercise.

Validation of the 7-item knee replacement patient education questionnaire (KR-PEQ-7), based on the 16-item knee osteoarthritis patient education questionnaire (KOPEQ).

BACKGROUND: The aim of this study was to investigate the content validity including item reduction, construct validity and internal consistency of the existing 16-item Knee Osteoarthritis Patient Education Questionnaire. Former research had indicated that a reduction of items was necessary. Participants were patients with severe knee osteoarthritis who, prior to undergoing a knee replacement operation, participated routinely in a preoperative educational intervention. METHODS: A mixed method design was used. The first step was directed at the reduction in the number of items on the 16-item Knee Osteoarthritis Patient Education Questionnaire. Based on a priori hypotheses, this was followed by a cross-sectional validation study, performed to compare the resulting 7-item Knee Replacement Patient Education Questionnaire to a patient-testing Interview Protocol that was tailored to the same patient educational material. Additionally, the revised questionnaire was correlated with both the Short Test of Functional Health Literacy and the Mini-Mental State Examination score. RESULTS: A relatively high internal consistency was found for the 7-item Knee Replacement Patient Education Questionnaire, with a Cronbach's alpha of 0.84 (SE: 0.036). Explanatory factor analysis showed no evidence against a one-factor model, with the first and second eigenvalues being 3.8 and 0.31, respectively. Bayesian Estimation of the correlation between the 7-item Knee Replacement Patient Education Questionnaire and the Interview Protocol was 0.78 (mode) (95% HPD 0.58-0.89). CONCLUSIONS: The 7-item Knee Replacement Patient Education Questionnaire shows good psychometric properties and could provide valuable support to health professionals. It can provide valid feedback on how patients waiting for a knee replacement operation experience an applied patient education intervention. Further investigation is needed to assess the applicability of the 7-item Knee Replacement Patient Education Questionnaire to larger samples in different hospitals and countries.

Construct validity of change scores of the Chair Stand Test versus Timed Up and Go Test, KOOS questionnaire and the isometric muscle strength test in patients with severe knee osteoarthritis undergoing total knee replacement.

INTRODUCTION: The Chair Stand Test (CST) is a frequently used performance-based test in clinical studies involving individuals with knee osteoarthritis and demonstrates good reliability. AIM: To assess the construct validity of change scores of the CST compared to three other measures in patients before and after total knee replacement surgery. METHODS: The construct validity of change scores of the CST compared to the Timed Up and Go (TUG) test, the Knee Injury and Osteoarthritis Outcome Score questionnaire (KOOS, subscale ADL) and the isometric muscle strength test of the knee extensors (IMS sum) was measured 1-2 week before and 3 months after surgery. RESULTS: Change (%) CST = -4.45, TUG = -2.08, KOOS ADL = 43.90, IMS sum = -13.24. Correlations CST-TUG = 0.56 (95% confidence interval (CI) 0.29, 0.74), CST-KOOS = -0.31 (95% CI -0.57, 0.01), CST-IMS sum = -0.11 (95% CI -0.42, 0.22). Comparison of pairwise correlations: CST-KOOS versus CST-TUG (p < 0.0004), CST-TUG versus CST-IMS sum (p < 0.0068), CST-KOOS versus CST-IMS sum (p < 0.3100). CONCLUSION: For patients undergoing TKR, the CST might not be an ideal measure to assess change between pre-surgery and 3 months post-surgery. Construct validity of change scores was close to zero but the result might have been influenced by the relatively small homogeneous sample size and the chosen timespan of measurement. We ordered pairwise correlations based on the strength of correlation between the different instruments, which to our knowledge has never been done before.

Development of the knee osteoarthritis patient education questionnaire: a new measure for evaluating preoperative patient education programmes for patients undergoing total knee replacement.

OBJECTIVE: The aim of this study was to develop a generic instrument for the use of patients, named the Knee Osteoarthrtis Patient Education Questionnaire (KOPEQ), to assess the validity of a preoperative educational intervention and to make a preliminary test of its psychometric properties. METHODS: A patient-reported outcome instrument was designed, using the conceptual framework of Wilson and Cleary as a methodological guide. Likert items with a five-point scale were chosen for the scoring option. The feasibility and interpretability of administering the KOPEQ was tested through conducting interviews with targeted patients. Items of the KOPEQ were linked to the International Classification of Functioning, Disability and Health (ICF). Psychometric testing contained internal consistency for reliability, and factor analysis for validity properties. RESULTS: A final list of 16 items was derived and linked to the ICF. Targeted patients confirmed in interviews, that all 16 questions were highly understandable and that the length of the questionnaire was feasible and acceptable. There was a good internal consistency for the 16-item KOPEQ with a Cronbach's alpha of 0.83 (95% confidence interval 0.71-0.94). Sixty-one percent of the variance was explained by a four-factor model and the factors were named "didactics", "addressability", "empowerment" and "theory". Results of a factor analysis provided a loading of the separate items between 0.469 and 0.958. CONCLUSIONS: The KOPEQ can help to provide health professionals with reliable feedback on how patients assessed the applied patient education intervention. Interviews with patients and a factor analysis revealed new and important insight.

Effect of preoperative neuromuscular training (NEMEX-TJR) on functional outcome after total knee replacement: an assessor-blinded randomized controlled trial.

BACKGROUND: Improving functional status preoperatively through exercise may improve postoperative outcome. Previous knowledge on preoperative exercise in knee osteoarthritis is insufficient. The aim of the study was to compare the difference in change between groups in lower extremity function from baseline to 3 months after Total Knee Replacement (TKR) following a neuromuscular exercise programme (NEMEX-TJR) plus a knee school educational package (KS) or KS alone. METHODS: 45 patients (55-83 years, 53% male, waiting for TKR) were randomized to receive a minimum of 8 sessions of NEMEXTJR plus 3 sessions of KS or 3 sessions of KS alone. Function was assessed with the Chair Stand Test (CST, primary endpoint) and the Knee Injury and Osteoarthritis Outcome Score (KOOS) subscales focusing on daily living function (ADL) and pain (secondary endpoints). Assessments were performed immediately before and after the intervention, and at 6 weeks, 3 months and 12 months after surgery by a physiotherapist, blinded to group allocation. RESULTS: After intervention before surgery we observed a small improvement for primary and secondary endpoints in both groups, which did not differ significantly between groups: comparing the exercise to the control group the treatment effect for the CST was -1.5 seconds (95% CI: -5.3, 2.2), for KOOS ADL and KOOS pain the treatment effect was 1.3 points (-10.1, 12.8) and -2.3 (-12.4, 7.9) respectively. At 3 months after surgery we observed a small improvement in the primary endpoint in the control group and a significant improvement in the secondary endpoints in both exercise and control groups, which did not differ significantly between groups: comparing the exercise group to the control group the treatment effect in the CST was 2.0 seconds (-1.8, 5.8), for KOOS ADL and KOOS pain the treatment effect was -4.9 points (-16.3, 6.5) and -3.3 points (-13.5, 6.8) respectively. CONCLUSIONS: A median (IQR) of 10 (8, 14) exercise sessions before surgery showed an additional small but non-significant improvement in all functional assessments compared to patient education alone. These benefits were not sustained after TKR. Our trial doesn't give a conclusive answer to whether additional preoperative exercise on postoperative functional outcomes is beneficial.

Effect of pre-operative neuromuscular training on functional outcome after total knee replacement: a randomized-controlled trial.

BACKGROUND: Total Knee Replacement (TKR) is the standard treatment for patients with severe knee osteoarthritis (OA). Significant improvement in pain and function are seen after TKR and approximately 80% of patients are very satisfied with the outcome. Functional status prior to TKR is a major predictor of outcome after the intervention. Thus, improving functional status prior to surgery through exercise may improve after surgery outcome. However, results from several previous trials testing the concept have been inconclusive after surgery. METHODS/DESIGN: In a randomized controlled trial (RCT) we will test the effect of a pre-operative neuromuscular training program versus an attention control program on lower extremity function - before and after surgery. We will enroll 80 participants, aged between 55-90 years, who are scheduled for TKR. In this single-blinded RCT, the intervention group will receive a minimum of 8 and a maximum of 24 training sessions plus 3 educational sessions of the knee school. The control group will receive the 3 educational sessions only. Assessments are performed immediately before and after the intervention (before surgery), at 6 weeks, 3 months and 12 months (after surgery). The primary outcome will include the Chair Stand Test as a measure of leg strength and reaction time. Secondary outcomes are knee function and pain assessed with the self-reported Knee Injury and Osteoarthritis Outcome Score (KOOS). All measurements will be carried out by a specially trained physical therapist, blinded to group allocation. DISCUSSION: To our knowledge this is the first single-blinded RCT to test the effect of pre-operative neuromuscular training plus knee school against knee school alone--on knee function and pain, assessed immediately after the interventions prior to surgery and repeatedly after surgery. TRIAL REGISTRATION: Clinical Trials NCT00913575.

Psychosocial factors associated with the effects of physiotherapy in the acute hospital.

PURPOSE: To examine the associations between psychosocial factors and physical functioning at admission, and functional recovery during an acute hospital admission. METHOD: Included into this multi-centre cohort study were 642 patients with cardiopulmonary, musculoskeletal and neurological conditions recruited from 32 Swiss hospitals. Functional status was measured at admission and discharge using the Barthel Index (BI); BI change was used as an indicator for functional recovery. Sense of coherence (SOC) and depression were assessed at admission using the SOC questionnaire and the Hospital Anxiety and Depression Scale (HADS); patient motivation was judged at discharge by physiotherapists on a Visual Analogue Scale. Mixed effect regression was used to assess associations of SOC, depression and motivation with functional status at admission and functional recovery. Distinct models were built to control for sets of behavioural, socio-economic and disease-related variables. RESULTS: Functional status at admission was significantly associated with SOC, depression and motivation. Functional recovery was significantly associated with motivation, but not with SOC. Significant associations between functional recovery and depression were found in some of the models. CONCLUSIONS: As motivation showed strong associations with functional recovery, future studies should examine how functional recovery is influenced by motivation and how motivation can be improved.

Assessment of functioning in the acute hospital: operationalisation and reliability testing of ICF categories relevant for physical therapists interventions.

OBJECTIVE: To operationalize items based on categories of the International Classification of Functioning, Disability and Health (ICF) relevant to patient problems that are addressed by physiotherapeutic interventions in the acute hospital, and to test the reliability of these items when applied by physiotherapists. METHODS: A selection of 124 ICF categories was operation-alized in a formal decision-making and consensus process. The reliability of the newly operationalized item list was tested with a cross-sectional study with repeated measurements. RESULTS: The item writing process resulted in 94 dichotomous and 30 polytomous items. Data were collected in a convenience sample of 28 patients with neurological, musculoske-letal, cardiopulmonary, or internal organ conditions, requiring physical therapy in an acute hospital. Fifty-six percent of the polytomous and 68% of the dichotomous items had a raw agreement of 0.7 or above, whereas 36% of all polytomous and 34% of all dichotomous items had a kappa coefficient of 0.7 and above. CONCLUSION: The study supports that the ICF is adaptable to professional and setting-specific needs of physiotherapists. Further research towards the development of reliable instruments for physiotherapists based on the ICF seems justified. :

The ICF as a way to specify goals and to assess the outcome of physiotherapeutic interventions in the acute hospital.

OBJECTIVE: The aim of this study was to demonstrate the use of the International Classification of Functioning, Disability and Health (ICF) to measure the effect of physiotherapy treatment. DESIGN: A prospective cohort study with an additional case report. PATIENTS: Individuals were eligible for the study if they were patients at the University Hospital of Zurich and had received physiotherapeutic interventions during their inpatient stay. METHODS: Patient's functioning was assessed by physiotherapists at initiation of physiotherapeutic treatment and at discharge using ICF Core Sets. RESULTS: A total of 425 patients were analysed, mean age 60 years, 42% female. The median of treatment days varied between 4 (intensive care unit) and 19 (low back pain). The majority of patients had improved or stable results; improvement was most prominent in the surgical and internal medicine group. The ICF category d450 "Walking" appears in 4 out of 6 ICF Core Sets, being only infrequently treated in intensive care unit and low back pain CONCLUSION: Analysis showed that the ICF can be used to record precise information on patients' functioning in the acute hospital. Typical impairments and restrictions, intervention goals and trajectories of functioning could be documented. The qualifiers used in our clinical example were sensitive to change. Definitions of qualifiers, however, should be the subject of further research.

Intervention goals determine physical therapists' workload in the acute care setting.

BACKGROUND: Investigating determinants of physical therapy workload in the acute care setting is essential for planning interventions, for justifying resource allocation, and for reimbursement. OBJECTIVE: The objective of this study was to examine whether International Classification of Functioning, Disability and Health (ICF) intervention goals (ICF categories representing goals of physical therapy interventions typical for an acute care hospital) could predict physical therapy workload in the acute care hospital setting. DESIGN: This investigation was a multicenter, observational cohort study. METHODS: Patients were recruited from a representative sample of 32 acute care hospitals across Switzerland if they received physical therapy during their inpatient stay for the treatment of any injury or disease in 1 of 3 main diagnostic categories: musculoskeletal, neurological, and cardiopulmonary conditions. Physical therapists completed questionnaires at the time of the patients' discharge to report on ICF intervention goals. Information on workload was collected retrospectively from hospital documentation systems. Multivariable regression models were used to identify the intervention goals independently associated with workload. RESULTS: The mean workload for 642 patients (mean age=61 years [SD=18 years], 45% women) was 370 minutes. The daily workload for interventions ranged from 33 minutes (cardiopulmonary conditions) to 49 minutes (neurological conditions). There were significant variations in workload across hospital sites and medical disciplines. The goal "maintaining a body position" emerged as a significant indicator of a higher workload for all condition groups; the goals "attention functions" and "transferring oneself" were indicators for neurological and musculoskeletal conditions, respectively. LIMITATIONS: Not all potential predictors of workload could be examined. Other, person- or setting-specific variables might have been relevant to workload. Case mix and clinical practice were representative only for Swiss hospitals. CONCLUSIONS: A small set of intervention goals were the major factors influencing physical therapy workload, independent of diagnosis or clinical specialty. Describing variability in physical therapists' practices in the acute care setting and relating these data to relevant patient-centered outcomes are the initial steps for improving resource allocation and reimbursement for interventions that maintain or improve functioning.

Identification of intervention categories for physical therapy, based on the international classification of functioning, disability and health: a Delphi exercise.

BACKGROUND AND PURPOSE: Disability or limitations in human functioning are universal experiences that concern all people. Physical therapists aim to improve functioning and prevent disability. With the approval of the new International Classification of Functioning, Disability and Health (ICF), we can now rely on a globally recognized framework and classification to be used in different health care situations by all health care professionals in multidisciplinary teams. The objective of this study was to identify ICF categories that describe the most relevant and common patient problems managed by physical therapists in acute, rehabilitation, and community health care situations taking into account 3 major groups of health conditions: musculoskeletal, neurological, and internal. SUBJECTS: The subjects were physical therapists who were identified as possible participants by the heads of physical therapy departments who were members of the Swiss Association of Physical Therapy Department Heads or who were recruited from the membership of the Swiss Association of Physiotherapy. METHODS: A consensus-building, 3-round, electronic-mail survey with 9 groups of physical therapists was conducted using the Delphi technique. RESULTS: Two hundred sixty-three physical therapists participated in at least one round of the Delphi exercise. They had consensus levels of 80% or higher for categories in all ICF components (Body Functions, Body Structures, Activities and Participation, and Environmental Factors 1 and 2). DISCUSSION AND CONCLUSION: This study is a first step toward identifying a list of intervention categories relevant for physical therapy according to the ICF. The ICF, designed as a common language for multidisciplinary use, is also a very helpful framework for defining the core competence for the physical therapy profession.