Is multimodal occupational therapy in addition to usual care cost-effective in people with thumb carpometacarpal osteoarthritis? A cost-utility analysis of a randomised controlled trial.

OBJECTIVE: The aim was to evaluate the cost-utility of a 3-month multimodal occupational therapy intervention in addition to usual care in patients with thumb carpometacarpal osteoarthritis (CMC1 OA). METHODS: A cost-utility analysis was performed alongside a multicentre randomised controlled trial including three rheumatology departments in Norway. A total of 180 patients referred to surgical consultation due to CMC1 OA were randomised to either multimodal occupational therapy including patient education, hand exercises, assistive devices and orthoses (n=90), or usual care receiving only information on OA (n=90). The outcome measure was quality-adjusted life-years (QALYs) derived from the generic questionnaire EQ-5D-5L over a 2-year period. Resource use and health-related quality of life of the patients were prospectively collected at baseline, 4, 18 and 24 months. Costs were estimated by taking a healthcare and societal perspective. The results were expressed as incremental cost-effectiveness ratios, and a probabilistic sensitivity analysis with 1000 replications following intention-to-treat principle was done to account for uncertainty in the analysis. RESULTS: During the 2-year follow-up period, patients receiving multimodal occupational therapy gained 0.06 more QALYs than patients receiving usual care. The mean (SD) direct costs were €3227 (3546) in the intervention group and €4378 (5487) in the usual care group, mean difference €-1151 (95% CI -2564, 262). The intervention was the dominant treatment with a probability of 94.5% being cost-effective given the willingness-to-pay threshold of €27 500. CONCLUSIONS: The within-trial analysis demonstrated that the multimodal occupational therapy in addition to usual care was cost-effective at 2 years in patients with CMC1 OA. TRIAL REGISTRATION NUMBER: NCT01794754.

Patient Goals and Motivation for Thumb Carpometacarpal Osteoarthritis Surgery.

BACKGROUND: Knowledge is lacking on patient goals and motivation for carpometacarpal joint osteoarthritis (CMCJ OA) surgery. The objective of this study was to explore patient goals and motivation for surgery, whether patient goals were reflected in self-reports of pain and function, and factors characterizing patients highly motivated for surgery. METHODS: This cross-sectional study included 180 patients referred from their general practitioner for CMCJ surgical consultation. Goals for surgery were collected with an open-ended question, categorized with the International Classification of Functioning, Disability and Health coding system, and compared to self-reports of pain and function. Motivation for surgery was rated with a Numeric Rating Scale (NRS, 0-10, 0 = not motivated). Factors characterizing patients highly motivated for surgery (NRS ≥ 8) were explored with multivariate regression analyses. RESULTS: The mean age of the participants was 63 years (SD = 7.6), and 142 (79%) were women. The most common goals for surgery were to reduce pain and improve arm and hand use, but these were not reflected in self-reports of pain and function. Fifty-six (31%) of the patients were characterized as highly motivated for surgery. High motivation for surgery was strongly associated with reporting more activity limitations (odds ratio [OR] = 4.00, P = .008), living alone (OR = 3.18, P = .007), and a young age (OR = 0.94, P = .002). CONCLUSIONS: Decisions on CMCJ OA surgery should be based on assessment and discussion of patients' life situation, hand pain, activity limitations for, and goals and motivation for surgery. According to the european league against rheumatism (EULAR) recommendations, previously received conservative and pharmacological treatment should also be evaluated.

The Measure of Activity Performance of the hand (MAP-Hand) - A reliable and valid questionnaire for use in patients with hand osteoarthritis with specific involvement of the thumb.

STUDY DESIGN: Cross-sectional methodological study with test-retest design. INTRODUCTION: The Measure of Activity Performance of the Hand (MAP-Hand) is an assessment tool measuring hand-related activity limitations. PURPOSE: To assess reliability, validity, and interpretability of the MAP-Hand in patients with hand osteoarthritis with specific involvement of the thumb (CMC1). METHODS: One hundred-and-eighty patients referred to surgical consultation for hand osteoarthritis affecting the CMC1 were included in the evaluation of validity and interpretability. Among these, 59 stable patients were included in reliability analyses, completing the questionnaire twice with a 2-week retest interval. The MAP-Hand has 18 predefined and 5 optional patient-specific items, scored on a 4-point scale (1 = no difficulty to 4 = not able to do). Relative (ICC2.1) and absolute (SDC95%ind) reliability were calculated. An ICC of >0.70 was considered acceptable. Nine (75%) or more of 12 predetermined hypotheses had to be confirmed for acceptable construct validity. Interpretability was assessed using floor and ceiling effects and considered present if 15% scored at eitherend of the scale. RESULTS: Mean (SD) age was 63 (8) years, and most patients were women (79%). The mean total score of predefined items showed acceptable reliability (ICC2.1 0.74, SDC95%ind 0.60) and construct validity. The mean total score of the patient-specific items did not reach acceptable reliability. Ceiling effect was found for the predefined items. DISCUSSION AND CONCLUSIONS: We found that the mean total score of the predefined items on MAP-Hand had acceptable reliability and construct validity but a ceiling effect in patients with hand osteoarthritis with CMC1 affection.

Short-Term Effects of Occupational Therapy on Hand Function and Pain in Patients With Carpometacarpal Osteoarthritis: Secondary Analyses From a Randomized Controlled Trial.

OBJECTIVE: To assess the short-term effects of multimodal occupational therapy on pain and hand function in patients referred for surgical consultation due to first carpometacarpal (CMC1) joint osteoarthritis (OA). METHODS: In this randomized controlled trial, patients with CMC1 joint OA referred for surgical consultation at 3 rheumatology departments were randomized to 3 months multimodal occupational therapy (including patient education, hand exercises, orthoses, and assistive devices) or usual treatment (OA information). Pain was measured on a numeric rating scale from 0 to 10 (0 = no pain). Function included grip and pinch strength (Newtons), range-of-motion (palmar and CMC1 joint abduction [°]; flexion deficit in digits 2-5 [mm]), and self-reported Measure of Activity Performance of the Hand (MAP-Hand; range 1-4, 1 = no activity limitation) and short version of the Disability of the Arm, Shoulder, and Hand (QuickDASH; range 0-100, 0 = no disability). Between-group difference was assessed with follow-up values as dependent variables and group as an independent variable, adjusted for baseline values and time to follow-up. RESULTS: Among 180 patients (mean ± SD age 63 ± 8 years; 81% women), 170 completed the short-term follow-up assessment (3-4 months after baseline). Compared to usual treatment, occupational therapy yielded significantly improved pain at rest (-1.4 [95% confidence interval (95% CI) -0.7, -2.0]; P < 0.001), pain following grip strength (-1.1 [-0.5, -1.7]; P = 0.001), grip strength (23.4 [95% CI 7.5, 39.3]; P = 0.004), MAP-Hand score (-0.18 [95% CI -0.09, -0.28]; P = 0.001), and QuickDASH score (-8.1 [95% CI -4.6, -11.5]; P < 0.001). CONCLUSION: The multimodal occupational therapy intervention had significant short-term effects on pain, grip strength, and hand function in patients with CMC1 joint OA.

The MAP-Hand: Psychometric properties and differences in activity performance between patients with carpometacarpal osteoarthritis and rheumatoid arthritis.

OBJECTIVE: To assess construct validity (Rasch analyses) of the Measure of Activity Performance of the Hand (MAP-Hand) in people with carpometacarpal osteoarthritis (CMC1 OA), and to explore differences in activity performance between people with CMC1 OA and those with rheumatoid arthritis. DESIGN: Cross-sectional study. SUBJECTS: A total of 180 people with CMC1 OA referred for surgical consultation were recruited from rheumatology clinics in Norway, and 340 people with rheumatoid arthritis were recruited from outpatient rheumatology clinics in the UK. METHODS: The MAP-Hand consists of 18 predefined items scored on a 4-point scale from 1 (no difficulty) to 4 (unable to do), from which a mean score is calculated. Construct validity was assessed using Rasch analyses. Differences between the 2 groups were assessed using an independent sample t-test at the group level and differential item functioning (condition as grouping variable) at the item level. RESULTS: Some mis-targeting of data and clusters of dependency were found, but the MAP-Hand scores showed an overall fit to the model. No between-group difference in total mean MAP-Hand score was found, but there were significant differences between the 2 groups on item levels. CONCLUSION: The MAP-Hand showed satisfactory construct validity and could differentiate between people with CMC1 OA and those with rheumatoid arthritis on item levels.

Does occupational therapy delay or reduce the proportion of patients that receives thumb carpometacarpal joint surgery? A multicentre randomised controlled trial.

Objectives: To evaluate whether occupational therapy, provided in the period between referral and surgical consultation, might delay or reduce the need of surgery in thumb carpometacarpal joint (CMCJ) osteoarthritis and to explore predictors for CMCJ surgery. Methods: This multicentre randomised controlled trial included patients referred for surgical consultation due to CMCJ osteoarthritis. An occupational therapy group received hand osteoarthritis education, assistive devices, CMCJ orthoses and exercises. A control group received only hand osteoarthritis information. Primary outcome was the proportion of patients that had received CMCJ surgery after 2 years. We examined the primary outcome and predictors for surgery with regression models, and time to surgery with the log-rank test and cox regression analyses. Results: Of 221 patients screened for eligibility, 180 were randomised. Information on the primary outcome was collected from medical records for all included patients. Surgery was performed on 22 patients (24%) that had received occupational therapy and 29 (32%) control patients (OR 0.56, 95% CI 0.26 to 1.21; p=0.14). Median time to surgery was 350 days (IQR 210-540) in the occupational therapy group and 296 days (IQR 188-428) in the control group (p=0.13). Previous non-pharmacological treatment (OR 2.72, 95% CI 1.14 to 6.50) and higher motivation for surgery (OR 1.25, 95% CI 1.09 to 1.43) were significant predictors for CMCJ surgery. Conclusions: Occupational therapy showed a small non-significant tendency to delay and reduce the need for surgery in CMCJ osteoarthritis. Previous non-pharmacological treatment and higher motivation for surgery were significant predictors for surgery.

Non-pharmacological treatment gap preceding surgical consultation in thumb carpometacarpal osteoarthritis - a cross-sectional study.

BACKGROUND: Osteoarthritis (OA) in the thumb carpometacarpal joint (CMCJ) is a prevalent disease which may lead to structural damage, severe pain and functional limitations. Evidence-based treatment recommendations state that all patients with hand OA should be offered non-pharmacological treatment. Surgery should be considered only when other treatment has proven insufficient in relieving pain. The purpose of this study was to investigate prior treatment and characteristics of patients referred to specialist health care surgical consultation due to CMCJ OA. The study includes exploring differences in pain and function between referred and non-referred hand, between men and women, and between patients with and without OA affection of other finger joints than CMCJ. METHODS: Patients in this cross-sectional study reported prior non-pharmacological treatment for CMCJ OA. Patient demographics, disease and functional variables were assessed based on hand radiographs, patient-reported and observer-based outcome measures. Differences in pain and function between referred and non-referred hand, men and women, and between patients with and without additional affection of finger joints other than CMCJ, were analysed using Paired-samples T-tests, Wilcoxon Signed Rank, or Chi-Square tests. RESULTS: One hundred and eighty patients were included. The mean age was 63 years and 79% were women. Only 21% reported having received non-pharmacological treatment before referral to surgical consultation. The results show a statistically significant worse function for referred hands, women and involvement of additional interphalangeal joints. Most patients reported no pain or mild pain in their referred hand. CONCLUSIONS: The results of this study show a non-pharmacological treatment gap in OA care. Most patients report no pain or mild pain, and that they had not received non-pharmacological treatment prior to being referred to CMCJ OA surgical consultation. The results furthermore show that CMCJ OA negatively affects all aspects of function. Strategies need to be developed to improve OA care, including educating general practitioners in evidence-based treatment recommendations and in the assessment of hand pain, and encourage the routine referral of patients with symptomatic hand OA to occupational therapy before considering surgery.

Occupational problems and barriers reported by individuals with obesity.

BACKGROUND: Even if occupational therapists meet many people with obesity in the course of their work, a majority of them do not seem to view weight management as within their area of professional practice. AIM: To explore the occupational problems and barriers among persons with severe obesity from an occupational therapy perspective. MATERIALS AND METHODS: The study used the Canadian Model of Occupation and Engagement (CMOP-E) and Canadian Occupational Performance Measure (COPM) to identify and analyze prioritized occupational performance problems and barriers perceived by 63 individuals with obesity. RESULTS: The occupational problems individuals with obesity most frequently prioritized comprised playing with (grand)children, purchasing clothes, implementing regular meals and going to the swimming pool, while the barriers they most frequently described were dyspnea, musculoskeletal disorders, narrow chairs and seats, fear of glances and comments from others, and social anxiety. CONCLUSION: Persons with obesity struggle with a large variety of occupational performance problems, which occur in the dynamic relationship between these individuals, their environment and their occupation. Occupational therapists have the skills to take more active role in helping persons with obesity to perform valued occupations and establish healthier everyday routines.

Does occupational therapy reduce the need for surgery in carpometacarpal osteoarthritis? Protocol for a randomized controlled trial.

BACKGROUND: In the absence of disease-modifying interventions for hand osteoarthritis (OA), occupational therapy (OT) comprising patient education, hand exercises, assistive devices and orthoses are considered as core treatments, whereas surgery are recommended for those with severe carpometacarpal (CMC1) OA. However, even though CMC1 surgery may reduce pain and improve function, the risk of adverse effects is high, and randomized controlled trials comparing surgery with non-surgical interventions are warranted. This multicentre randomized controlled trial aims to address the following questions: Does OT in the period before surgical consultation reduce the need for surgery in CMC1-OA? What are patients' motivation and reasons for wanting CMC1-surgery? Are there differences between departments of rheumatology concerning the degree of CMC1-OA, pain and functional limitations in patients who are referred for surgical consultation for CMC1 surgery? Is the Measure of Activity Performance of the Hand a reliable measure in patients with CMC1-OA? Do patients with CMC1-OA with and without affection of the distal and proximal interphalangeal finger joints differ with regard to symptoms and function? Do the degree of CMC1-OA, symptoms and functional limitations significantly predict improvement after 2 years following OT or CMC1-surgery? Is OT more cost-effective than surgery in the management of CMC1-OA? METHODS/DESIGN: All persons referred for surgical consultation due to their CMC1-OA at one of three Norwegian departments of rheumatology are invited to participate. Those who agree attend a clinical assessment and report their symptoms, function and motivation for surgery in validated outcome measures, before they are randomly selected to receive OT in the period before surgical consultation (estimated n = 180). The primary outcome will be the number of participants in each group who have received surgical treatment after 2 years. Secondary and tertiary outcomes are pain, function and satisfaction with care over the 2-year trial period. Outcomes will be collected at baseline, 4, 18 and 24 months. The main analysis will be on an intention-to-treat basis, using logistic regression, comparing the number of participants in each group who have received surgical treatment after 2 years. DISCUSSION: The findings will improve the evidence-based management of HOA. TRIAL REGISTRATION IDENTIFIER: NCT01794754 . First registrated February 15th 2013.

Patient education--which parts of the content predict impact on coping skills?

AIMS: Studies investigating the effect of patient education usually evaluate whole educational programmes. The aim of this study was to describe the content of several locally developed educational programmes and investigate which parts predicted improved coping skills in the participants. METHOD: A prospective observational study investigating the content of several educational programmes and the participants' coping skills 4 months afterwards. RESULTS: The content of 35 different educational programmes was described. The programmes lasted on average 12 hours. The main focus was increased knowledge about the disease and improved coping skills. Programmes developed locally and tailored to the specific participant group in collaboration between services users and health professionals led to improved coping skills. The participants' level of activity was the strongest predictor for improved coping skills (adjOR = 4.1 (95% CI 1.5-11.2) p = 0.007). CONCLUSIONS: The group process during patient education might be more important for improving coping skills than the content of the programme. Future patient education programmes should focus on group processes and improving participants' activity.

Self-management strategies to support performance of daily activities in hand osteoarthritis.

AIMS: The main aim of this study was to explore self-management strategies in persons with hand osteoarthritis (HOA). METHODS: Self-management strategies were explored in semi-structured interviews, in which 125 participants described strategies, use of devices or equipment, and advice they would give to people with HOA concerning how to manage their daily life. RESULTS: The participants made a total of 483 statements, which were classified into 27 discrete strategies, and thereafter grouped into 13 broader strategies within three categories: general behavioural strategies, HOA-specific behavioural strategies, and cognitive strategies. The broad strategy "activity accommodations" specifically addressed performance of daily activities in people with HOA, comprising "use assistive devices", "adapt tools, materials or working techniques", "practise activity pacing" and "stop or avoid certain activities", of which the two first were the most frequently stated by participants. CONCLUSIONS: People with HOA use a wide variety of self-management strategies to support performance of daily activities, in which use of assistive devices and activity adaptation are the most frequently reported strategies. Patient-recommended self-management strategies should be included in written information material and patient education programmes, which should be developed in cooperation with patient representatives and made available for patients soon after they are diagnosed.

Validity and responsiveness of the Measure of Activity Performance of the Hand (MAP-Hand) in patients with hand osteoarthritis.

BACKGROUND: The Measure of Activity Performance of the Hand (MAP-Hand) is reliable and valid in patients with rheumatoid arthritis. OBJECTIVE: To assess the validity and responsiveness of the MAP-Hand in patients with hand osteoarthritis. METHODS: Patients were recruited from 2 rheumatology centres. The internal consistency of the MAP-Hand was assessed by Cronbach's α. Content validity was evaluated based on patient interviews. Construct validity and responsiveness were based on predefined hypotheses of correlation between the MAP-Hand and concurrent measures. RESULTS: Ten men and 201 women, mean age 62.8 years (standard deviation (SD) 6.8) and disease duration 12.5 (SD 7.5) years were included. A Cronbach's α of 0.86 was determined. All 18 items in the MAP-Hand were described in the interviews. Sixty-seven percent of the correlation coefficients for baseline scores and 75% for change scores were in correspondence with the predefined hypotheses. A high correlation was found between the MAP-Hand and the Australian/Canadian Hand Osteoarthritis Index function score at baseline (rho = 0.76). A moderate correlation was found for change scores (rho = 0.52). CONCLUSION: The content of the MAP-Hand adequately reflects described activity limitations in patients with hand osteoarthritis. The results suggest that the MAP-Hand has adequate internal consistency and responsiveness. Before the MAP-Hand is used in patients with hand osteoarthritis, evaluations of reliability and further construct validity are warranted.

Effect of assistive technology in hand osteoarthritis: a randomised controlled trial.

OBJECTIVE: Hand osteoarthritis (HOA) is a common joint disorder with an expected rise in prevalence due to the increasing ageing population, but with few available effective treatment options. The main aim of this study was to evaluate the effect of assistive technology (AT) in patients with HOA. METHODS: In this observer-blinded, randomised controlled trial, 35 patients with HOA (AT group) received provision of information and AT (assistive devices and splints), while 35 patients received information only (control group). Primary outcomes were activity performance and satisfaction with performance, measured by the Canadian occupational performance measure (COPM) on a 1-10 scale. Secondary outcomes included measures of disease activity, pain, fatigue and function. Outcome assessments were made at 3 months follow-up. RESULTS: Of 70 participants randomised, 66 participants completed all assessments. Provision of AT was associated with improvement in the COPM performance score (mean difference (95% CI) in change scores 1.8 (1.1 to 2.6) and in the satisfaction score (1.7 (0.7 to 2.6)), indicating a moderate to large treatment effect (effect sizes 0.9). There was a significant improvement in the Australian/Canadian hand index function score in the AT group after 3 months (-0.4, p<0.001), and an adjusted mean difference between groups of -0.3 (p=0.06, effect size -0.5). No other differences were found in the secondary outcomes. Self-reported AT usage rate in the AT group was 92%, and participants rated their comfort with AT usage as high. CONCLUSIONS: Use of AT is well tolerated and significantly improves activity performance and satisfaction with performance in patients with HOA. The trial is registered in the ISRCTN register (ISRCTN40357804).

Bariatric surgery versus lifestyle interventions for morbid obesity--changes in body weight, risk factors and comorbidities at 1 year.

BACKGROUND: Few studies have looked at non-surgical alternatives for morbid obese patients. This study aims to compare 1-year weight loss and changes in risk factors and comorbidities after bariatric surgery and three conservative treatments. METHODS: Patients with morbid obesity (BMI > 40 or BMI > 35 kg/m(2) plus comorbidities) on waiting list for bariatric surgery, were non-randomly allocated to (A) bariatric surgery or to one of three conservative treatments; (B) residential intermittent program; (C) commercial weight loss camp and (D) hospital outpatient program. Body weight, risk factors and comorbidities were assessed at baseline and 1 year. RESULTS: Of 206 participants, 179 completed the study. All treatments resulted in significant weight loss, but bariatric surgery (40 ± 14 kg, 31 ± 9%) led to the largest weight loss (P < 0.0001). There were no differences in weight loss between B and C (22 ± 13 kg, 15 ± 8% vs. 18 ± 12 kg, 13 ± 8%), but these resulted in larger weight loss compared with D (7 ± 10 kg, 5 ± 8%). There were no differences in changes in total or LDL cholesterol, triacylglycerols or glucose between groups; however, the increase in HDL cholesterol was significantly larger in groups A and C. There were no differences in comorbidities resolution between groups A and B, C and D combined (except hypertension, which was better in group A). CONCLUSION: In conclusion, although bariatric surgery leads to a greater weight loss at 1 year compared with conservative treatment, in patients with morbid obesity, clinical significant weight loss and similar improvements in risk factors and comorbidities resolution can also be achieved with lifestyle interventions.