Acute pain after total hip and knee arthroplasty does not affect chronic pain during the first postoperative year: observational cohort study of 389 patients.

Chronic pain is frequently reported after total hip and knee arthroplasties (THA/TKA) in osteoarthritis (OA) patients. We investigated if severity of acute postoperative pain following THA/TKA in OA patients was associated with pain during the first postoperative year. From an observational study, OA patients scheduled for primary THA/TKA (June 2012-December 2017) were included from two hospitals in the Netherlands. Acute postoperative pain scores were collected within 72 h postoperatively and categorized as no/mild (NRS ≤ 4) or moderate/severe (NRS > 4). Pain was assessed preoperatively, 3, 6 and 12 months postoperatively using the HOOS/KOOS subscale pain. With Multilevel Mixed-effects-analyses, we estimated associations between acute and chronic pain until one year postoperative, adjusted for confounders and including an interaction term (Time*Acute pain). 193 THA and 196 TKA patients were included, 29% of THA and 51% of TKA patients reported moderate/severe pain acutely after surgery. In the THA group, the difference in pain at 3 months between the no/mild and moderate/severe groups, was approximately six points, in favor of the no/mild group (95% CI [-12.4 to 0.9]) this difference became smaller over time. In the TKA group we found similar differences, with approximately four points (95% CI [-9.6 to 1.3]) difference between the no/mild and moderate/severe group at 6 months, this difference attenuated at 12 months. No association between severity of acute postoperative pain and pain during the first postoperative year was found. These findings suggest that measures to limit acute postoperative pain will likely not impact development of chronic pain.

Improvement of physical activity levels in children and adolescents after surgery for congenital heart disease: preferences and use of physical therapy.

PURPOSE: After surgery for congenital heart disease in children and adolescents, an active lifestyle is important to achieve and maintain good physical fitness. This study aimed to describe physical activity, as well as the use of patients' and parents' preferences for rehabilitative care after surgery for congenital heart disease. METHODS: This cross-sectional study included patients aged 4-16 years old, who had undergone surgery for congenital heart disease 2 years prior to the study onset. Patients and/or parents were invited to complete questionnaires on physical activity, and on their preferences for, and -use of, rehabilitative care after surgery. RESULTS: Forty-five of the 92 eligible patients and/or parents completed the questionnaires. The median age of the children was 12.2 years (IQR 7.8-16.1). Two children (4%) met the recommendations for taking part in moderate physical activity and 13 (29%) having done so for vigorous physical activity. Postoperatively 15 children (33%) had had physical therapy in primary care. More than 50% of the patients/parents would have preferred to have had more information on physical activity and to have taken part in an individual exercise program delivered during their primary care. CONCLUSION: The majority of eligible patients do not meet public health recommendations for engaging in physical activity and do not use physical therapy after surgery for congenital heart disease. The majority of patients and parents preferred more information as well as individual physical therapy treatments.Implications for rehabilitationsTwo years after surgery for congenital heart disease children and adolescents are less active compared to typically developing peers.Patients with a congenital heart disease and their parents need more information and support regarding stimulation of physical activity and physical fitness after heart surgery.In the postoperative process, a well-structured and supportive (individual) rehabilitation program should be introduced to improve physical activity and physical fitness.

Referral to and enrolment in cardiac rehabilitation after open-heart surgery in the Netherlands.

AIM: Although referral to phase 2 cardiac rehabilitation (CR) following open-heart surgery is recommended in professional guidelines, according to the literature, participation rates are suboptimal. This study investigates the referral and enrolment rates, as well as determinants for these rates, for phase 2 CR following open-heart surgery via sternotomy. METHODS: A cross-sectional survey study was conducted among patients who underwent open-heart surgery via sternotomy in a university hospital. Data on referral and enrolment rates and possible factors associated with these rates (age, sex, type of surgery, educational level, living status, employment, income, ethnicity) were collected by a questionnaire or from the patient's medical file. Univariate logistic regression analysis (odds ratio) was used to study associations of patient characteristics with referral and enrolment rates. RESULTS: Of the 717 eligible patients, 364 (51%) completed the questionnaire. Their median age was 68 years (interquartile range 61-74) and 82 (23%) were female. Rates for referral to and enrolment in phase 2 CR were 307 (84%) and 315 (87%), respectively. Female sex and older age were independently associated with both non-referral and non-enrolment. Additional factors for non-enrolment were surgery type (coronary artery bypass grafting with valve surgery and miscellaneous types of relatively rare surgery), living alone and below-average income. CONCLUSION: Phase 2 CR referral and enrolment rates for patients following open-heart surgery were well over 80%, suggesting adequate adherence to professional guidelines. During consultation, physicians and specialised nurses should pay more attention to certain patient groups (at risk of non-enrolment females and elderly). In addition, in-depth qualitative research to identify reasons for non-referral and/or non-enrolment is needed.

Patients who underwent total hip or knee arthroplasty are more physically active than the general Dutch population.

Total hip arthroplasty (THA) and total knee arthroplasty (TKA) bring relief of pain and functional disability to patients with end-stage osteoarthritis, and however, the literature on their impact on patients' level of physical activity (PA) is scarce. Cross-sectional study in patients who underwent THA/TKA surgery in the preceding 6-22 months and a random sample of persons aged >40 years from the Dutch general population, participating in a national survey. PA in minutes per week (min/week) and adherence to the Dutch recommendation for PA (NNGB yes/no) were measured by the short questionnaire to assess health-enhancing PA. Multivariable linear (total min/week) and logistic regression analyses (meeting recommendations PA), adjusting for confounders, were performed for THA and TKA separately. In total, 258 THA [62.3% female, aged 69.4 (9.1)] and 221 TKA [65.7% female, aged 69.5 (8.9)] patients and 4373 persons from the Dutch general population [51.4% female, aged 58.9 (11.6)] were included. The presence of THA was associated after adjusting for age, sex, BMI education and musculoskeletal comorbidities, with more total min/week spent on PA (THA 13.8% increase, 95% CI 1.6-27.6%), whilst both TJA groups were associated with adhering to NNGB (THA: OR 1.79, 95% CI 1.26-2.56; TKA: OR 1.73, 95% CI 1.20-2.51). As this study used questionnaires to compare the PA of THA/TKA patients to the general population, some recall and selection bias might have been induced. After surgery, overall, TJA patients are more likely to adhere NNGB than a representative sample of persons >40 years from the Dutch general population.

Healthcare costs and loss of productivity in patients with trapeziometacarpal osteoarthritis.

The objective of this study was to analyse healthcare and productivity costs in patients with trapeziometacarpal osteoarthritis. We included 161 patients who received surgery or steroid injection and calculated their healthcare costs in Euro (€) over 1 year. Patients filled out the Work Productivity and Activity Impairment Questionnaire to assess loss of productivity at baseline, and after 3, and 12 months. In the surgical group, loss of productivity among employed patients first increased and then decreased (50%, 64%, and 25% at 0, 3, and 12 months). Productivity was more stable over time in the injection group (52%, 38%, and 48%). In the surgical group, estimated total annual healthcare and productivity costs were €5770 and €5548, respectively. In the injection group, healthcare and productivity costs were €348 and €3503. These findings highlight the need for assessing productivity costs to get a comprehensive view of the costs associated with a treatment.Level of Evidence III.

The association between comorbidities and pain, physical function and quality of life following hip and knee arthroplasty.

The aim of the study was to examine the relationship between comorbidities and pain, physical function and health-related quality of life (HRQoL) after total hip arthroplasty (THA) and total knee arthroplasty (TKA). A cross-sectional retrospective survey was conducted including 19 specific comorbidities, administered in patients who underwent THA or TKA in the previous 7-22 months in one of 4 hospitals. Outcome measures included pain, physical functioning, and HRQoL. Of the 521 patients (281 THA and 240 TKA) included, 449 (86 %) had ≥1 comorbidities. The most frequently reported comorbidities (>15 %) were severe back pain; neck/shoulder pain; elbow, wrist or hand pain; hypertension; incontinence of urine; hearing impairment; vision impairment; and cancer. Only the prevalence of cancer was significantly different between THA (n = 38; 14 %) and TKA (n = 52; 22 %) (p = 0.01). The associations between a higher number of comorbidities and worse outcomes were stronger in THA than in TKA. In multivariate analyses including all comorbidities with a prevalence of >5 %, in THA dizziness in combination with falling and severe back pain, and in TKA dizziness in combination with falling, vision impairments, and elbow, wrist or hand pain was associated with worse outcomes in most of the analyses. A broad range of specific comorbidities needs to be taken into account with the interpretation of patients' health status after THA and TKA. More research including the ascertainment of comorbidities preoperatively is needed, but it is conceivable that in particular, the presence of dizziness with falling, pain in other joints, and vision impairments should be assessed and treated in order to decrease the chance of an unfavorable outcome.

Mortality in osteoarthritis patients.

OBJECTIVES: To investigate whether all-cause mortality and deaths due to cardiovascular disease are increased in patients who have consulted primary or secondary health care with symptoms and signs of osteoarthritis (OA). METHOD: This study included 383 patients with symptomatic OA at multiple sites from the Genetics ARthrosis and Progression (GARP) study (mean age 60 years, 82% women, 3693 person-years of follow-up) and 459 patients with primary hand, knee, or hip OA from the Osteoarthritis Care Clinic (OCC) study (mean age 61 years, 88% women, 1890 person-years of follow-up). Standardized mortality ratios (SMRs) with 95% confidence intervals (CIs) were calculated for all-cause mortality and causes of deaths in comparison to the general population. Cox proportional hazard ratios (HRs) with 95% CIs were used to associate baseline characteristics with all-cause mortality. RESULTS: In the GARP study, 26 patients died whereas 48 deaths were expected (SMR 0.54, 95% CI 0.37-0.79). The SMR was 0.47 (95% CI 0.29-0.76) in women and 0.73 (95% CI 0.39-1.35) in men. Similar results were found in the OCC study (SMR 0.45, 95% CI 0.25-0.82). Malignancy and cardiovascular disease were the main causes of deaths in GARP. Male sex (HR 3.04, 95% CI 1.38-6.69), increasing age (HR 1.10, 95% CI 1.05-1.16), and self-reported cancer (HR 8.29, 95% CI 3.12-22.03) were associated with increased mortality in GARP. CONCLUSIONS: Patients consulting health care for their OA are not at higher risk of death than the general population. These results suggest that the management of OA patients may not need to focus specifically on the treatment of cardiovascular risk factors and comorbidities.

Outcome measures and their measurement properties for trapeziometacarpal osteoarthritis: a systematic literature review.

The objective was to identify all outcome measures used in studies on trapeziometacarpal osteoarthritis (TMC OA) and evaluate their measurement properties. In a two-step systematic literature review, we first identified studies including TMC OA patients and extracted all outcome measures. They were categorized according to the Outcome Measures in Rheumatology (OMERACT) core set for OA including five dimensions: pain, physical function, global assessment, imaging, and quality of life (QoL). Secondly, we retrieved articles on the measurement properties of the identified outcome measures for TMC OA patients. First, 316 articles including 101 different outcome measures were identified, addressing the OMERACT pain and function domains most frequently but under-representing QoL. Second, 12 articles investigating measurement properties of 12 outcome measures were identified. The methodological quality of these studies was poor to fair, implying that based on the literature no recommendations to use any of the outcome measures can yet be made.

Individual quality of life: adaptive conjoint analysis as an alternative for direct weighting?

In the schedule for the evaluation of individual quality of life (SEIQoL) the weights for five individualized quality of life domains have been derived by judgment analysis and direct weighting (DW). We studied the feasibility and validity of adaptive conjoint analysis (ACA) as an alternative method to derive weights in 27 cancer patients and 20 patients with rheumatoid arthritis. Further, we assessed the convergence between direct weights and weights derived by ACA, and their correlation with global quality-of-life scores. All respondents finished the ACA task, but one in five respondents were upset about the ACA task. Further, the task was vulnerable to judgment 'errors', such as inconsistent answers. The agreement between the two weights was low. Both weighted index scores were strongly correlated to the unweighted index score. The relationships between the index score and scores on a visual analogue scale for global individual quality of life and global quality of life were similar whether or not the index score was calculated with DW weights, with ACA weights, or without using weights. We conclude that, because weights did not improve the correlation between the index score and global quality of life scores, it seems sufficient to use the unweighted index score as a measure for global individual quality of life.

A multidisciplinary hand clinic for patients with rheumatic diseases: a pilot study.

To describe the characteristics, management strategies and outcomes of patients with rheumatic diseases and complex hand function problems referred to a multidisciplinary hand clinic. Assessments (baseline and after three months of follow-up) included sociodemographic and disease characteristics and various hand function measures. The most frequently mentioned impairments and limitations of the 69 patients enrolled in the study pertained to grip, pain, grip strength, and shaking hands. Fifty-six patients received treatment advice, conservative therapy (n=39), surgery (n=12), or a combination of both (n=5). In 38 of 56 patients (68%) the recommended treatment was performed, and 33 completed the follow-up assessment. On average, patients improved, with an increase in grip strength and the Michigan Hand Outcomes Questionnaire scores reached statistical significance. Two-thirds of patients with rheumatic conditions visiting a multidisciplinary hand clinic reportedly followed the treatment advice (recommendations), with an overall trend toward a beneficial effect on hand function. To further determine the added value of a structured, multidisciplinary approach a controlled comparison with other treatment strategies is needed.

The impact of the implementation of a rehabilitation tool on the contents of the communication during multidisciplinary team conferences in rheumatology.

OBJECTIVE: Problems with multidisciplinary team conferences in health care include the exchange of too much (discipline-specific) information. The aim of this study was to investigate the effect of the implementation of a rehabilitation tool on the contents of communication during multidisciplinary team conferences in a rheumatology setting. METHODS: All initial and follow-up team conferences of 25 consecutive patients with rheumatoid arthritis admitted to a day patient care ward were videotaped during a period before (period I) and after (period II) the introduction of a rehabilitation tool. The aims of the rehabilitation tool were to enhance discussions on the co-ordination of care rather than merely exchange of information. This was achieved by providing a framework for the setting and evaluation of common treatment goals and management strategies as well as accompanying electronic and printed records. For every team conference, the duration of time spent on three types of communication was recorded: (1) grounding regarding the patient's health status, (2) the making of practical arrangements by no more than two health professionals, and (3) the co-ordination of common treatment goals or management strategies. Comparisons of the proportions of time spent on the different types of communication between the two periods were done by means of the Mann-Whitney U-test. RESULTS: Apart from the 25 initial team conferences in both periods, 86 and 71 follow-up team conferences were available in periods I and II, respectively. Regarding the initial team conferences, the proportion of time spent on grounding and practical arrangements was significantly smaller in period II than in period I. In addition, the proportion of time spent on common goals or management strategies was significantly greater in period II than in period I. For the follow-up team conferences, the proportion of time spent on practical arrangements was significantly smaller in period II, than in period I. Moreover, the proportions of time spent on the other types of communication did not differ significantly between the two periods. CONCLUSION: The implementation of a rehabilitation tool including a computer application increased the proportion of time spent on the discussion of common treatment goals or management strategies during initial but not during follow-up team conferences in a day patient rheumatology clinic.

A multidisciplinary job retention vocational rehabilitation programme for patients with chronic rheumatic diseases: patients' and occupational physicians' satisfaction.

OBJECTIVE: To investigate patients' and occupational physicians' satisfaction with the quality of a vocational rehabilitation programme for maintaining work ability in chronic rheumatic diseases. METHODS: The vocational rehabilitation programme was developed for patients with rheumatic diseases and consisted of systematic assessment of the problems at work and the development of individual solutions. The programme was run by a multidisciplinary team comprising a rheumatologist, a social worker, a physical and occupational therapist, and a psychologist. Satisfaction ratings were measured using a multidimensional questionnaire involving a rating scale (0-10) and a structured telephone interview. RESULTS: 59 of the 65 patients who participated in the programme (91%) completed the questionnaire. Patients were most satisfied with the interpersonal approach and professional knowledge, and least satisfied with the waiting time for the final report and the practical application of the given advice. Mean satisfaction score was 7.3 (SD 1.0). Twenty eight of the occupational physicians involved were interviewed. They were satisfied with the programme overall; 21 (75%) stated that their role in the vocational rehabilitation process could be defined more clearly, and they would appreciate more contact with the team members, preferably in the early phases. CONCLUSIONS: Patients' and occupational physicians' satisfaction with a multidisciplinary vocational rehabilitation programme was good. Areas for improvement mainly concerned the speed of the process and the communication between team members and occupational physicians.

Communication between Dutch rheumatologists and occupational physicians in the occupational rehabilitation of patients with rheumatic diseases.

BACKGROUND: Rheumatic diseases are a major cause of permanent work disability. In the process of occupational rehabilitation several health professionals may have a role. OBJECTIVE: To assess the quality and quantity of communication and cooperation between Dutch rheumatologists and occupational physicians. METHODS: A postal survey among 187 Dutch rheumatologists. RESULTS: 153/187 rheumatologists (82%) returned the questionnaire. They considered reducing pain and fatigue to be their major responsibility in the process of occupational rehabilitation, followed by improving work participation (68/153 (44%)) and quality of work (55/153 (36%)). Although 112/153 (73%) of the rheumatologists judged the communication and cooperation with occupational physicians as reasonable to good, 119/153 (78%) of them were willing to improve the collaboration. Perceived bottlenecks mentioned were a lack of clarity about the occupational physician's position and activities, and the absence of practice guidelines. The most important prerequisites for improvement were found to be guarantees about the occupational physician's professional independence and more clarity about the competence of the occupational physicians and how they used the information provided. CONCLUSION: Dutch rheumatologists are willing to improve cooperation and communication with occupational physicians. The perceived lack of clarity about their mutual tasks appears to be a major obstacle. Thus the development of a joint education programme and a guideline for occupational rehabilitation in rheumatic diseases may be appropriate first steps towards improvement.