Health equity profile of knee replacement patients in the South African public sector: A descriptive study.

Background: Knee replacement surgery can significantly improve the quality of life of patients with severe knee osteoarthritis. Equitable access to knee replacement surgery is important to ensure that everyone, regardless of their socioeconomic status or geographical location, have fair and timely access. Objectives: The aim of our study was to (1) describe the health equity profile and quality of life of patients awaiting knee replacement at a single academic hospital in South Africa and to (2) describe the association between these health equity factors and the waiting time. Method: A cross-sectional survey and retrospective record review of patients awaiting knee replacement was conducted using the PROGRESS-Plus health equity framework. Chi-square statistics were used to calculate association between health equity factors and the waiting time. Results: Three-hundred and two (N = 302) patients (77% female; mean age 67 years) participated, of whom one in three patients waited 5 years or longer for surgery. Elderly patients (> 70 years) and patients from lower socio-economic background were less likely to have equitable access to surgery. Conclusion: The current screening protocol for knee replacement surgery in the public health care sector does not provide equitable access to surgery. A more holistic screening approach alongside selective surgical prioritisation and rehabilitation could reduce the waiting list and facilitate equitable access to care. Clinical implications: Health equity factors such as socioeconomic status, age, and other patient characteristics such as life roles and employability should be taken into consideration when screening patients for elective knee replacement waiting lists.

Factors affecting quality of life in adults with HIV: A local cross-sectional study.

Background: Understanding health-related quality of life (HRQOL) among people with HIV (PWH) can inform strategies to maintain or improve health and functioning. Most HRQOL research has focused on resource-rich settings, underrepresenting younger cohorts in low-resource settings. Objectives: To assess HRQOL and associated factors in PWH visiting two primary healthcare clinics in the Western Cape, South Africa. Method: A cross-sectional study included 48 PWH (58.3% women; mean age: 39.2 [10.3]). Health-related QOL was assessed using EQ-5D-5L descriptive domains, visual analogue scale (EQ-VAS), and index score (EQ-index). Mobility was assessed using clinical tests. Tobit regression determined associations. Results: Mean and median EQ-VAS scores were 88.14 (16.35) and 95.00. Mean and median EQ-index scores were 0.84 (0.10) and 0.90. PWH reported problems as pain/discomfort (35.4%), depression/anxiety (25.0%), mobility (22.9%), usual activities (18.7%) and self-care (12.5%) domains. Slow chair rise (p = 0.012), low income (p = 0.030), longer HIV duration (p = 0.009) and polypharmacy (p = 0.034) were associated with lower HRQOL. Antiretroviral therapy (ART) adherence was associated with higher HRQOL (p = 0.020). Conclusion: Despite high overall HRQOL, specific domains presented challenges to PWH. Health-related QOL was associated with chair rise repetitions, income, HIV duration, polypharmacy, and treatment adherence. Comprehensive care and contextualised interventions to address these through rehabilitation, including health promotion, are proposed strategies for future investigation. Clinical implications: Clinicians should be cognisant of potential physical and mental functioning problems, and factors related to drug therapy, socio-economic status and disease duration that may affect HRQOL even in seemingly unimpaired PWH.

Global profile of individuals undergoing total knee replacement through the PROGRESS-PLUS equity lens: Protocol for a systematic review.

Background: Osteoarthritis (OA) is a heterogenous degenerative disorder often causing destructive joint changes with severe pain and functional disability. Modifiable and non-modifiable risk factors, social context and psychological factors influence the development and progression of the disease. Total knee replacement (TKR) aims at reducing pain and improving function and is more successful with pre-operative and post-operative rehabilitation. However, most international research on rehabilitation interventions is conducted in high income contexts. Objective: The aim of our systematic review is to gain an overview of the demographic and social profiles of adults undergoing TKR for primary knee OA in lower, middle- and high-income countries through a health equity lens to inform the translation of intervention research in local contexts. Methods: A systematic review will be conducted and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement. Eligibility criteria include observational studies and grey literature (theses) since the beginning of the databases reporting on demographic data of adults awaiting or undergoing TKR surgery. The PROGRESS-Plus framework will be used to describe equity elements. Results: A narrative summary and description of the global profile of individuals undergoing total knee replacement for osteoarthritis. Conclusion: A snapshot of the global demographic and social profile of individuals receiving TKR for primary knee OA through an equity lens will shed light on the similarities and differences between individuals from different contexts. Global demographic profile information may inform or assist in the development of translational strategies for evidence-based rehabilitation. Clinical implications: Translation of existing rehabilitation interventions to local contexts could improve pre-operative and post-operative outcomes for individuals on our surgical waiting lists.

Assessing biomechanics and associated factors in individuals with patellofemoral pain in a clinical setting: A qualitative study based on interviews with expert clinicians.

OBJECTIVES: To explore the perspectives of ten clinicians from different medical disciplines with experience in managing PFP on how to conduct biomechanical assessments in individuals with PFP in a clinical setting. METHODS: An explorative qualitative design was used to explore the perspectives of ten clinicians with at least five years of experience managing patients with patellofemoral pain. A series of semi-structured interviews were done over Zoom video chat. The participants were from six different medical disciplines (physiotherapy, biokinetics, podiatry, sport science, sports medicine, orthopaedic surgery). Data was analysed thematically. RESULTS: Four main themes emerged from the data. These were: 1) biomechanical contributing factors that clinicians routinely screen for in patients with PFP; 2) relevant functional activities for biomechanical screening in patients with PFP; 3) conducting gait analysis assessments in a clinical setting; and 4) challenges of biomechanical assessment in patients with PFP. The clinicians expressed conflicting opinions on the usefulness of clinical gait analysis. The clinicians questioned the clinical applicability of some of the biomechanical factors identified as important in the evidence. CONCLUSIONS: It is important for clinicians to include the biomechanical assessment of functional activities linked to pain when managing patients with PFP. However, some of the biomechanical factors identified in the evidence are too difficult to observe without 3D movement analysis equipment and should not be considered clinically relevant. Expert clinical opinion is important to provide contextual information when addressing biomechanics in individuals with PFP.

Physical Rehabilitation Needs in the BRICS Nations from 1990 to 2017: Cross-National Analyses Using Data from the Global Burden of Disease Study.

Background: This study analyzes the current and evolving physical rehabilitation needs of BRICS nations (Brazil, Russian Federation, India, China, South Africa), a coalition of large emergent economies increasingly important for global health. Methods: Secondary, cross-national analyses of data on Years Lived with Disability (YLDs) were extracted from the Global Burden of Disease Study 2017. Total physical rehabilitation needs, and those stratified per major condition groups are analyzed for the year 2017 (current needs), and for every year since 1990 (evolution over time). ANOVAs are used to detect significant yearly changes. Results: Total physical rehabilitation needs have increased significantly from 1990 to 2017 in each of the BRICS nations, in every metric analyzed (YLD Counts, YLDs per 100,000 people, and percentage of YLDs relevant to physical rehabilitation; all p < 0.01). Musculoskeletal & pain conditions were leading cause of physical rehabilitation needs across the BRICS nations but to varying degrees: from 36% in South Africa to 60% in Brazil. Country-specific trends include: 25% of South African needs were from HIV-related conditions (no other BRICS nation had more than 1%); India had both absolute and relative growths of pediatric rehabilitation needs (p < 0.01); China had an exponential growth in the per-capita needs from neurological and neoplastic conditions (p < 0.01; r2 = 0.97); Brazil had a both absolute and relative growth of needs coming from musculoskeletal & pain conditions (p < 0.01); and the Russian Federation had the highest neurological rehabilitation needs per capita in 2017 (over than three times those of India, South Africa or Brazil). Conclusions: total physical rehabilitation needs have been increasing in each of the BRICS nations, both in absolute and relative values. Apart from the common growing trend, each of the BRICS nations had own patterns for the amount, typology, and evolution of their physical rehabilitation needs, which must be taken into account while planning for health and physical rehabilitation programs, policies and resources.

What low back pain is and why we need to pay attention.

Low back pain is a very common symptom. It occurs in high-income, middle-income, and low-income countries and all age groups from children to the elderly population. Globally, years lived with disability caused by low back pain increased by 54% between 1990 and 2015, mainly because of population increase and ageing, with the biggest increase seen in low-income and middle-income countries. Low back pain is now the leading cause of disability worldwide. For nearly all people with low back pain, it is not possible to identify a specific nociceptive cause. Only a small proportion of people have a well understood pathological cause-eg, a vertebral fracture, malignancy, or infection. People with physically demanding jobs, physical and mental comorbidities, smokers, and obese individuals are at greatest risk of reporting low back pain. Disabling low back pain is over-represented among people with low socioeconomic status. Most people with new episodes of low back pain recover quickly; however, recurrence is common and in a small proportion of people, low back pain becomes persistent and disabling. Initial high pain intensity, psychological distress, and accompanying pain at multiple body sites increases the risk of persistent disabling low back pain. Increasing evidence shows that central pain-modulating mechanisms and pain cognitions have important roles in the development of persistent disabling low back pain. Cost, health-care use, and disability from low back pain vary substantially between countries and are influenced by local culture and social systems, as well as by beliefs about cause and effect. Disability and costs attributed to low back pain are projected to increase in coming decades, in particular in low-income and middle-income countries, where health and other systems are often fragile and not equipped to cope with this growing burden. Intensified research efforts and global initiatives are clearly needed to address the burden of low back pain as a public health problem.

Primary care clinical practice guidelines in South Africa: qualitative study exploring perspectives of national stakeholders.

BACKGROUND: Clinical practice guidelines (CPGs) are common tools in policy and clinical practice informing clinical decisions at the bedside, governance of health facilities, health insurer and government spending, and patient choices. South Africa's health sector is transitioning to a national health insurance system, aiming to build on other primary health care initiatives to transform the previously segregated, inequitable services. Within these plans CPGs are an integral tool for delivering standardised and cost effective care. Currently, there is no accepted standard approach to developing, adapting or implementing CPGs efficiently or effectively in South Africa. We explored the current players; drivers; and the context and processes of primary care CPG development from the perspective of stakeholders operating at national level. METHODS: We used a qualitative approach. Sampling was initially purposeful, followed by snowballing and further sampling to reach representivity of primary care service providers. Individual in-depth interviews were recorded and transcribed verbatim. We used thematic content analysis to analyse the data. RESULTS: We conducted 37 in-depth interviews from June 2014-July 2015. We found CPG development and implementation were hampered by lack of human and funding resources for technical and methodological work; fragmentation between groups, and between national and provincial health sectors; and lack of agreed systems for CPG development and implementation. Some CPG contributors steadfastly work to improve processes aiming to enhance communication, use of evidence, and transparency to ensure credible guidance is produced. Many interviewed had shared values, and were driven to address inequity, however, resource gaps were perceived to create an enabling environment for commercial interests or personal agendas to drive the CPG development process. CONCLUSIONS: Our findings identified strengths and gaps in CPG development processes, and a need for national standards to guide CPG development and implementation. Based on our findings and suggestions from participants, a possible way forward would be for South Africa to have a centrally coordinated CPG unit to address these needs and aspects of fragmentation by devising processes that support collaboration, transparency and credibility across sectors and disciplines. Such an initiative will require adequate resourcing to build capacity and ensure support for the delivery of high quality CPGs for South African primary care.

Factors informing fear of reinjury after anterior cruciate ligament reconstruction.

OBJECTIVE: Fear of reinjury is associated with cessation of sport after anterior cruciate ligament (ACL) reconstruction despite normal postoperative knee function. The objective of this study is to describe factors informing athletes' experience of fear of reinjury post ACL reconstruction, in athletes who cited fear as the sole reason for not returning to their pre-injury level of sport. DESIGN: Mixed-methods study design of qualitative and a preliminary quantitative component. SETTING: A conveniently selected private hospital. PARTICIPANTS: Ten male and two female athletes, aged between 19 and 45 years, were eligible for the interview from 68 male and 32 female potential participants (age range 17-50) who underwent an ACL reconstruction using any graft type, excluding revision or multi-ligament surgery. MAIN OUTCOME MEASURES: To explore factors informing fear of reinjury in participants citing fear of reinjury as the sole reason for not returning to sport, albeit normal knee function. RESULTS: From the participant interview, four themes emerged: undergoing the surgery and recovery again, nature of the pre-injury sport imposing risk of reinjury, personality traits, and social priorities. CONCLUSIONS: Clinicians should be aware of factors informing fear of reinjury post ACL reconstruction. Modifiable fears including pain, mode and length of rehabilitation and psychological factors should be considered during rehabilitation to potentially improve the return to sport rate.

Targeting pain catastrophization in patients with fibromyalgia using virtual reality exposure therapy: a proof-of-concept study.

[Purpose] Pain catastrophizing is a key predictor of poor compliance to exercises among patients with fibromyalgia syndrome. Alteration of pain catastrophizing in this group is thus warranted. This study aimed to provide proof-of-concept of a novel virtual reality exposure therapy program as treatment for exercise-related pain catastrophizing in patients with fibromyalgia syndrome. [Subjects and Methods] An exploratory, case-controlled study was conducted (fibromyalgia syndrome group and matched control group). Functional magnetic resonance imaging was used to acquire neural correlates. The functional magnetic resonance imaging task consisted of two stimuli: active (exercise activity visuals) and passive (relaxing visuals). Structural images and blood-oxygenation-level-dependent contrasts were acquired for the conditions and compared within subjects/groups and between groups. Statistic images were thresholded using corrected clusters (determined by Z>2.3; level of significance: 0.05). [Results] Thirteen fibromyalgia syndrome subjects and nine healthy matched controls were included. The right inferior frontal gyrus, right middle frontal gyrus, right posterior cerebellum, left thalamus, and left supramarginal gyrus were activated in the fibromyalgia syndrome subjects. [Conclusion] The study results provide preliminary proof indicating that exposing patients with fibromyalgia syndrome to visuals of exercises elicits neurophysiological changes in functional brain areas associated with pain catastrophization and add to the current body of knowledge regarding the possibility of objectively identifying cognitive behavioral strategies like pain catastrophization.

The relationship between sitting posture and seated-related upper quadrant musculoskeletal pain in computing South African adolescents: A prospective study.

BACKGROUND: There is evidence that consistent sitting for prolonged periods is associated with upper quadrant musculoskeletal pain (UQMP). It is unclear whether postural alignment is a significant risk factor. OBJECTIVE AND DESIGN: The aim of the prospective study (2010-2011) was to ascertain if three-dimensional sitting postural angles, measured in a real-life school computer classroom setting, predict seated-related UQMP. METHOD: Asymptomatic Grade 10 high-school students, aged 15-17 years, undertaking Computer Application Technology, were eligible to participate. Using the 3D Posture Analysis Tool, sitting posture was measured while students used desk-top computers. Posture was reported as five upper quadrant angles (Head flexion, Neck flexion; Craniocervical angle, Trunk flexion and Head lateral bending). The Computer Usage Questionnaire measured seated-related UQMP and hours of computer use. The Beck Depression Inventory and the Multidimensional Anxiety Scale for Children assessed psychosocial factors. Sitting posture, computer use and psychosocial factors were measured at baseline. UQMP was measured at six months and one-year follow-up. RESULTS: 211, 190 and 153 students participated at baseline, six months and one-year follow-up respectively. 34.2% students complained of seated-related UQMP during the follow-up period. Increased head flexion (HF) predicted seated-related UQMP developing over time for a small group of students with pain scores greater than the 90th pain percentile, adjusted for age, gender, BMI, computer use and psychosocial factors (p = 0.003). The pain score increased 0.22 points per 1° increase in HF. CONCLUSIONS: Classroom ergonomics and postural hygiene should therefore focus on reducing large HF angles among computing adolescents.

Cross-cultural adaptation and validation of the South African Pain Catastrophizing Scale (SA-PCS) among patients with fibromyalgia.

BACKGROUND: Pain catastrophization has recently been recognized as a barrier to the healthy development of physical functioning among chronic pain patients. Levels of pain catastrophization in chronic pain patients are commonly measured using the Pain Catastrophizing Scale (PCS). OBJECTIVE: To cross-culturally adapt and validate the South African PCS (SA-PCS) among English-, Afrikaans- and Xhosa-speaking patients with fibromyalgia living in the Cape Metropole area, Western Cape, South Africa. METHODS: The original PCS was cross-culturally adapted in accordance with international standards to develop an English, Afrikaans and Xhosa version of the SA-PCS using a repeated measures study design. Psychometric testing included face/content validity, internal consistency (Cronbach's alpha-α), test-retest reliability (intraclass coefficient correlations-ICC), sensitivity-to-change and cross-sectional convergent validity (by comparing the adapted SA-PCS to related constructs). RESULTS: The cross-culturally adapted English, Afrikaans and Xhosa SA-PCS showed good face and content validity, excellent internal consistency (with Chronbach's α = 0.98, 0.98 and 0.97 for the English, Afrikaans and Xhosa SA-PCS, as a whole, respectively), excellent test-retest reliability (with ICC's of 0.90, 0.91 and 0.89 for the English, Afrikaans and Xhosa SA-PCS, respectively); as well as satisfactory sensitivity-to-change (with a minimum detectable change of 8.8, 9.0 and 9.3 for the English, Afrikaans and Xhosa SA-PCS, respectively) and cross-sectional convergent validity (when compared to pain severity as well as South African versions of the Tampa scale for Kinesiophobia and the revised Fibromyalgia Impact Questionnaire). CONCLUSION: The SA-PCS can therefore be recommended as simple, efficient, valid and reliable tool which shows satisfactory sensitivity-to-change and cross-sectional convergent validity, for use among English, Afrikaans and Xhosa-speaking patients with fibromyalgia attending the public health sector in the Western Cape area of South Africa.

Reaching consensus on the physiotherapeutic management of patients following upper abdominal surgery: a pragmatic approach to interpret equivocal evidence.

BACKGROUND: Postoperative pulmonary complications remain the most significant cause of morbidity following open upper abdominal surgery despite advances in perioperative care. However, due to the poor quality primary research uncertainty surrounding the value of prophylactic physiotherapy intervention in the management of patients following abdominal surgery persists. The Delphi process has been proposed as a pragmatic methodology to guide clinical practice when evidence is equivocal. METHODS: The objective was to develop a clinical management algorithm for the post operative management of abdominal surgery patients. Eleven draft algorithm statements extracted from the extant literature by the primary research team were verified and rated by scientist clinicians (n=5) in an electronic three round Delphi process. Algorithm statements which reached a priori defined consensus-semi-interquartile range (SIQR)<0.5-were collated into the algorithm. RESULTS: The five panelists allocated to the abdominal surgery Delphi panel were from Australia, Canada, Sweden, and South Africa. The 11 draft algorithm statements were edited and 5 additional statements were formulated. The panel reached consensus on the rating of all statements. Four statements were rated essential. CONCLUSION: An expert Delphi panel interpreted the equivocal evidence for the physiotherapeutic management of patients following upper abdominal surgery. Through a process of consensus a clinical management algorithm was formulated. This algorithm can now be used by clinicians to guide clinical practice in this population.

Virtual reality exposure therapy as treatment for pain catastrophizing in fibromyalgia patients: proof-of-concept study (Study Protocol).

BACKGROUND: Albeit exercise is currently advocated as one of the most effective management strategies for fibromyalgia syndrome (FMS); the implementation of exercise as a FMS treatment in reality is significantly hampered by patients' poor compliance. The inference that pain catastrophizing is a key predictor of poor compliance in FMS patients, justifies considering the alteration of pain catastrophizing in improving compliance towards exercises in FMS patients. The aim of this study is to provide proof-of-concept for the development and testing of a novel virtual reality exposure therapy (VRET) program as treatment for exercise-related pain catastrophizing in FMS patients. METHODS: Two interlinked experimental studies will be conducted. Study 1 aims to objectively ascertain if neurophysiological changes occur in the functional brain areas associated with pain catastrophizing, when catastrophizing FMS subjects are exposed to visuals of exercise activities. Study 2 aims to ascertain the preliminary efficacy and feasibility of exposure to visuals of exercise activities as a treatment for exercise-related pain catastrophizing in FMS subjects. Twenty subjects will be selected from a group of FMS patients attending the Tygerberg Hospital in Cape Town, South Africa and randomly allocated to either the VRET (intervention) group or waiting list (control) group. Baseline neurophysiological activity for subjects will be collected in study 1 using functional magnetic resonance imaging (fMRI). In study 2, clinical improvement in pain catastrophizing will be measured using fMRI (objective) and the pain catastrophizing scale (subjective). DISCUSSION: The premise is if exposing FMS patients to visuals of various exercise activities trigger the functional brain areas associated with pain catastrophizing; then as a treatment, repeated exposure to visuals of the exercise activities using a VRET program could possibly decrease exercise-related pain catastrophizing in FMS patients. Proof-of-concept will either be established or negated. The results of this project are envisaged to revolutionize FMS and pain catastrophizing research and in the future, assist health professionals and FMS patients in reducing despondency regarding FMS management. TRIAL REGISTRATION: PACTR201011000264179.

The association between postural alignment and psychosocial factors to upper quadrant pain in high school students: a prospective study.

Prolonged sitting and psychosocial factors have been associated with musculoskeletal symptoms among adolescents. However, the impact of prolonged static sitting on musculoskeletal pain among South African high school students is uncertain. A prospective observational study was performed to determine whether sitting postural alignment and psychosocial factors contribute to the development of upper quadrant musculoskeletal pain (UQMP) in grade ten high school students working on desktop computers. The sitting postural alignment, depression, anxiety and computer use of 104 asymptomatic students were measured at baseline. At three and six months post baseline, the prevalence of UQMP was determined. Twenty-seven students developed UQMP due to seated or computer-related activities. An extreme cervical angle (<34.75 degrees or >43.95 degrees; OR 2.8; 95% CI: 1.1-7.3) and a combination of extreme cervical and thoracic angles (<63.1 degrees or >71.1 degrees; OR 2.2; 95% CI: 1.1-5.6) were significant postural risk factors for the development of UQMP. Boys with any extreme angle were more likely to suffer pain compared with boys with all middle range angles (OR 4.9; 95% CI: 1.0-24.5). No similar effect was found for girls. There was no strong relationship between depression, anxiety, computer exposure and UQMP among South African high school students.