Pastoral care and religious support as a part of treatment of religious patient with the severe form of osteoarthritis.

Introduction: Religious needs of patients are consistently being neglected in the clinical medicine. Pastoral care is a religious support which a religious patient receives from priests, chaplains, imams, rabbis or other religious authorities. Religious support, in terms of clinical medicine, is a spiritual support which religious patients obtain from religious and trained medical workers. The aim of this report was to present the effects of pastoral care and religious support in hospital treatment of a 73-year-old patient with the severe form of osteoarthritis. Case report: The 73- year-old, highly religious patient with severe form of osteoarthritis was admitted at the Clinic for Physical Medicine and Rehabilitation, Military Medical Academy in Belgrade, due to heterogeneous problems in the activities of daily living. The patient walked with difficulty using a stick, suffered pain, and was anxious and depressive. In order to objectively demonstrate effects of both pastoral care and religious support in this patient we performed multiple treatment with reversal design, in which the basic treatment consisting of hospital care, pharmacotherapy and physical therapy (the treatment A) was alternatively changed with the treatment that included combination of the basic treatment and religious support provided by religious physiatrist and physiotherapist (the treatment B) or combination of the basic treatment and pastoral care provided by military priest (the treatment C). The treatment A was applied three times and lasted two weeks, every time. Treatments B and C were applied once and lasted three weeks, each. The order of the treatments was: A→B→A→C→A. During the whole treatment period the patient's condition was assessed by several measuring scale: the level of depression by The Hamilton Rang Scale for Depression and The Zung Self Rating Depression Scale; the level of anxiety by The Zung Self Rating Anxiety Scale; the functional capability of patient by The Barthel Index and The Functional Independent Measure. Measuring was carried out on a daily basis. In statistical analysis two nonparametric statistic were used: the percentage of non-overlapping data (PND) and the percentage of data points exceeding the median (PEM). PND and PEM values below 0.7 reflect questionable effectiveness of the treatment. The values between 0.7 and 0.9 reflect moderate effects. The values above 0.9 are considered as a highly effective treatment. The anxiety of the patient was moderately to significantly reduced after introducing religious support (treatment B: mean and mean deviation = 50.1 ± 10.89; variability = 4.598653; mean shift = 0.219626; PND = 0.6; PEM = 0.9) and pastoral care (treatment C: mean and mean deviation = 53.5 ± 5.90; variability = 9.062591; mean shift = 0.207407; PND = 0.9; PEM = 0.9). The patient's depression was reduced after introducing pastoral care (treatment C: mean and mean deviation = 51.3 ± 4.66; variability = 10.99005; mean shift = 0.08881; PND = 0; PEM = 0.9). On the contrary, the patient's functional capability was not significantly improved. Conclusion: In the highly religious patient with severe osteoarthritis pastoral care and religious support, applied along with the standard medical treatment of this condition, produced some beneficial effects on anxiety and depressive mood, but with no significant effect on patient's functional capability.

Diagnostic accuracy of the A-test and cutoff points for assessing outcomes and planning acute and post-acute rehabilitation of patients surgically treated for hip fractures and osteoarthritis.

Background/Aim: The A-test is used in daily clinical practice for monitoring functional recovery of orthopedic patients during early rehabilitation. The aim of this study was to determine the accuracy of A-test and cutoff point at which the test can separate patients with and without functional disability at the end of early rehabilitation. Also, it was important to determine whether A-test has that discriminative ability (and at which cutoff points) in the first days of early rehabilitation in order to have time to plan post acute rehabilitation. Methods: This measurement-focused study was conducted in the Orthopedic Ward during early inpatient rehabilitation (1st−5th day after the operation) of 60 patients with hip osteoarthritis (HO) that underwent arthroplasty and 60 surgically treated patients with hip fracture (HF). For measurements we used the A-test and the University of Iowa Level of Assistance Scale (ILAS) as the gold standard. For statistical analysis we used the receiver operating characteristic (ROC) curve and the area under the curve (AUC) with 95% confidence interval for the results of A-test from the first to the fifth day of rehabilitation, sensitivity, specificity, the rate of false positive and false negative errors, positive and negative predictive value, ratio of positive and negative likelihood ratio, accuracy, point to the ROC curve closest to 0.1 and Youden index for all the cutoff points. Results: The AUC was 0.825 (0.744−0.905) for the first day of rehabilitation, 0.922 (0.872−0.972) for the second day of rehabilitation, 0.980 (0.959−1.000) for the third day of rehabilitation, 0.989 (0.973−1.004) for the fourth day, and 0.999 (0.996−1.001) for the fifth day of rehabilitation. The optimal cutoff for the results of A-test was: 7/8 for the first day, 29/30 for the fourth day, and 34/35 for the fifth day of rehabilitation. On the second and the third day A-test had two cutoff points, the lower point safely separated the patients with functional disability, while the upper point ruled out functional disability. On the 2nd rehabilitation day the cutoff points were 12/13 and 17/18, on the 3rd rehabilitation day cutoff points were 13/14 and 18/19. Conclusion: The A-test has all characteristics of an accurate tool which can be used for separating patients with and without functional disability at all stages of early rehabilitation after surgically treated hip disease or fracture. Based on the results of A-test within the first days of early rehabilitation, it is possible to make a plan for postacute rehabilitation.

The A-test: assessment of functional recovery during early rehabilitation of patients in an orthopedic ward--content, criterion and construct validity.

BACKGROUND/AIM: The A-test was designed for assessment of functional recovery during early rehabilitation of patients in an orthopedic ward. This performance-based test consists of 10 items for assessing basic activities by a six level ordinal scale (0-5). Total scores can range from 0 to 50, i.e. from inability to perform any activity despite the help of therapists to complete independence and safety in performing all activities. The aim of this study was to examine the A-test validity. METHODS: This prospective study was conducted in an orthopedic ward and included 120 patients [60 patients with hip osteoarthritis that underwent arthroplasty and 60 surgically treated patients with hip fracture (HF)] during early inpatient rehabilitation (1st-5th day). Validity was examined through 3 aspects: content validity--floor and ceiling effect, range, skewness; criterion validity--concurrent validity [correlation with the University of Iowa Level of Assistance Scale (ILAS) for patients with hip osteoarthritis, and with the Cumulated Ambulation Score (CAS) for patients with HF, Spearman rank correlation] and predictive validity [the New Mobility Score (NMS) 4 weeks after surgery, Mann-Whitney U test]; construct validity--4 hypotheses: 1) on the fifth day of rehabilitation in patients underwent arthroplasty due to hip osteoarthritis, the A-test results will strongly correlate with those of ILAS, while the correlation with the Harris hip score will be less strong; 2) in patients with HF, the A-test results will be significantly better in those with allowed weight bearing as compared to patients whom weight bearing is not allowed while walking; 3) results of the A-test will be significantly better in patients with hip osetoarthritis than in those with HF; 4) the A-test results will be significantly better in patients younger than 65 years than in those aged 65 years and older. RESULTS: The obtained results were: low floor (1%) and ceiling (2%) effect, range 0-50, skewness 0.57, strong correlation with ILAS for the patients with hip osteoarthritis (r = -0.97, p = 0.000) and with CAS for the patients with hip fracture (r = 0.91, p = 0.000). The patients with the A-test score 35 and more on the fifth day of rehabilitation (n = 46, Md = 4) had significantly higher NMS rank 4 weeks after surgery than the patients with the A-test score less than 35 (n = 59, Md = 2), (U = 379, z = -6.47, p = 0.000, r = 0.63). All 4 hypotheses were confirmed. CONCLUSION: The A-test is simple and valid instrument for everyday evaluation of pace and degree of functional recovery during early rehabilitation of patients surgically treated in an orthopedic ward.

The A-test--reliability of functional recovery assessment during early rehabilitation of patients in an orthopedic ward.

BACKGROUND/AIM: There are few tests for evaluation of functional abilities of patients surgically treated for hip fractures or osteoarthritis during early rehabilition period. The aim of this study was to investigate reliability (interobserver reproducibility and internal consistency) of the A-test, an original test for functional recovery evaluation during early rehabilitation of patients in an orthopedic ward. METHODS: The investigation included 105 patients (55 patients with hip osteoarthritis that underwent arthroplasty and 50 surgically treated patients with hip fracture). It was conducted in an orthopedic ward during early inpatient rehabilitation (from 1st to 5th day). For their functional recovery evaluation during early rehabilitation we used the A-test, a performance-based test with 10 items for assessing basic activities by six level ordinal scale (0-5). For internal consistency of the test the Cronbach coefficient alpha was calculated for the A-test results collected during early rehabilitation for all patients (105 patients x 5 days = 525 measures) and separately for the results of patients with hip osteoarthritis (275 measures) and hip fracture (250 measures). Values of this coefficient > 0.7 imply good internal consistency of the test. Interobserver reproducibility was estimated as follows: two physiotherapists together conducted physical therapy with the patients, and then, separately, rated the performance of each activity from the test (78 measures). The agreement between their estimations was expressed by the linear weighted kappa coefficient (for very good agreement values of kappa coefficeent have to be in the range 0.81-1). RESULTS: The Cronbach coefficient alpha was 0.98 (the results of all the patients and the results of the patients with hip osteoarthritis) and 0.97 (the results of the patients with hip fracture). The values of kappa coefficient were in the range 0.81-0.92 for all items. CONCLUSION: The A-test is a reliable instrument for everyday evaluation of functional recovery during early rehabilitation of patients surgically treated in an orthopedic ward.

The effects of short-term preoperative physical therapy and education on early functional recovery of patients younger than 70 undergoing total hip arthroplasty.

BACKGROUND/AIM: Hip arthroplasty is a routine operation which relieves pain in patients with osteoarthritis. The role of physical therapy after hip arthroplasty was recognized, but the importance of preoperative physical therapy and education is still to be judged. The aim of this paper was to investigate the effect of short-term preoperative program of education and physical therapy on patients' early functional recovery immediately after total hip arthroplasty (THA). METHODS: This prospective study included 45 patients with hip osteoarthritis scheduled to undergo primary THA and admitted to the Department of Orthopedics of Military Medical Academy. They were randomized into 2 groups: study and control one (with and without preoperative education and physical therapy). Preoperative education was conducted through conversation (1 appointment with physiatrist) and brochure. The study group was instructed to perform exercises and basic activities from the postoperative rehabilitation program (2 practical classes with physiotherapist). Effects were measured with questionnaires (Harris, Oxford and Japanese Orthopaedic Association (JOA) hip scores), range of motion and visual analog scale of pain. Marks showing ability to perform basic activities and endurance were from 0 (did not perform activity) to 5 (independent and secure). Analyses examined differences between the groups over the preoperative and immediate postoperative periods and 15 months after the operation. RESULTS: There were no differences between the groups at discharge according to pain, range of motion, Harris hip score and JOA hip score. Oxford hip score did not differ between the groups 15 months after the operation. The groups started to walk at the same time, but the study group walked up and down stairs (3.7+/-1.66 vs 5.37+/-1.46, p< or =0.002), used toilet (2.3+/-0.92 vs 3.2+/-1.24, p< or =0.02) and chair (2.2+/-1.01 vs 3.25+/-1.21, p< or =0.006) significantly earlier than the control group. On the third day after the operation the study group was significantly more independent than the control one while performing any basic activities (changing position in bed from supine to side lying, from supine to sitting on the edge of the bed, from sitting to standing, from standing to lying in the bad, standing, walking, using toilet and chair). At discharge the patients from the control group still needed the therapist help for walking up and down stairs (3+/-1.26), while the patients from the study group performed there activities independently (4.85+/-0.37) (p< or =0.000). Endurance while walking was significantly better in the study group than in the control one. The length of hospital stay after the operation was similar for both groups, but the patients from the study group needed significantly less classes with the therapist (5.2+/-2.35 vs 6.85+/-1.14, p< or =0.02) during hospital stay. CONCLUSION: The short-term preoperative program of education with the elements of physical therapy accelerated early functional recovery of patients (younger than 70) immediately after THA and we recommend it for routine use.