Return-to-Work Experiences in Ontario Policing: Injured But Not Broken.

PURPOSE: Police officers and others working in police services are exposed to challenging and traumatic situations that can result in physical and/or psychological injuries requiring time off work. Safely returning to work post-injury is critical, yet little is known about current return-to-work (RTW) practices in police services. This study examines RTW practices and experiences in police services from the perspective of RTW personnel and workers with physical and/or psychological health conditions. METHODS: We used a purposive sampling approach to recruit sworn and civilian members from several police services in Ontario, Canada. The recruited members had experienced RTW either as a person in a RTW support role or as a worker with a work-related injury/illness. We conducted and transcribed interviews for analysis and used qualitative research methods to identify themes in the data. RESULTS: Five overarching themes emerged. Two pointed to the context and culture of police services and included matters related to RTW processes, injury/illness complexity, the hierarchical nature of police organizations, and a culture of stoicism and stigma. The remaining three themes pointed to the RTW processes of accommodation, communication and trust-building. They included issues related to recovery from injury/illness, meaningful accommodation, timely and clear communication, malingering and trust. CONCLUSIONS: Our findings point to potential areas for improving RTW practices in police services: greater flexibility, more clarity, stricter confidentiality and reduced stigma. More research is needed on RTW practices for managing psychological injuries to help inform policy and practice.

Primary care physicians' perceptions about and confidence in deciding which patients to refer for total joint arthroplasty of the hip and knee.

OBJECTIVE: The purpose of this study is to examine the perceptions of primary care physicians (PCPs) regarding indications, contraindications, risks and benefits of total joint arthroplasty (TJA) and their confidence in selecting patients for referral for TJA. DESIGN: PCPs recruited from among those providing care to participants in an established community cohort with hip or knee osteoarthritis (OA). Self-completed questionnaires were used to collect demographic and practice characteristics and perceptions about TJA. Confidence in referring appropriate patients for TJA was measured on a scale from 1 to 10; respondents scoring in the lowest tertile were considered to have 'low confidence'. Descriptive analyses were conducted and multiple logistic regression was used to determine key predictors of low confidence. RESULTS: 212 PCPs participated (58% response rate) (65% aged 50+ years, 45% female, 77% >15 years of practice). Perceptions about TJA were highly variable but on average, PCPs perceived that a typical surgical candidate would have moderate pain and disability, identified few absolute contraindications to TJA, and overestimated both the effectiveness and risks of TJA. On average, PCPs indicated moderate confidence in deciding who to refer. Independent predictors of low confidence were female physicians (OR = 2.18, 95% confidence interval (CI): 1.06-4.46) and reporting a 'lack of clarity about surgical indications' (OR = 3.54, 95% CI: 1.87-6.66). CONCLUSIONS: Variability in perceptions and lack of clarity about surgical indications underscore the need for decision support tools to inform PCP - patient decision making regarding referral for TJA.

Patients do not have a consistent understanding of high risk for future fracture: a qualitative study of patients from a post-fracture secondary prevention program.

UNLABELLED: We examined fracture patients' understanding of "high" fracture risk after they were screened through a post-fracture secondary prevention program and educated about their risk verbally, numerically, and graphically. Our findings suggest that messages about fracture risk are confusing to patients and need to be modified to better suit patients' needs. INTRODUCTION: The aim of this study was to examine fracture patients' understanding of high risk for future fracture. METHODS: We conducted an in-depth qualitative study in patients who were high risk for future fracture. Patients were screened through the Osteoporosis Exemplary Care Program where they were educated about fracture risk: verbally told they were "high risk" for future fracture, given a numerical prompt that they had a >20 % chance of future fracture over the next 10 years, and given a visual graph highlighting the "high risk" segment. This information about fracture risk was also relayed to patients' primary care physicians (PCPs) and specialists. Participants were interviewed at baseline (within six months of fracture) and follow-up (after visit with a PCP and/or specialist) and asked to recall their understanding of risk and whether it applied to them. RESULTS: We recruited 27 patients (20 females, 7 males) aged 51-87 years old. Fractures were sustained at the wrist (n = 7), hip (n = 7), vertebrae (n = 2), and multiple or other locations (n = 11). While most participants recalled they had been labeled as "high risk" (verbal cue), most were unable to correctly recall the other elements of risk (numerical, graphical). Further, approximately half of the patients who recalled they were high risk did not believe that high risk applied, or had meaning, to them. Participants also had difficulty explaining what they were at risk for. CONCLUSIONS: Our results suggest that health care providers' messages about fracture risk are confusing to patients and that these messages need to be modified to better suit patients' needs.

Non-pharmacological strategies used by patients at high risk for future fracture to manage fracture risk--a qualitative study.

UNLABELLED: We examined patients' self-management of bone health and fracture risk, particularly behaviors other than medication use and seeking diagnostic testing. Awareness of fracture risk was accompanied by positive lifestyle changes in participants' lives such as being careful. Future research should evaluate how lifestyle changes mitigate fracture risk. INTRODUCTION: We examined patients' understanding of bone health and self-management decisions regarding bone health and fracture risk, particularly behaviors other than medication use and seeking diagnostic testing. METHODS: A phenomenological (qualitative) study was conducted. English-speaking patients, 65+ years old, who were "high risk" for future fracture and prescribed pharmacotherapy after being screened through a post-fracture osteoporosis initiative were eligible. Patients were interviewed for 1-2 h and were asked to discuss perceptions of bone health status (bone densitometry results and perceived fracture risk), recommendations received for bone health, and lifestyle changes since their most recent fracture. We analyzed the data guided by Giorgi's methodology. RESULTS: We interviewed 21 fracture patients (6 males and 15 females), aged 65 to 88 years old. With the exception of one participant, all participants appeared to understand that they had low bone mass and were at risk of sustaining another fracture. Most participants (n = 20) were predominantly concerned about being careful, and they focused their responses on personal and environmental factors that they perceived to be modifiable. Participants also spoke about strategies to manage their bone health such as exercise, having a healthy diet and taking supplements, and using aids and devices. Non-pharmacological strategies used by patients appeared to be independent of current use of pharmacotherapy. CONCLUSIONS: Awareness of fracture risk was accompanied by a number of positive lifestyle changes in participants' lives such as being careful and engaging in exercise. Future research needs to evaluate how lifestyle changes such as being careful mitigate fracture risk.

Return to work and workplace activity limitations following total hip or knee replacement.

OBJECTIVE: Total hip (THR) and knee (TKR) replacements increasingly are performed on younger people making return to work a salient outcome. This research evaluates characteristics of individuals with early and later return to work following THR and TKR. Additionally, at work limitations pre-surgery and upon returning to work, and factors associated with work limitations were evaluated. METHODS: 190 THR and 170 TKR of a total 931 cohort participants were eligible (i.e., working or on short-term disability pre-surgery). They completed questionnaires pre-surgery and 1, 3, 6 and 12 months post-surgery that included demographics, type of occupation, and the Workplace Activity Limitations Scale (WALS). RESULTS: 166 (87%) and 144 (85%) returned to work by 12 months following THR and TKR, respectively. Early (1 month) return to work was associated with, male gender, university education, working in business, finance or administration, and low physical demand work. People with THR returned to work earlier than those with TKR. For both groups, less pain and every day functional limitations were associated with less workplace activity limitations at the time return to work. CONCLUSIONS: The majority of individuals working prior to surgery return to work following hip or knee replacement for osteoarthritis (OA) and experience fewer limitations at work than pre-surgery. The changing workforce dynamics and trends toward surgery at younger ages mean that these are important outcomes for clinicians to assess. Additionally, this is important information for employers in understanding continued participation in employment for people with OA.

The importance of perceived helplessness and emotional health in understanding the relationship among pain, function, and satisfaction following revision knee replacement surgery.

OBJECTIVE: Little is known about the relationships among pain, function, psychological variables like perceived helplessness and emotional health, and patient satisfaction in people with revision knee replacement surgery. We hypothesized that pain and function would have a direct association with satisfaction as well as an indirect association through patient perceptions of helplessness and emotional health. DESIGN: This longitudinal study included 145 participants undergoing revision knee replacement surgery. Demographic data and expectation of benefit from surgery were recorded prior to surgery. The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), the Arthritis Helplessness Scale (AHS) and the Mental Component Scale (MCS) of the SF-36 (emotional health) were collected prior to and 2 years post-surgery. Satisfaction was recorded 2 years post-surgery. Regression analyses were conducted to test for mediation effects of helplessness and MCS. RESULTS: Participants were on average 69 years old and 54% were women. Participants were satisfied with the results of the surgery (mean ± standard deviation (SD) = 70.42 ± 31.46). Less pain and functional disability were associated with increased patient satisfaction and, the effect of pain or function was also mediated through helplessness whereby more pain and disability were associated with perceptions of helplessness and helplessness was associated with lower satisfaction. MCS did not mediate the relationship of pain and function with satisfaction. CONCLUSION: Helplessness plays an important role in understanding patient satisfaction. Interventions aimed at improving patient outcome should target not only pain and function but also should address strategies to support people in managing following knee revision surgery to maximize satisfaction with outcome.

Patients reject the concept of fragility fracture--a new understanding based on fracture patients' communication.

UNLABELLED: We examined patients' communication about fragility fractures to gain insight into why patients do not connect fractures to bone health. The term "fragility" fracture was a misnomer to patients who perceived the event as physically and emotionally traumatic. Improved communication about such fractures could facilitate awareness of bone health. INTRODUCTION: We examined patients' communication about fragility fractures to gain insight into why patients do not perceive the connection between their fracture and low bone mass. METHODS: A descriptive phenomenological (qualitative) study was conducted. During face-to-face interviews, the participants described the experience of their fracture in detail and the circumstances surrounding the fracture. Data analysis was guided by Giorgi's methodology. English-speaking male and female patients aged 65+ years and "high" risk for future fracture were eligible and screened for osteoporosis through an established screening program at an urban teaching hospital. RESULTS: We recruited 30 participants (9 males, 21 females), aged 65-88, who presented with a hip (n = 11), wrist (n = 11), shoulder (n = 6), or other (n = 2) fracture. Ten of the 30 fractures occurred inside the home and the remaining fractures occurred outside the home. Sustaining a fragility fracture was perceived as a traumatic event, both physically and emotionally. In general, participants used forceful, action-oriented words and referred to hard surfaces to describe the experience. Explanations for the fracture, other than bone quality, were often reported, especially that falls were "freak" or "fluke" events. Patients who sustained a fracture under more mundane circumstances seemed more likely to perceive a connection between the fracture and their bone health. CONCLUSIONS: The term fragility fracture was a misnomer for many older adults. By reexamining how this term is communicated to fracture patients, health care providers may better facilitate patients' awareness of bone health.

The trajectory of recovery and the inter-relationships of symptoms, activity and participation in the first year following total hip and knee replacement.

OBJECTIVE: Primary total hip (THR) and knee (TKR) replacement outcomes typically include pain and function with a single time of follow-up post-surgery. This research evaluated the trajectory of recovery and inter-relationships within and across time of physical impairments (PI) (e.g., symptoms), activity limitations (AL), and social participation restrictions (PR) in the year following THR and TKR for osteoarthritis. DESIGN: Participants (hip: n=437; knee: 494) completed measures pre-surgery and at 2 weeks, 1, 3, 6 and 12 months post-surgery. These included PI (Hip Disability and Osteoarthritis Outcome Score (HOOS)/Knee Injury and Osteoarthritis Outcome Score (KOOS) symptoms and Chronic Pain Grade); AL (HOOS/KOOS activities of daily living and sports/leisure activities); and, PR (Late Life Disability and the Calderdale community mobility). Repeated measures analysis of variance (RANOVA) was used to evaluate the trajectory of recovery of outcomes and the inter-relationships of PI, AL and PR were evaluated using path analysis. All analyses were adjusted for age, sex, obesity, THR/TKR, low back pain and mood. RESULTS: THR: age 31-86 years with 55% female; TKR: age 35-88 years with 65% female. Significant improvements in outcomes were observed over time. However, improvements were lagged over time with earlier improvements in PI and AL and later improvements in PR. Within and across time, PI was associated with AL and AL was associated with PR. The magnitude of these inter-relationships varied over time. CONCLUSION: Given the lagged inter-relationship of PI, AL and PR, the provision and timing of interventions targeting all constructs are critical to maximizing outcome. Current care pathways focusing on short-term follow-up with limited attention to social and community participation should be re-evaluated.

A review of patient-centred post-fracture interventions in the context of theories of health behaviour change.

The purpose of this literature review is to determine whether and to what extent current post-fracture osteoporosis interventions utilize theories of health behaviour change and whether those that are theory-based are more successful in producing desired behaviour changes. Studies were identified by applying additional criteria to the final selection stage of a systematic review of non-surgical osteoporosis interventions in the orthopaedic environment. We identified 42 primary studies targeted at patients and improving post-fracture osteoporosis care. As well as describing the studies (in terms of design, population, interventions, outcomes), we focused on theoretical framework and elements of behaviour change models. The 42 studies included in this review utilized a variety of post-fracture interventions; however, none of them reported using an underlying theoretical base. Only three studies drew on what we felt to be elements of a theoretical framework. The lack of theoretically based studies points to a currently under-utilized area of behaviour change research that could be applied to post-fracture interventions in order to make them more effective. Despite an abundance of literature supporting theories of behaviour change, post-fracture osteoporosis interventions do not report utilizing these theories. Theories of behaviour change could be applied to post-fracture osteoporosis interventions to explain why patients initiate osteoporosis management. Future research should explore the application of theories of health behaviour change to post-fracture interventions.

The multidimensionality of sleep quality and its relationship to fatigue in older adults with painful osteoarthritis.

OBJECTIVE: To evaluate subjective sleep quality and its relationship to fatigue in older adults with osteoarthritis (OA). METHOD: In a community cohort with hip/knee OA, subjective sleep quality was assessed using the Pittsburgh Sleep Quality Index (PSQI) and fatigue was measured by the Profile of Mood States - Fatigue subscale (POMS-F). Correlates of sleep quality and fatigue were determined by standardized interviews including socio-demographics, OA severity (Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) summary score), comorbidity, depression (Center for Epidemiologic Studies Depression Scale, CES-D), stressful life events, daytime napping, symptoms of restless legs syndrome (RLS) and prior sleep disorder diagnoses. Logistic regression examined correlates of poor sleep (PSQI score>5). Linear regression evaluated the relationship between poor sleep and fatigue, and the effect of napping on this relationship. RESULTS: In 613 respondents, mean age was 78 years, 78% were female, 11% had concomitant fibromyalgia, and 26% had 3+ comorbid conditions. Responses indicated moderate OA severity. Seventy percent reported poor sleep; 25% met criteria for RLS and 6.5% reported a diagnosed sleep disorder. Independent correlates of poor sleep were: greater arthritis severity (adjusted odds ratio (OR) per unit increase in WOMAC score=1.03, P<0.0001), 3+ comorbid conditions (adjusted OR=1.88; P=0.03), depressed mood (adjusted OR per unit increase in CES-D score=1.09, P<0.0001), and RLS (adjusted OR=1.87; P=0.02). Controlling for previously reported fatigue correlates, poor sleep was significantly associated with greater fatigue (parameter estimate=1.63, P=0.0003) and napping did not moderate this relationship (P=0.55 for the interaction between napping and poor sleep). CONCLUSIONS: Among older people with OA, poor sleep is highly prevalent and significantly linked with fatigue. Identifying the nature of sleep disturbances in OA is important as treatment of sleep disturbances may reduce OA-related fatigue.

Not all "quality-adjusted life years" are equal.

BACKGROUND: There is evidence that utility elicitation methods used in the calculation of quality-adjusted life years (QALYs) yield different results. It is not clear how these differences impact economic evaluations. METHODS: Using a mathematical model incorporating data on efficacy, costs, and utility values, we simulated the experiences of 100,000 hypothetical rheumatoid arthritis patients over 10 years (50,000 exposed to infliximab plus methotrexate [MTX] and 50,000 exposed to MTX alone). QALYs, were derived from the Health Utilities Index 2 and 3 (HUI2 and HUI3), the Short Form 6-D (SF-6D), and the Euroqol 5-D (EQ-5D). Incremental cost-utility ratios were determined using each instrument to calculate QALYs and the results were compared using cost-effectiveness acceptability curves. RESULTS: Using the different utility measurement methods, the mean difference in QALYs between the infliximab plus MTX and MTX groups ranged from a high of 1.95 QALYs (95% CI=1.93-1.97) using the HUI3 to 0.89 QALYs (95% CI=0.88-0.91) using the SF-6D. Adopting the commonly cited value of society's willingness to pay for a QALY of $50,000, 91% of the simulations favored the cost utility of infliximab plus MTX when using the HUI3 to calculate QALYs. However, when using the EQ-5D, HUI2, or the SF-6D utility values to calculate QALYS, the proportion of simulations that favored the cost utility of infliximab were 63%, 45%, and 12%, respectively. CONCLUSION: Depending on the method for determining utility values used in the calculation of QALYs, very different incremental cost-utility ratios are generated.

Psychometric properties of the "Osteoporosis and You" questionnaire: osteoporosis knowledge deficits among older community-dwelling women.

UNLABELLED: In older women, knowledge about risk factors for osteoporosis was good, with over 75% responding correctly to questions about lifestyle factors, family history, height loss, and menopausal status. However, significant knowledge deficits were identified regarding osteoporosis "consequences" and "prevention and treatment." INTRODUCTION: We examined osteoporosis knowledge by testing the psychometric properties of the 10-item knowledge component of the "Osteoporosis and You" questionnaire. Several knowledge domains were hypothesized. METHODS: Community-dwelling women aged 65-90 years residing within two regions of Ontario, Canada were studied (N = 869). Data were collected by standardized telephone interviews in 2003 and 2004. Items to which 75% or more responded correctly were identified as having a low index of difficulty; the remaining items identified areas of knowledge deficit. Confirmatory factor analysis was used to test scale structure. RESULTS: Six of the ten items had a low index of difficulty. These items largely examined osteoporosis risk factors. The remaining four items identified significant knowledge deficits in the areas of osteoporosis consequences, prevention, and treatment. Confirmatory factor analysis identified four distinct osteoporosis knowledge domains. However, the internal consistency was low for all but one domain, which examined "prevention and treatment." CONCLUSION: Although older women appear to be aware of osteoporosis risk factors, knowledge deficits regarding the consequences of osteoporosis and that treatment exists to prevent bone loss were identified. Better understanding of the multi-dimensional aspects of osteoporosis knowledge may help to inform the development of effective educational interventions.

Adaptation to chronic illness and disability and its relationship to perceptions of independence and dependence.

This study extends research on living with chronic physical illness and disability by examining how adaptation processes are associated with different activity domains and how the combination of adaptations and activity domains relate to older adults' perceptions of their independence and dependence, helplessness, emotional reactivity, and coping efficacy. The study investigated the behavioral efforts that 286 older adults with osteoarthritis and/or osteoporosis used to adapt to disability arising from their condition. The findings revealed that adults used a wide range of adaptations, including compensations for loss, optimizing performance, limiting or restricting activities, and gaining help from others. The relative use of each of these adaptations varied across 5 domains of activity: personal care, in-home mobility, community mobility, household activities, and valued activities. Moreover, older adults' perceptions of their independence, dependence, helplessness, emotional reactivity, and coping efficacy varied depending on the domain of activity examined and the type of adaptation used.

An evaluation of a psychotherapeutic group intervention for persons having difficulty coping with musculoskeletal disorders.

This study evaluated an 8-9 week psychotherapeutic group program designed to help people cope with the difficulties and changes that arise when living with musculoskeletal (MSK) disorders. Also examined were individual differences in client expectations about the benefits of the groups. Participants were 64 community-dwelling adults who completed questionnaires at the beginning, end, and three months after their final group session. Outcomes were mastery, coping efficacy, helplessness, self-acceptance and depression. Significant changes from pre- to post-intervention were found in mastery, depression, and coping-efficacy with effect sizes of .50 or greater. Individuals who had concerns or reservations about participating in the groups gained from the intervention in the same ways as others who were more positive at the outset of the groups.

Determinants of self rated health for Canadians with chronic disease and disability.

OBJECTIVE: To identify the factors associated with self rated health of people with and without chronic health conditions or long term disability. SETTING: Canadian household population. DESIGN: Analysis of 1994/95 National Population Health Survey interview data with 13,995 respondents aged 20 years and older. Determinants of poor and good compared with excellent health were examined using multivariate nominal logistic regression. Factors included in the analyses were illness related (chronic disease, long and short-term disability, and pain) demographic, lifestyle (smoking, physical activity, drinking), and social psychological resources (mastery, chronic stress, distress, self esteem, and social support). RESULTS: Illness related variables were associated with poor health, with smaller but significant contributions from demographic and lifestyle factors. Psychological resources, especially high mastery and self esteem, are associated with better health in those with chronic conditions or disability. CONCLUSION: The determinants of self rated health for people with chronic illness and disability make the greatest contribution to the findings for the overall population.

A conceptual model of independence and dependence for adults with chronic physical illness and disability.

This paper presents a conceptual model of physical independence and dependence as it relates to adult onset, chronic physical illness and disability. Physical independence and dependence are presented as two separate, continuous, and multiply determined constructs, and illustrations are provided of situations where people can be independent, dependent, not independent, or experience imposed dependence. The paper also discusses potential determinants of physical independence and dependence, including different domains of disability, the role of subjective perceptions, demographics, the physical and social/political environments, personal resources, attitudes and coping resources, illness and efficacy appraisals, and the nature of the assistive relationship. The paper extends work on physical independence and dependence by synthesizing the findings from previous studies and incorporating the findings from other relevant areas of research into the area. It also expands on the concepts of physical independence and dependence, as well as their determinants, and relates independence and dependence to other outcomes of interest such as service delivery.

Caregivers' appraisals of efficacy in coping with dementia.

This study investigated the types, prevalence, and stability of appraisals of coping efficacy made by 87 family caregivers of persons with dementia. With the use of content analysis, 12 efficacy appraisals were identified that reflected caregivers' perceptions of progress in problem-solving, regulating emotional distress, protecting self-esteem, managing social interactions, and self-development. Most appraisal types showed variability across 2 time points, which suggests that appraisals reflect changing person-environment transactions. Five of the appraisals-namely, nonefficacious coping outcomes, no coping options, no control, an improved ability to cope, and means/ends insights-were prospectively related to distress and well-being. The findings suggest that a broad set of goals guides coping efforts in the context of chronic stress.