Healthcare Quality Indicators for Physiotherapy Management in Hip and Knee Osteoarthritis and Rheumatoid Arthritis: A Delphi Study.

OBJECTIVES: The aim of the present study was to develop healthcare quality indicators (HCQIs) for the physiotherapy (PT) management of patients with hip or knee osteoarthritis (HKOA) or rheumatoid arthritis (RA) in the Netherlands. METHODS: Two multidisciplinary expert panels, including patients, were instituted. A draft HCQI set was derived from recommendations included in two existing Dutch PT guidelines for HKOA and RA. The panels suggested additional topics, after which a Delphi procedure was performed. All propositions were scored for their potential to represent good-quality PT care (score range 0-9). Based on predefined rules, the Delphi panel HCQIs were discussed and selected. Lastly, every indicator was rephrased, resulting in its output consisting of a numerator and denominator, to facilitate comparisons within and among practices. RESULTS: After two Delphi rounds, two final sets of 17 HCQI - one for HKOA and one for RA - were composed, both containing 16 process indicators (regarding initial assessment, treatment and evaluation) and one outcome indicator. CONCLUSIONS: Two sets of HCQIs for PT management in HKOA and RA were developed for measuring the quality of PT care in daily clinical practice. Each indicator was formulated in a measurable way. Future research should focus on the feasibility of both indicator sets for daily clinical practice.

Physical therapists' management of rheumatoid arthritis: results of a Dutch survey.

BACKGROUND AND AIM: For tailored implementation of evidence-based recommendations and guidelines on physical therapy in patients with rheumatoid arthritis (RA), insight into current physical therapy practice is needed. METHOD: Two hundred and fifty general physical therapists and 211 specialized physical therapists with advanced arthritis training were sent a questionnaire to assess the frequency with which they applied a set of assessments (n = 10) and interventions (n = 7) included in a Dutch physical therapy guideline for RA. Differences between general and specialist physical therapists were analysed using Student's t-tests or chi-square tests where appropriate. RESULTS: In total, 233 physical therapists (51%) responded. Of these, 96 (41%) had completed an additional arthritis course and were designated as specialist physical therapists. Among the physical therapists who returned the questionnaire, 69% (or more) reported that they 'always' assessed limitations in daily functioning, pain, morning stiffness, muscle strength, joint range of motion, joint stability, gait and limitations in leisure activities as part of their initial assessment, and 37% and 48% reported 'always' to assess aerobic capacity and limitations in work situations, respectively. Concerning interventions, exercise therapy and education were 'always' applied by 70% and 68% of the responders, respectively. Only a minority of responders reported 'always' applying ultrasound, electrical stimulation, heat therapy, massage and passive mobilizations (0%, 0%, 5%, 5% and 14%, respectively). Apart from aerobic capacity and work limitations, all other assessments were reported as 'always' applied by significantly (p < 0.05) more specialist physical therapists than general physical therapists. Regarding interventions, significantly more specialist physical therapists reported that they 'always' applied exercise therapy and education. Significantly fewer specialist physical therapists than in the general group reported 'always' using heat therapy, massage and mobilizations (p < 0.05). CONCLUSION: The majority of physical therapists reported that they 'always' applied most of the assessments and interventions recommended in a Dutch physical therapy guideline for the management of RA. Areas for improvement include the assessment of aerobic capacity and work limitations. The observed differences between specialist and general physical therapists support the added value of advanced arthritis courses.

Physiotherapy in hip and knee osteoarthritis: development of a practice guideline concerning initial assessment, treatment and evaluation.

BACKGROUND: An update of a Dutch physiotherapy practice guideline in Hip and Knee Osteoarthritis (HKOA) was made, based on current evidence and best practice. METHODS: A guideline steering committee, comprising 10 expert physiotherapists, selected topics concerning the guideline chapters: initial assessment, treatment and evaluation. With respect to treatment a systematic literature search was performed using various databases, and the evidence was graded (1-4). For the initial assessment and evaluation mainly review papers and textbooks were used. Based on evidence and expert opinion, recommendations were formulated. A first draft of the guideline was reviewed by 17 experts from different professional backgrounds. A second draft was field-tested by 45 physiotherapists. RESULTS: In total 11 topics were selected. For the initial assessment, three recommendations were formulated, pertaining to history taking, red flags, and formulating treatment goals. Concerning treatment, 7 recommendations were formulated; (supervised) exercise therapy, education and self management interventions, a combination of exercise and manual therapy, postoperative exercise therapy and taping of the patella were recommended. Balneotherapy and hydrotherapy in HKOA, and thermotherapy, TENS, and Continuous Passive Motion in knee OA were neither recommended nor discouraged. Massage therapy, ultrasound, electrotherapy, electromagnetic field, Low Level Laser Therapy, preoperative physiotherapy and education could not be recommended. For the evaluation of treatment goals the following measurement instruments were recommended: Lequesne index, Western Ontario and McMaster Universities osteoarthritis index, Hip disability and Osteoarthritis Outcome Score and Knee injury and Osteoarthritis Outcome Score, 6-minute walktest, Timed Up and Go test, Patient Specific Complaint list, Visual Analoge Scale for pain, Intermittent and Constant OsteoArthritis Pain Questionnaire, goniometry, Medical Research Council for strength, handheld dynamometer. CONCLUSIONS: This update of a Dutch physiotherapy practice guideline on HKOA included 11 recommendations on the initial assessment, treatment and evaluation. The implementation of the guideline in clinical practice needs further evaluation.

Physiotherapy in rheumatoid arthritis: development of a practice guideline.

BACKGROUND: To improve the quality of the physiotherapy management in patients with rheumatoid arthritis (RA) a Dutch practice guideline, based on current scientific evidence and best practice, was developed. This guideline comprised all elements of a structured approach (assessment, treatment and evaluation) and was based on the Internatio-nal Classification of Functioning, disability and Health (ICF) and the ICF core sets for RA. METHODS: A guideline steering committee, comprising 10 expert physiotherapists, selected topics concerning the guideline chapters initial assessment, treatment and evaluation. With respect to treatment a systematic literature search was performed using various databases, and the evidence was graded (1-4). For the initial assessment and evaluation mainly review papers and textbooks were used. Based on evidence and expert opinion, recommendations were formulated. A first draft of the guideline was reviewed by 10 experts from different professional backgrounds resulting in the final guideline. RESULTS: In total 7 topics were selected. For the initial assessment, three recommendations were made. Based on the ICF core sets for RA a list of health problems relevant for the physiotherapist was made and completed with red flags and points of attention. Concerning treatment, three recommendations were formulated; both exercise therapy and education on physiotherapy were recommended, whereas passive interventions (delivery of heat or cold, mechanical, electric and electromagnetic energy, massage, passive mobilization/manipulation and balneotherapy) were neither recommended nor discouraged. For treatment evaluation at the level of activities and participation, the Health Assessment Questionnaire was recommended. For evaluating specific body structures and functions the handheld dynamometer, 6-minute walk test or Ästrand bicycle test (including Borg-scale for rating the perceived exertion), Escola Paulista de Medicina Range of Motion Scale and a Visual Analog Scale for pain and morning stiffness were recommended. CONCLUSION: This physiotherapy practice guideline for RA included seven recommendations on the initial assessment, treatment and evaluation, which were all based on the ICF and the ICF Core Set for RA. The implementation of the guideline in clinical practice needs further evaluation.

Motivation as a determinant of physical activity in patients with rheumatoid arthritis.

OBJECTIVE: A sufficient level of physical activity is important in reducing the impact of disease in rheumatoid arthritis (RA) patients. According to self-determination theory, the achievement and maintenance of physical activity is related to goal setting and ownership, which can be supported by health professionals. Our objective was to examine the association between physical activity and the extent to which RA patients 1) believe that physical activity is a goal set by themselves (autonomous regulation) or by others (coerced regulation) and 2) feel supported by rheumatologists (autonomy supportiveness). METHOD: A random selection of 643 RA patients from the outpatient clinics of 3 hospitals were sent a postal survey to assess current physical activity level (Short Questionnaire to Assess Health-Enhancing Physical Activity), regulation style (Treatment Self-Regulation Questionnaire), and the autonomy supportiveness of their rheumatologists (modified Health Care Climate Questionnaire). RESULTS: Of the 271 patients (42%) who returned the questionnaire, 178 (66%) were female, their mean +/- SD age was 62 +/- 14 years, and their mean +/- SD disease duration was 10 +/- 8 years. Younger age, female sex, higher education level, shorter disease duration, lower disease activity, and a more autonomous regulation were univariately associated with more physical activity. Hierarchical multiple regression analyses demonstrated that younger age and a more autonomous regulation were significantly associated with a higher physical activity level (P = 0.000 and 0.050, respectively). CONCLUSION: Regulation style was a significant determinant of physical activity in RA patients. This finding may contribute to further development of interventions to enhance physical activity in RA patients.

Reproducibility of the measurement of knee joint proprioception in patients with osteoarthritis of the knee.

OBJECTIVE: To estimate the inter- and intrarater reliability and agreement of instrumented knee joint proprioception measurement in subjects with knee osteoarthritis (OA) and healthy subjects; to assess the effect of variations in the measurement procedure on agreement parameters. METHODS: Proprioception was measured by a computer-controlled knee angular motion-detecting device in a movement-detecting task. The angular displacement between the starting position and the position at the instant of movement detection by the subject was recorded. Two raters independently assessed knee joint proprioception. After 14 days the assessment was repeated. Complete data were obtained from 24 subjects with knee OA and 26 healthy subjects. The inter- and intrarater reliability coefficients (intraclass correlation coefficients [ICC]) and inter- and intrarater agreement measures (standard error of measurement [SEM] and minimal detectable difference [MDD]) were calculated. Additionally, the effect of changing the velocity of angular displacement and applying headphone music during the measurement on the absolute error (i.e., SEM and MDD) was estimated at the second occasion. RESULTS: Interrater reliability was good in subjects with knee OA and healthy subjects (ICC 0.91 and 0.89, respectively). Interrater agreement was higher in subjects with knee OA than in healthy subjects (SEM 2.13 degrees versus 0.43 degrees , MDD 5.90 degrees versus 1.19 degrees ). Intrarater reliability was good in subjects with knee OA and healthy subjects (ICC 0.91 and 0.86, respectively). Intrarater agreement (SEM and MDD) was 2.26 degrees and 6.26 degrees in subjects with knee OA and 0.39 degrees and 1.08 degrees in healthy subjects. The original measurement and the 2 variations in measurement showed comparable measurement errors for subjects with knee OA and healthy subjects. CONCLUSION: In knee OA subjects and healthy subjects, knee proprioception measurement shows adequate intra- and interreliability. However, the absolute measurement error is rather high. Therefore, this measurement has limited value in the assessment of individual subjects, but can be recommended for scientific research in groups of individuals.