Osteoarthritis year in review 2022: rehabilitation.

This year in review presents key highlights from research relating to osteoarthritis (OA) rehabilitation published from the 1st April 2021 to the 18th March 2022. To identify studies for inclusion in the review, an electronic database search was carried out in Medline, Embase and CINAHLplus. Following screening, included studies were grouped according to their predominant topic area, including core OA rehabilitation treatments (education, exercise, weight loss), adjunctive treatments, novel and emerging treatments or research methods, and translation of rehabilitation evidence into practice. Studies of perceived high clinical importance, quality, or controversy in the field were selected for inclusion in the review. Headline findings include: the positive role of technology to support remote delivery of core OA rehabilitation treatments, the importance of delivering educational interventions alongside exercise, the clinical and cost-effectiveness of a stepped approach to exercise, controversy around the potential mechanisms of action of exercise, mixed findings regarding the use of splinting for thumb base OA, increasing research on blood flow restriction training as a potential new intervention for OA, and evidence that the beneficial effects from core OA treatments seen in randomised controlled trials can be seen when implemented in clinical practice. A consistent finding across several recently published systematic reviews is that randomised controlled trials testing OA rehabilitation interventions are often small, with some risk of bias. Whilst future research is warranted, it needs to be large scale and robust, to enable definitive answers to important remaining questions in the field of OA rehabilitation.

Psychological factors not strength deficits are associated with severity of gluteal tendinopathy: A cross-sectional study.

BACKGROUND: Gluteal tendinopathy is the most common lower limb tendinopathy presenting to general practice. It has a high prevalence amongst middle-aged women and impacts on daily activities, work participation and quality of life. The aim was to compare physical and psychological characteristics between subgroups of severity of pain and disability. METHODS: A multicentre cross-sectional cohort of 204 participants (mean age 55 years, 82% female) who had a clinical diagnosis of gluteal tendinopathy with magnetic resonance imaging confirmation were assessed. A range of physical and psychosocial characteristics were recorded. Pain and disability were measured with the VISA-G questionnaire. A cluster analysis was used to identify mild, moderate and severe subgroups based on total VISA-G scores. Between-group differences were then evaluated with a MANCOVA, including sex and study site as covariates, followed by a Bonferroni post hoc test. Significance was set at 0.05. RESULTS: There were significantly higher pain catastrophizing and depression scores in the more severe subgroups. Lower pain self-efficacy scores were found in the severe group compared to the moderate and mild groups. Greater waist girth and body mass index (BMI), lower activity levels and poorer quality of life were reported in the severe group compared to the mild group. Hip abductor muscle strength and hip circumference did not differ between subgroups of severity. CONCLUSIONS: Individuals with severe gluteal tendinopathy present with psychological distress, poorer quality of life, greater BMI and waist girth. Given these features, the consideration of psychological factors in more severe patients may be important to optimize patient outcomes and reduce healthcare utilization. SIGNIFICANCE: Patients with severe gluteal tendinopathy exhibit greater psychological distress, poorer quality of life and greater waist girth and BMI when compared to less severe cases. This implies that clinicians ought to consider psychological factors in the management of more severe gluteal tendinopathy.

Trajectories of adherence to home-based exercise programs among people with knee osteoarthritis.

OBJECTIVE: To investigate the presence of different trajectories of self-reported adherence to home exercise programs among people with knee osteoarthritis (OA), and to compare baseline characteristics across identified groups. DESIGN: Pooled analysis of data from three randomised controlled trials involving exercise interventions for people aged ≥50 years with clinical knee OA (n = 341). Exercise adherence was self-reported on an 11-point numerical rating scale (NRS; 0 = not at all-10 = completely as instructed). Latent class growth analysis was used to identify distinct trajectories of adherence, at intervals from 12 to 78 weeks from baseline. Baseline characteristics of these groups were compared using chi-squared tests, one-way analysis of variance (ANOVA) and Kruskal Wallis tests where appropriate. RESULTS: Three distinct adherence trajectories were identified: a "Rapidly declining adherence" group (n = 157, 47.4%) whose adherence was 7.7 ± 1.6 (/10) at 12 weeks, declined to 4.2 ± 2.2 by 22 weeks and remained low thereafter; a "Gradually declining adherence" group (n = 153, 45.1%) whose adherence declined from 8.5 ± 1.5 to 7.8 ± 1.5 over the same period, and continued to decline slowly, and a "Low adherence" group (n = 21, 6.3%) whose adherence was 2.2 ± 1.4 at 12 weeks and remained low. At baseline the "Rapidly declining adherence" group reported significantly lower Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain (mean difference (95% Confidence Interval (CI)) -0.8 (-1.4, -0.2)) and better WOMAC function compared to the "Gradually declining adherence" group (-3.1 (-5.2, -1.1)). CONCLUSION: Three trajectories of self-reported adherence to home exercises were found among people with knee OA. Findings highlight the need for close monitoring of adherence from initiation of a home exercise program in order to identify and intervene when low or rapidly declining adherence is identified.

Use of nondrug, nonoperative interventions by community-dwelling people with hip and knee osteoarthritis.

OBJECTIVE: Guidelines recommend nondrug, nonoperative treatments as the first-line approach for hip and knee osteoarthritis (OA), yet there is limited data regarding use of these treatments in OA. This study describes the use of nondrug, nonoperative interventions in people with hip and knee OA. METHODS: A convenience sample of 591 people with hip or knee OA completed a questionnaire indicating their past and/or current use of 17 nondrug, nonoperative interventions each for their hip or knee OA. Descriptive analyses, based on frequency counts and proportions, and chi-square tests described the use of each intervention in the total cohort, and within subgroups of knee and hip OA. RESULTS: Participants were currently using a mean ± SD of 0.8 ± 0.9 of the strongly recommended interventions. Making efforts to lose weight (50%, n = 294) and shoe orthoses (30%, n = 175) were the most common currently used interventions. Strengthening (26%, n = 152) and stretching exercises (23%, n = 133) were the most common interventions that participants had tried in the past but were no longer utilizing. Of note, 12% (n = 71) had never used any of the interventions. Use of 5 treatments (shoe orthoses, heat and/or cold, muscle strengthening exercises, walking aids, and transcutaneous electrical nerve stimulation) was significantly different between the hip and knee cohorts (P < 0.05). CONCLUSION: Use of nondrug, nonoperative interventions was low among people with hip and knee OA. Our findings show evidence­practice gaps, particularly with respect to the interventions most strongly recommended in clinical guidelines for hip and knee OA (weight loss and exercise).

Ethical review of health service research in the UK: implications for nursing.

BACKGROUND: This paper examines the current systems and structures for ethical review of health services research in the United Kingdom (UK). Past criticisms and the adequacy of recent governance arrangements for Ethics Committees in addressing these are discussed. The implications for nurses are then considered. RATIONALE: This examination of the situation is prompted by the demand for more innovative research designs in health care evaluation, new regulations and guidance, and a climate of public anxiety regarding research conduct in the UK. FINDINGS: The evolution of Research Ethics Committees (RECs) has been slow and resulted in a lack in consistency. Criticisms made of RECs can be categorized into four main areas. New governance arrangements for RECs have emerged as potential solutions to these criticisms. This review identifies the limitations of the new governance arrangements in addressing past criticisms because of two factors. The first is insufficient funding. The second is confusion about the confidentiality and consent requirements of clinicians working in areas where research is conducted and on whom recruitment processes often rely. The current situation regarding health research ethical review has implications for nurses, whether they are working as researchers, members of Ethics Committees or clinicians where research is conducted. CONCLUSION: The new governance arrangements may go some way to addressing past problems. However, investment in RECs is required. It is also important to realize that maintaining ethical probity in health service research is a tripartite concern. It is reliant as it is on the actions of Ethics Committees and clinical research partners as well as those of the researchers themselves.

Soft contact lens polymers: an evolution.

A review of patents and literature reveals an evolution in materials technologies. The evolution has been driven by an increased understanding of the physiological needs of the cornea, beginning with the first hydrogel lenses developed by Wichterle, followed by a variety of high water hydrogels. Oxygen transmission requirements have been addressed through the use of siloxane and fluorosiloxane containing hydrogels. An important development has been the appreciation of the importance of polymer phase morphology on lens movement on the eye. In parallel with these activities have come the advancements in materials suitable to high volume, low cost production necessary for today's daily disposable lenses.

Extended scope of nursing practice: a multicentre randomised controlled trial of appropriately trained nurses and pre-registration house officers in pre-operative assessment in elective general surgery.

OBJECTIVES: (1) To determine whether pre-operative assessment carried out by an appropriately trained nurse (ATN) is equivalent in quality to that carried out by a pre-registration house officer (PRHO). (2) To assess whether pre-assessments carried out by ATNs and PRHOs are equivalent in terms of cost. (3) To determine whether assessments carried out by ATNs are acceptable to patients. (4) To investigate the quality of communication between senior medical staff and ATNs. DESIGN: The study design was principally a prospective randomised equivalence trial but was accompanied by additional qualitative assessment of patient and staff perceptions, and an economic evaluation. SETTING: The study was carried out at four NHS hospitals, three of which were teaching hospitals, in three NHS Trusts in Southampton, Sheffield and Doncaster. SUBJECTS: All patients attending at one site for assessment prior to general anaesthetic for elective general, vascular, urological or breast surgery were potentially included in the study. Of 1907 patients who were randomised, 1874 completed the study with a full evaluation. INTERVENTIONS: The intervention consisted of a pre-operative assessment carried out by either an ATN or a PRHO. Of the patients who completed the study with a full evaluation, 926 patients were randomised to the PRHO arm of the trial and 948 to the ATN arm. Three ATNs took part in the study, one from each centre, together with a total of 87 PRHOs. MAIN OUTCOME MEASURES: Immediately following the initial assessment of a patient by a PRHO or an ATN, one of a number of clinical research fellows, all specialist registrars in anaesthetics, repeated the assessment and recorded it on a study form, together with a list of investigations required. The clinical research fellow then evaluated the competency of the initial assessor by comparing the quality of their assessment with their own. Any deficiencies in ordering of investigations and referral to other specialities were met in order to maximise patient care. Three areas of ATN and PRHO performance were judged separately, history taking, examination and ordering of tests, and each was graded into one of four categories, the most important of which was under-assessment, which would possibly have affected peri-operative management. In the case of ordering of tests, it was possible to have both over- and under-assessed a patient on different tests. RESULTS: The pre-operative assessments carried out by the ATNs were essentially equivalent to those performed by the PRHOs in terms of under-assessment that might possibly have affected peri-operative management, although there was variation between the ATNs in terms of the quality of history taking. This may be related to the low number of patients seen at one study site. PRHOs ordered significantly more unnecessary tests than the ATNs. The substitution of ATNs for PRHOs was calculated to be cost neutral. The results of the qualitative assessment showed that the use of ATNs for pre-operative assessment was acceptable to patients; however, there was no evidence that communication between senior medical staff and those carrying out pre-operative assessments was improved by their introduction. CONCLUSIONS: This study demonstrated no reason to inhibit the development of fully nurse-led pre-operative assessment, provided that the nurses are appropriately trained and maintain sufficient workload to retain skills. CONCLUSIONS--IMPLICATIONS FOR THE HEALTH SERVICE: ATNs provide an acceptable and efficient alternative to PRHOs for the purposes of routine pre-operative assessment. Consideration will have to be given, however, to the positions of these nurses within the surgical team, and also to their career structure. CONCLUSIONS--RECOMMENDATIONS FOR FUTURE RESEARCH: Further research is needed in the following areas: (1) the extent and type of training needed for nurses undertaking the pre-operative assessment role; (2) the use, costs and benefits of routine pre-operative testing.

The psychosocial impact of spasticityrelated problems for people with multiple sclerosis: a focus group study.

This focus group, qualitative study (N = 18) reports the psychosocial impact, specifically, of spasticity symptoms on a sample of people with MS (multiple sclerosis). MS, a chronic disabling disease which attacks the central nervous system, currently affects about 100,000 people in the UK and estimates indicate that worldwide prevalence varies from around 10 to 250 per 100,000. The cause remains unknown and the rate of disease progression varies among individuals. The disease of MS itself has a severe impact on psychological well-being and quality of life. However, there is little evidence about the additional impact of the spasticity-related symptoms, which include involuntary muscle contractions, loss of dexterity, loss of balance, incontinence and pain. These are shown here to lead to further distress and embarrassment and to have a detrimental influence on emotional and social relationships.

General practitioners' perceptions of store-and-forward teledermatology.

We studied the views of 26 general practitioners (GPs) towards store-and-forward tele-dermatology before its introduction into their practices. A postal questionnaire was developed using Likert-type questions with respondents able to explain their answers in free text. Questions related to the GPs' knowledge, perceptions and expectations of tele-dermatology, as well as their attitudes towards being part of a research trial. Most of the GPs had limited prior knowledge of tele-dermatology. They perceived its role to relate to quicker access to specialist opinions, decreased referrals, increased convenience for patients, diagnosis, and education and teaching. There was an overwhelming view that any system needed to be quick, easy to use, efficient and reliable. Concerns were expressed about being part of the clinical trial, using new technology and an increased workload. The future of tele-dermatology was thought to depend on the clinical adequacy of the system.

The patient's burden: physical and psychological effects of acute exacerbations of chronic bronchitis.

In this prospective qualitative study we evaluated the subjective perspectives of the quality of life of patients with chronic bronchitis. Individuals with diagnoses which fulfilled the clinical criteria of chronic bronchitis, i.e. daily production of sputum for at least three consecutive months in two consecutive years, were recruited into four focus groups from general practices in two industrial cities. Younger patients (those of pre-retirement age) of both sexes-a significant, but frequently 'invisible' minority in this patient population-were targeted. The groups were constituted with the aim of stimulating variation in the discussions. Twenty sufferers (10 males and 10 females, ranging in age from 30 to 86 years) were eventually included in the study; there were five in each group. Group discussions were recorded and transcribed verbatim and the data were analysed thematically. It was evident from the discussions that chronic bronchitis had led to a high degree of psychological distress in the participants, particularly in relation to dependency on medication, and disruption of social and family relationships. Acute exacerbations of chronic bronchitis (AECB) were met with dread. They brought about further reductions in quality of life, increased anxieties about breathlessness, fear of atmospheric pollution and of changes in and extremes of temperature, embarrassment about coughing up phlegm in public and suspicion of medical practitioners' motives if they were unwilling to prescribe antibiotics on request. Patients' health-related behaviour and beliefs were often contradictory. For example, AECB in some patients led to increased smoking. There were also gender and age differences; for example, it was the perception of males that they received more support from their partners than did females. Younger participants appeared more distressed by AECB than older ones. The results of this study suggest that raising the standard of care for patients with chronic bronchitis requires that greater attention be paid to patients' subjective experiences of the disease.

The menstrual cycle, science and femininity: assumptions underlying menstrual cycle research.

This paper examines the relationship between popular knowledge of menstruation and scientific research. It suggests that despite evidence to indicate that pre-menstrual cognitive, behavioural and emotional 'impairment' is relatively rare, the population notion that PMS routinely affects many women adversely is difficult to displace. It concludes that mainstream menstrual cycle research is subject to the influence of misogynist mythology upheld as staunchly by women influenced by patriarchy as by men. Reasons are suggested which lie in the differential power of claims to knowledge.

The ideas and experiences of pregnancy and childbirth of Asian and non-Asian women in east London.

This study examined differences between the ideas and experiences of pregnancy and childbirth of Asian and non-Asian women giving birth in East London, and sources of variability in Asian women's accounts. In line with the findings of previous research, Asian women's ideas about diet in pregnancy, the gender of their children and postnatal care (e.g. the need for rest and recovery, and restrictions on their activities) were influenced by cultural beliefs and practices. However, in other ways Asian women demonstrated a strong commitment to Western maternity care. In contrast to some other studies Asian women wanted their husbands or partners present at delivery, indicating the extent to which traditional ideas are being modified. Qualitative analysis of Asian women's fuller accounts indicated that women subscribed to traditional practice as well as Western maternity care. Acculturation or familiarity with Western ideas about maternity care was associated with variability in Asian women's ideas and experiences, in line with previous research. However, in spite of frequent assumptions about its significance, religion was not associated with variability in Asian women's ideas and experiences. Parity, however, was a major variable, for Asian and for non-Asian women, suggesting that the first birth has different significance for parents than subsequent births. The implications for the provision of maternity care are discussed, especially the need to go beyond stereotypical views based on women's ethnicity or religion to consider the beliefs and preferences of women as individuals and their personal circumstances.

Bioprogressive brackets and pentamorphic arches.

The use of high torque values with no tip in preadjusted incisor brackets in the Bioprogressive system, in conjunction with narrow anterior rectangular archwires may produce crown spacing, root crowding and upright central incisors. The solution to these problems would seem either to reduce the time spent in rectangular wires or to change to a bracket with reduced torque, together with appropriate second order compensations in the archwire or the bracket.

Understanding postnatal depression: a mother-centred approach.

Research findings on the causes and correlates of postnatal depression divide into two explanatory frameworks. The clinical/medical model identifies the mothers as being 'ill', and the social science model suggests a particular vulnerability to additional social stress factors. Despite attempts to predict those women at risk, and develop preventative programmes, most treatment initiatives are reactive, which is a direct result of the inconclusive nature of available evidence. The study reported here suggests that the concept 'postnatal depression' needs to be re-examined and that rather than it being an individual illness or vulnerability, it is more akin to a normal grief reaction and part of a normal postnatal profile. It only becomes a problem when it is defined and treated inappropriately. The implications from this research lead to a new approach to understanding the mother's experience of postnatal depression, and types of counselling and support which might effectively be employed by midwives and health visitors.