A multicenter investigation of reablement in Norway: a clinical controlled trial.

BACKGROUND: Reablement is an emerging approach in rehabilitation services, but evidence for its efficacy is rather weak and inconsistent. The purpose of the present study is therefore to investigate the health effects of reablement in home-dwelling adults. METHODS: A multicenter, clinical controlled trial involving 47 municipalities in Norway, with assessments at baseline, and after 10 weeks and at 6 and 12 months. The sample consisted of 707 persons that received a 4-10 week reablement program and 121 underwent treatment as usual. Primary outcomes were activity performance and satisfaction with performance measured by the Canadian Occupational Performance Measure (COPM, 1-10). Secondary outcomes included the Short Physical Performance Measure Battery (SPPB), the European Quality of Life Scale (EQ-5D-5 L), and the Sense of Coherence Questionnaire (SOC). Overall treatment effects were estimated with mixed-model repeated measures analyses. RESULTS: Significant treatment effects in the rehabilitation group compared with the control group were found in COPM-Performance and COPM-Satisfaction scores at 10 weeks (mean differences between groups (MD), 1.61, 95% confidence interval (CI), 1.13, 2.10 and MD 1.47, CI 0.98, 1.97, respectively), and at 6 months (MD 1.42; CI 0.82,2.02 and MD 1.37; CI 0.77,1.98, respectively). There were also significant treatment effects in the SPPB-subscales for balance and walking after 6 months, in the total SPPB score and in the subscale for sit-to-stand after 12 months. In the EQ-5D-5 L assessment, significant treatment effects were found in the subscales for mobility, and for usual activities and health after 6 months. There was a significant difference in the SOC after six months. CONCLUSION: Reablement seems to be a more effective rehabilitation service for persons with functional decline than traditional home-based services after six months. After 12 months, the differences between the groups decreased. TRIAL REGISTRATION: The trial was registered at ClinicalTrials.gov on October 24, 2014, (retrospectively registered) identifier: NCT02273934 .

Measurement properties for the revised patient-reported OsteoArthritis Quality Indicator questionnaire.

OBJECTIVES: To assess validity, reliability, responsiveness and interpretability of the revised OsteoArthritis Quality Indicator (OA-QI) questionnaire version 2 (v2) assessing patient-reported quality of osteoarthritis care. METHODS: The OA-QI v2 (16 items, score range 0-100 (100 = best score)) was included in a longitudinal cohort study. Attendees of a 4.5 h osteoarthritis patient education programme at Diakonhjemmet Hospital, Norway, completed the OA-QI at four time points: 2 weeks before, immediately before, immediately after, and 3 months after the programme. Test-retest reliability and measurement error over a 2-week time period were assessed in those that had not seen health professionals in the interim. Construct validity and responsiveness were assessed with predefined hypotheses. Floor and ceiling effects, smallest detectable change (SDC95%) and minimal important change (MIC) were assessed to evaluate interpretability. RESULTS: The intraclass correlation coefficient for all 16 items was 0.89. For single items the test-retest kappa estimates ranged 0.38-0.85 and percent agreement 69-92%. Construct validity was acceptable with all six predefined hypotheses confirmed. Responsiveness was acceptable with 33 of 48 and three of four predefined hypotheses confirmed for single items and all items, respectively. There were no floor or ceiling effects. The SDC95% was 29.1 and 3.0 at the individual and group levels, respectively. MIC was 20.4. CONCLUSIONS: The OA-QI v2 had higher reliability estimates compared to v1, showed acceptable validity, and is the recommended version for future use. The results of responsiveness testing further support the use of the OA-QI v2 as an outcome measure in studies aiming to improve osteoarthritis care.

Developing and testing a consensus-based core set of outcome measures for rehabilitation in musculoskeletal diseases.

OBJECTIVES: Rehabilitation is important for people with musculoskeletal diseases (MSDs), and evaluating the effect of rehabilitation on both an individual and group level is advocated. A consensus concerning use of outcome measures will improve collaboration between healthcare providers, and increase the possibility of conducting meta-analyses in future research. The aim of this study was to develop a consensus-based core set of outcome measures for rehabilitation in MSDs, and to test the feasibility and responsiveness of the set. METHOD: The core set was developed through a stepwise process comprising a Delphi consensus procedure, systematic literature searches, and a pilot study, including 386 patients, to test the feasibility and responsiveness of the set. RESULTS: The following aspects and outcome measures were selected: pain [numeric rating scale (NRS)], fatigue (NRS), physical fitness (the 30-second Sit to Stand test), mental health (Hopkins Symptom Checklist 5), daily activities (Hannover Functional Questionnaire), goal attainment (Patient-Specific Functional Scale including motivation score for baseline assessment), quality of life (5-level EuroQol 5 Dimensions), social participation (the social participation item from COOP/WONCA) and coping (Effective Musculoskeletal Consumer Scale-17). All tested outcome measures were found to be feasible, with high completion rates and acceptable score distribution. Standard response means varied from 0.3 to 0.9. CONCLUSIONS: A consensus-based core set of patient reported outcome measures is presented for evaluating rehabilitation in MSDs. The core set is feasible and responsive for use in Norway, but needs further testing in other countries.

Characterizing the concept of activity pacing as a non-pharmacological intervention in rheumatology care: results of an international Delphi survey.

OBJECTIVE: To develop a consensual list of the most important aspects of activity pacing (AP) as an intervention within the context of non-pharmacological rheumatology care. METHOD: An international, multidisciplinary expert panel comprising 60 clinicians and/or healthcare providers experienced in AP across 12 different countries participated in a Delphi survey. Over four Delphi rounds, the panel identified and ranked the most important goals of AP, behaviours of AP (the actions people take to meet the goal of AP), strategies to change behaviour in AP, and contextual factors that should be acknowledged when instructing AP. Additionally, topics for future research on AP were formulated and prioritized. RESULTS: The Delphi panel prioritized 9 goals, 11 behaviours, 9 strategies to change behaviour, and 10 contextual factors of AP. These items were integrated into a consensual list containing the most important aspects of AP interventions in non-pharmacological rheumatology care. Nine topics for future research on AP with the highest ranking were included in a research agenda highlighting that future research should focus on the effectiveness of AP interventions and on appropriate outcome measures to assess its effectiveness, as selected by 64% and 82% of the panellists, respectively. CONCLUSIONS: The diversity and number of items included in the consensual list developed in the current study reflect the heterogeneity of the concept of AP. This study is an important first step in achieving more transparency and homogeneity in the concept of AP in both rheumatology daily clinical practice and research.

Limited effects of exercises in people with hand osteoarthritis: results from a randomized controlled trial.

OBJECTIVE: To determine the clinical effectiveness of an exercise programme on self-reported hand activity performance in people with hand osteoarthritis (OA). DESIGN: In this randomized, controlled trial, participants with physician-confirmed hand OA were randomly allocated to a 12-week exercise intervention (group- and home-based) or usual care. The primary outcome was self-reported hand activity performance at 3 months measured by the Functional Index for Hand Osteoarthritis (FIHOA) and a patient-generated measure of disability, the Patient-Specific Functional Scale (PSFS). RESULTS: Of 130 randomized participants (mean age 66 (standard deviation (SD) 9); female 90%), 120 (92%) and 119 (92%) completed the 3- and 6-month follow-ups. The adjusted mean difference for the exercise vs control group was -0.5 points (95% confidence interval (CI) -1.6, 0.6) for the FIHOA score (0-30 scale, 0 = best) and 0.9 points (95% CI 0.1, 1.7) for the PSFS score (0-10 scale, 10 = best). Small significant mean differences in favour of the intervention group were found for hand pain, hand stiffness and disease activity, whereas no mean differences were observed in hand dexterity or maximal grip strength. A significantly larger proportion in the intervention (46%) vs control group (16%) fulfilled the Outcome Measures in Rheumatological Clinical Trials-Osteoarthritis Research Society International (OMERACT-OARSI) responder criteria at 3 months (OR = 4.4, 95% CI 1.9, 10.2). At the 6-month follow-up, there were no significant group differences in any outcome. CONCLUSIONS: The exercise programme was well tolerated among people with hand OA, but resulted only in small, beneficial short-term improvements on self-reported measures and not on most performance-based tests. Future studies should address optimal grip strength exercises and dosage. TRIAL REGISTRATION: ClinicalTrials.gov registration number: NCT01245842.

Current practice and barriers to the management of sexual issues in rheumatology: results of a survey of health professionals.

OBJECTIVES: To explore multidisciplinary health professionals' (HPs) management of disease-related sexual issues in patients with rheumatic diseases, including their perceptions and assessments, and identify factors that prevent HPs from addressing sexuality as a topic with patients. METHODS: A self-constructed questionnaire was sent to 647 nurses, physicians, physiotherapists, occupational therapists, social workers, and psychologists working within rheumatology care. A multivariate logistic regression model of significant determinants for initiating sexual topics with patients was built. RESULTS: The mean age of the responders (n = 274, 42% response rate, 87% female) was 46 years. While 96% considered sexuality a relevant topic in rheumatology care, 71% seldom/never raised the topic. The patient was the main initiator (53%), and 88% of HPs gave the patient responsibility to initiate. The HPs with relevant education in sexuality were significantly more comfortable talking about sexuality (p < 0.001) and raised sexual issues significantly more often (p < 0.001). In the multivariate analyses, higher age [odds ratio (OR) 3.69], having relevant education (OR 3.16), and being comfortable to some extent (OR 3.62) or to a large extent (OR 5.58) remained significant predictors to initiating sexual topics. CONCLUSIONS: Although HPs regarded sexuality as a relevant topic in rheumatic health care, they seldom raised the topic in consultations. Those with further education in sexuality addressed sexual issues more frequently and felt more comfortable. Correspondingly, the majority of respondents requested more education. Such training should be part of the basic HPs' education, as well as part of postgraduate courses.

Does the content really matter? A study comparing structure, process, and outcome of team rehabilitation for patients with inflammatory arthritis in two different clinical settings.

OBJECTIVES: To provide a thorough description of team rehabilitation care and compare the structure, process, and outcomes in two specialized arthritis rehabilitation settings. METHODS: Patients with inflammatory arthritis scheduled for inpatient rehabilitation in seven specialized rehabilitation centres and three rheumatology hospital departments in Norway were included consecutively in a prospective cohort study. Patients completed questionnaires at admission, at discharge, and at a 6-month follow-up, and kept a diary regarding structure and process variables during the rehabilitation stay. RESULTS: Eighty patients in rehabilitation centres and 73 in hospital departments were included and 80% responded to the 6-month follow-up questionnaire. The two clinical settings differed significantly with regard to structure variables such as cost, referral of patients, length of stay, and number of health professionals involved, and most process variables reflecting treatment modalities. The most remarkable difference was in the amount of individual intervention compared with group intervention. Despite significant improvements in most outcomes at discharge, the scores deteriorated towards baseline level 6 months later. There was a trend towards more significant improvement during rehabilitation for patients at rehabilitation centres whereas patients at hospitals had more prolonged improvement. CONCLUSIONS: Team rehabilitation for inflammatory arthritis in two different clinical settings differed across most variables for structure and process, but few significant differences in outcome were found. Considering the substantial differences in cost, there is an urgent need for consensus concerning which patients should receive rehabilitation in which setting. Future research on the development and evaluation of methods for prolonging the beneficial effects of rehabilitation is needed.

The Cochrane review of assistive technology for rheumatoid arthritis.

AIM: The aim of this systematic review is to summarise the available evidence on the effectiveness of assistive technology for adults with rheumatoid arthritis in terms of improving functional ability and reducing pain, and to assess potential adverse effects related to device use. METHODS: In this review, randomised controlled trials, clinical controlled trials, controlled before and after studies and interrupted time series available through systematic searches (electronic databases, grey literature, contact with authors, reference lists) up to October 2008 were included. Two reviewers independently selected trials for inclusion, assessed the validity of included trials, and extracted data. Investigators were contacted to obtain missing information. RESULTS: Out of 7177 hits, 13 articles were reviewed in full text and only one trial was finally included (N.=29). The study was a randomised crossover trial, in which the use of an eye drop device was compared to a standard bottle in people with rheumatoid arthritis suffering from persistent dry eyes. The results show that the eye drop device improved application of eye drops and prevented adverse effects in terms of touching the eye with the bottle tip. The study was considered to have low quality of evidence. CONCLUSION: Since only one trial met the inclusion criteria for this review, there is very limited evidence for the effect of assistive technology for adults with rheumatoid arthritis. There is an urgent need for high-quality research in this field, in order to reach sufficient evidence on the effectiveness of this commonly used intervention.

Patient experiences of rehabilitation in rheumatology: association with process and outcome.

OBJECTIVE: To evaluate health-care experiences of patients following inpatient rheumatology rehabilitation and to assess the association between these experiences and aspects of health-care delivery and patient characteristics. METHODS: Data were collected from 435 patients with a rehabilitation stay of >or= 1 week at 12 institutions in Norway in 2006. At discharge, patients completed the Rehabilitation Patient Experiences Questionnaire (Re-PEQ), which includes four important aspects of patient experiences. Multiple regression analysis was used to assess associations between Re-PEQ scores, health-care process, health and sociodemographic variables. RESULTS: A total of 412 (94.7%) patients completed the Re-PEQ; scores ranged from 69 (social environment) to 83 (care/organization) on the 0-100 scale, where 100 represents the best possible experience. The social environment scale had the largest component of variation explained by the independent variables, which included number of doctor visits, amount of group education, and individual exercise (p < 0.01). The type of institution, number of doctor visits, mental health, and gender also explained significant components of variation in the other Re-PEQ scale scores. CONCLUSION: Patients reported good experiences with rheumatology rehabilitation. Areas where poorer experiences emerged can help target areas for future initiatives aimed at improving the quality of care. Health and sociodemographic variables should be controlled for in studies of patient experiences.

Activity limitations and participation restrictions in women with hand osteoarthritis: patients' descriptions and associations between dimensions of functioning.

OBJECTIVE: To describe the functional consequences of hand osteoarthritis, and analyse associations between personal factors, hand impairment, activity limitations, and participation restrictions within the framework of the International Classification of Functioning (ICF). METHODS: 87 women with hand osteoarthritis completed a clinical examination including recording of sociodemographic data, measures of hand impairment, and completion of self reported health status measures. The function subscale of the AUSCAN Osteoarthritis Hand Index was used as a measure of hand related activity limitations, while the Canadian Occupational Performance Measure (COPM) was used to describe and measure activity limitations and participation restrictions as perceived by the individual. The study variables were categorised using the dimensions in the ICF framework and analysed using bivariate and multivariate statistical approaches. RESULTS: The patients described problems in many domains of activity and participation. The most frequently described hand related problems were activities requiring considerable grip strength combined with twisting of the hands. On the impairment level, the patients had reduced grip force and joint mobility in the hands, and resisted motion was painful. Regression analyses showed that hand related activity limitations were associated with measures of hand impairment, while activity and participation (as measured by the COPM) were more strongly associated with personal factors than with hand impairment. CONCLUSIONS: Hand osteoarthritis has important functional consequences in terms of pain, reduced hand mobility and grip force, activity limitations, and participation restrictions. Rehabilitation programmes should therefore be multidisciplinary and multidimensional, focusing on hand function, occupational performance, and coping strategies.

Use of commercially produced elastic wrist orthoses in chronic arthritis: a controlled study.

OBJECTIVE: To examine the efficacy of wrist orthoses on pain, motion, and function of the wrist. METHODS: Consecutive patients were randomized to a treatment group using wrist orthoses or to a control group using no wrist orthoses, in a prospective, controlled, 6-month study. RESULTS: Changes in wrist joint variables and general disease activity variables were not statistically different between the orthosis group (n = 36) and the control group (n = 33). Patients in the orthosis group had 25% and 12% improvements in grip strength and pinch grip and 50% reduction in pain while using the wrist orthosis. CONCLUSION: Use of wrist orthoses improves function and reduces pain, but has no effects after 6 months, compared to a control group, on measures of local or general disease activity.