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1.
BMJ Open ; 11(8): e052598, 2021 08 27.
Artigo em Inglês | MEDLINE | ID: mdl-34452970

RESUMO

OBJECTIVES: To evaluate whether a home-based rehabilitation programme for people assessed as being at risk of a poor outcome after knee arthroplasty offers superior outcomes to traditional outpatient physiotherapy. DESIGN: A prospective, single-blind, two-arm randomised controlled superiority trial. SETTING: 14 National Health Service physiotherapy departments in the UK. PARTICIPANTS: 621 participants identified at high risk of a poor outcome after knee arthroplasty using a bespoke screening tool. INTERVENTIONS: A multicomponent home-based rehabilitation programme delivered by rehabilitation assistants with supervision from qualified therapists versus usual care outpatient physiotherapy. MAIN OUTCOME MEASURES: The primary outcome was the Late-Life Function and Disability Instrument (LLFDI) at 12 months. Secondary outcomes were the Oxford Knee Score (a disease-specific measure of function), Knee injury and Osteoarthritis Outcome Score Quality of Life subscale, Physical Activity Scale for the Elderly, 5 dimension, 5 level version of Euroqol (EQ-5D-5L) and physical function assessed using the Figure of 8 Walk test, 30 s Chair Stand Test and Single Leg Stance. RESULTS: 621 participants were randomised between March 2015 and January 2018. 309 were assigned to CORKA (Community Rehabilitation after Knee Arthroplasty) home-based rehabilitation, receiving a median five treatment sessions (IQR 4-7). 312 were assigned to usual care, receiving a median 4 sessions (IQR 2-6). The primary outcome, LLFDI function total score at 12 months, was collected for 279 participants (89%) in the home-based CORKA group and 287 participants (92%) in the usual care group. No clinically or statistically significant difference was found between the groups (intention-to-treat adjusted difference=0.49 points; 95% CI -0.89 to 1.88; p=0.48). There were no statistically significant differences between the groups on any of the patient-reported or physical secondary outcome measures at 6 or 12 months.There were 18 participants in the intervention group reporting a serious adverse event (5.8%), only one directly related to the intervention, all other adverse events recorded throughout the trial related to underlying chronic medical conditions. CONCLUSIONS: The CORKA intervention was not superior to usual care. The trial detected no significant differences, clinical or statistical, between the two groups on either primary or secondary outcomes. CORKA offers an evaluation of an intervention utilising a different service delivery model for this patient group. TRIAL REGISTRATION NUMBER: ISRCTN13517704.


Assuntos
Artroplastia do Joelho , Idoso , Análise Custo-Benefício , Humanos , Modalidades de Fisioterapia , Estudos Prospectivos , Qualidade de Vida , Método Simples-Cego , Medicina Estatal
2.
Lancet ; 398(10298): 416-428, 2021 07 31.
Artigo em Inglês | MEDLINE | ID: mdl-34265255

RESUMO

BACKGROUND: Corticosteroid injections and physiotherapy exercise programmes are commonly used to treat rotator cuff disorders but the treatments' effectiveness is uncertain. We aimed to compare the clinical effectiveness and cost-effectiveness of a progressive exercise programme with a single session of best practice physiotherapy advice, with or without corticosteroid injection, in adults with a rotator cuff disorder. METHODS: In this pragmatic, multicentre, superiority, randomised controlled trial (2 × 2 factorial), we recruited patients from 20 UK National Health Service trusts. We included patients aged 18 years or older with a rotator cuff disorder (new episode within the past 6 months). Patients were excluded if they had a history of significant shoulder trauma (eg, dislocation, fracture, or full-thickness tear requiring surgery), neurological disease affecting the shoulder, other shoulder conditions (eg, inflammatory arthritis, frozen shoulder, or glenohumeral joint instability), received corticosteroid injection or physiotherapy for shoulder pain in the past 6 months, or were being considered for surgery. Patients were randomly assigned (centralised computer-generated system, 1:1:1:1) to progressive exercise (≤6 sessions), best practice advice (one session), corticosteroid injection then progressive exercise, or corticosteroid injection then best practice advice. The primary outcome was the Shoulder Pain and Disability Index (SPADI) score over 12 months, analysed on an intention-to-treat basis (statistical significance set at 1%). The trial was registered with the International Standard Randomised Controlled Trial Register, ISRCTN16539266, and EuDRACT, 2016-002991-28. FINDINGS: Between March 10, 2017, and May 2, 2019, we screened 2287 patients. 708 patients were randomly assigned to progressive exercise (n=174), best practice advice (n=174), corticosteroid injection then progressive exercise (n=182), or corticosteroid injection then best practice advice (n=178). Over 12 months, SPADI data were available for 166 (95%) patients in the progressive exercise group, 164 (94%) in the best practice advice group, 177 (97%) in the corticosteroid injection then progressive exercise group, and 175 (98%) in the corticosteroid injection then best practice advice group. We found no evidence of a difference in SPADI score between progressive exercise and best practice advice when analysed over 12 months (adjusted mean difference -0·66 [99% CI -4·52 to 3·20]). We also found no evidence of a difference between corticosteroid injection compared with no injection when analysed over 12 months (-1·11 [-4·47 to 2·26]). No serious adverse events were reported. INTERPRETATION: Progressive exercise was not superior to a best practice advice session with a physiotherapist in improving shoulder pain and function. Subacromial corticosteroid injection provided no long-term benefit in patients with rotator cuff disorders. FUNDING: UK National Institute for Health Research Technology Assessment Programme.


Assuntos
Corticosteroides/administração & dosagem , Terapia por Exercício/métodos , Guias de Prática Clínica como Assunto , Lesões do Manguito Rotador/terapia , Síndrome de Colisão do Ombro/terapia , Adulto , Idoso , Feminino , Humanos , Injeções Intra-Articulares , Masculino , Pessoa de Meia-Idade , Resultado do Tratamento
3.
Health Technol Assess ; 24(65): 1-116, 2020 11.
Artigo em Inglês | MEDLINE | ID: mdl-33250068

RESUMO

BACKGROUND: Over 100,000 primary knee arthroplasty operations are undertaken annually in the UK. Around 15-30% of patients do not report a good outcome. Better rehabilitation strategies may improve patient-reported outcomes. OBJECTIVES: To compare the outcomes from a traditional outpatient physiotherapy model with those from a home-based rehabilitation programme for people assessed as being at risk of a poor outcome after knee arthroplasty. DESIGN: An individually randomised, two-arm controlled trial with a blinded outcome assessment, a parallel health economic evaluation and a nested qualitative study. SETTING: The trial took place in 14 NHS physiotherapy departments. PARTICIPANTS: People identified as being at high risk of a poor outcome after knee arthroplasty. INTERVENTIONS: A multicomponent home-based rehabilitation package delivered by rehabilitation assistants with supervision from qualified therapists compared with usual-care outpatient physiotherapy. MAIN OUTCOME MEASURES: The primary outcome was the Late Life Function and Disability Instrument at 12 months. Secondary outcomes were the Oxford Knee Score (a disease-specific measure of function); Knee injury and Osteoarthritis Outcome Score; Quality of Life subscale; Physical Activity Scale for the Elderly; EuroQol-5 Dimensions, five-level version; and physical function assessed using the Figure-of-8 Walk Test, 30-Second Chair Stand Test and Single Leg Stance. Data on the use of health-care services, time off work and informal care were collected using participant diaries. RESULTS: In total, 621 participants were randomised. A total of 309 participants were assigned to the COmmunity based Rehabilitation after Knee Arthroplasty (CORKA) home-based rehabilitation programme, receiving a median of five treatment sessions (interquartile range 4-7 sessions). A total of 312 participants were assigned to usual care, receiving a median of four sessions (interquartile range 2-6 sessions). The primary outcome, Late Life Function and Disability Instrument function total score at 12 months, was collected for 279 participants (89%) in the home-based CORKA group and 287 participants (92%) in the usual-care group. No clinically or statistically significant difference was found between the groups (intention-to-treat adjusted difference 0.49 points, 95% confidence interval -0.89 to 1.88 points; p = 0.48). There were no statistically significant differences between the groups in any of the patient-reported or physical secondary outcome measures at 6 or 12 months post randomisation. The health economic analysis found that the CORKA intervention was cheaper to provide than usual care (£66 less per participant). Total societal costs (combining health-care costs and other costs) were lower for the CORKA intervention than usual care (£316 less per participant). Adopting a societal perspective, CORKA had a 75% probability of being cost-effective at a threshold of £30,000 per quality-adjusted life-year. Adopting the narrower health and social care perspective, CORKA had a 43% probability of being cost-effective at the same threshold. LIMITATIONS: The interventions were of short duration and were set within current commissioning guidance for UK physiotherapy. Participants and treating therapists could not be blinded. CONCLUSIONS: This randomised controlled trial found no important differences in outcomes when post-arthroplasty rehabilitation was delivered using a home-based, rehabilitation assistant-delivered rehabilitation package or a traditional outpatient model. However, the health economic evaluation found that when adopting a societal perspective, the CORKA home-based intervention was cost-saving and more effective than, and thus dominant over, usual care, owing to reduced time away from paid employment for this group. Further research could look at identifying the risk of poor outcome and further evaluation of a cost-effective treatment, including the workforce model to deliver it. TRIAL REGISTRATION: Current Controlled Trials ISRCTN13517704. FUNDING: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 65. See the NIHR Journals Library website for further project information.

4.
BMJ ; 371: m3576, 2020 10 13.
Artigo em Inglês | MEDLINE | ID: mdl-33051212

RESUMO

OBJECTIVE: To evaluate whether a progressive course of outpatient physiotherapy offers superior outcomes to a single physiotherapy review and home exercise based intervention when targeted at patients with a predicted poor outcome after total knee arthroplasty. DESIGN: Parallel group randomised controlled trial. SETTING: 13 secondary and tertiary care centres in the UK providing postoperative physiotherapy. PARTICIPANTS: 334 participants with knee osteoarthritis who were defined as at risk of a poor outcome after total knee arthroplasty, based on the Oxford knee score, at six weeks postoperatively. 163 were allocated to therapist led outpatient rehabilitation and 171 to a home exercise based protocol. INTERVENTIONS: All participants were reviewed by a physiotherapist and commenced 18 sessions of rehabilitation over six weeks, either as therapist led outpatient rehabilitation (progressive goal oriented functional rehabilitation protocol, modified weekly in one-one contact sessions) or as physiotherapy review followed by a home exercise based regimen (without progressive input from a physiotherapist). MAIN OUTCOME MEASURES: Primary outcome was Oxford knee score at 52 weeks, with a 4 point difference between groups considered to be clinically meaningful. Secondary outcomes included additional patient reported outcome measures of pain and function at 14, 26, and 52 weeks post-surgery. RESULTS: 334 patients were randomised. Eight were lost to follow-up. Intervention compliance was more than 85%. The between group difference in Oxford knee score at 52 weeks was 1.91 (95% confidence interval -0.18 to 3.99) points, favouring the outpatient rehabilitation arm (P=0.07). When all time point data were analysed, the between group difference in Oxford knee score was a non-clinically meaningful 2.25 points (0.61 to 3.90, P=0.01). No between group differences were found for secondary outcomes of average pain (0.25 points, -0.78 to 0.28, P=0.36) or worst pain (0.22 points, -0.71 to 0.41, P=0.50) at 52 weeks or earlier time points, or of satisfaction with outcome (odds ratio 1.07, 95% confidence interval 0.71 to 1.62, P=0.75) or post-intervention function (4.64 seconds, 95% confidence interval -14.25 to 4.96, P=0.34). CONCLUSIONS: Outpatient therapist led rehabilitation was not superior to a single physiotherapist review and home exercise based regimen in patients at risk of poor outcomes after total knee arthroplasty. No clinically relevant differences were observed across primary or secondary outcome measures. TRIALS REGISTRATION: Current Controlled Trials ISRCTN23357609 and ClinicalTrials.gov NCT01849445.


Assuntos
Artroplastia do Joelho/reabilitação , Terapia por Exercício/métodos , Osteoartrite do Joelho/reabilitação , Dor Pós-Operatória/reabilitação , Modalidades de Fisioterapia , Idoso , Artroplastia do Joelho/efeitos adversos , Protocolos Clínicos , Feminino , Humanos , Articulação do Joelho/patologia , Articulação do Joelho/cirurgia , Masculino , Pessoa de Meia-Idade , Osteoartrite do Joelho/cirurgia , Medição da Dor , Dor Pós-Operatória/etiologia , Cooperação do Paciente , Medidas de Resultados Relatados pelo Paciente , Resultado do Tratamento
5.
BMJ Open ; 10(7): e028915, 2020 07 02.
Artigo em Inglês | MEDLINE | ID: mdl-32620710

RESUMO

OBJECTIVES: To estimate the relationship between patient characteristics and referral decisions made by musculoskeletal hubs, and to assess the possible impact of an evidence-based referral tool. DESIGN: Retrospective analysis of medical records and decision tree model evaluating policy changes using local and national data. SETTING: One musculoskeletal interface clinic (hub) in England. PARTICIPANTS: 922 adults aged ≥50 years referred by general practitioners with symptoms of knee or hip osteoarthritis. INTERVENTIONS: We assessed the current frequency and determinants of referrals from one hub and the change in referrals that would occur at this centre and nationally if evidence-based thresholds for referral (Oxford Knee and Hip Scores, OKS/OHS) were introduced. MAIN OUTCOME MEASURE: OKS/OHS, referrals for surgical assessment, referrals for arthroplasty, costs and quality-adjusted life years. RESULTS: Of 110 patients with knee symptoms attending face-to-face hub consultations, 49 (45%) were referred for surgical assessment; the mean OKS for these 49 patients was 18 (range: 1-41). Of 101 hip patients, 36 (36%) were referred for surgical assessment (mean OHS: 21, range: 5-44). No patients referred for surgical assessment were above previously reported economic thresholds for OKS (43) or OHS (45). Setting thresholds of OKS ≤31 and OHS ≤35 might have resulted in an additional 22 knee referrals and 26 hip referrals in our cohort. Extrapolating hub results across England suggests a possible increase in referrals nationally, of around 13 000 additional knee replacements and 4500 additional hip replacements each year. CONCLUSIONS: Musculoskeletal hubs currently consider OKS/OHS and other factors when making decisions about referral to secondary care for joint replacement. Those referred typically have low OHS/OKS, and introducing evidence-based OKS/OHS thresholds would prevent few inappropriate (high-functioning, low-pain) referrals. However, our findings suggest that some patients not currently referred could benefit from arthroplasty based on OKS/OHS. More research is required to explore other important patient characteristics currently influencing hub decisions.


Assuntos
Artroplastia de Quadril , Adulto , Inglaterra , Humanos , Pessoa de Meia-Idade , Modelos Teóricos , Encaminhamento e Consulta , Estudos Retrospectivos
6.
BMC Urol ; 20(1): 1, 2020 Jan 16.
Artigo em Inglês | MEDLINE | ID: mdl-31941470

RESUMO

BACKGROUND: Urinary incontinence (UI) is highly prevalent and affects the lives of many men and women. We aimed to conduct a qualitative evidence synthesis (QES) to explore the experience of living with UI and to develop a conceptual model that can help us to understand this experience, and the potential barriers to appropriate healthcare. METHODS: We used the methods of meta-ethnography developed by Noblit and Hare and recently refined for larger studies. Meta-ethnography involves identifying concepts from the studies and abstracting these concepts into a line of argument. We searched for studies that explored the experience of adults with UI. We used the GRADE-CERQual framework to assess confidence in review findings. RESULTS: We screened 2307 titles, 429 abstracts, 107 full texts and included 41 studies (36 unique samples) in the synthesis. We organised the concepts into 26 conceptual categories, which we further abstracted into 6 themes: (1) Am I ill or is this normal? (2) It effects who I am and how I feel; (3) I feel stigmatised, ashamed and guilty; (4) talking can be difficult but it can help; (5) keeping incontinence under control; (6) have I got to the point that I need help? Our model conceptualises living with UI as navigating antagonists: Is UI normal or am I ill? Do I need help or am I managing? Do I keep UI to myself (and manage alone) or do I tell other people (and get the support that I need)? Do I use control strategies that focus on concealing (avoid risky situations, wear pads) versus, I use strategies that focus on improving the bodily function to improve continence. Our model highlights the experience of stigma, shame and guilt which exert a pull towards concealment. CONCLUSIONS: The culture of secrecy and profound sense of shame is barrier to seeking help. An environment which reduces the shame and stigma of UI may help people to switch the focus to strategies that will improve continence, rather than conceal incontinence.


Assuntos
Antropologia Cultural/métodos , Internacionalidade , Pesquisa Qualitativa , Vergonha , Incontinência Urinária/etnologia , Incontinência Urinária/terapia , Antropologia Cultural/normas , Feminino , Humanos , Masculino , Inquéritos e Questionários , Incontinência Urinária/diagnóstico
7.
J Back Musculoskelet Rehabil ; 33(2): 295-301, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-31356192

RESUMO

BACKGROUND: Abnormal sagittal spinal curvature is associated with pain, decreased mobility, respiratory problems and increased mortality. Time-of-flight technology of the Microsoft Kinect sensor can reconstruct a three-dimensional image of the back quickly and inexpensively. OBJECTIVE: To estimate the extent of the reproducibility of sagittal spine curvature measurement using the Microsoft Kinect sensor. METHODS: Simultaneous measurement of thoracic and lumbar spine using the Microsoft Kinect sensor in 37 participants. Two investigators gave standardised instructions and each captured 3 images. Thoracic kyphosis and lumbar lordosis angle indexes were calculated using maximum height divided by the length. RESULTS: Adult participants (mean age in years (SD) = 51.7 (20.6); 57% female; BMI in kg/m2 (SD) = 24.9 (3.3)) kyphosis and lordosis indexes showed high intra-rater and inter-rater ICC values (0.960-0.973). The means of the first images from both raters had significantly larger kyphosis indexes compared to the second and third images, yet no difference between means in lordosis data. CONCLUSIONS: The results indicate that the Microsoft Kinect sensor has a reproducible method with high intra-rater and inter-rater reliability. The difference between the means over repeated measures suggest the second image capture is more consistent. It is a reproducible and quick method in clinical and research settings.


Assuntos
Imageamento Tridimensional/métodos , Vértebras Lombares/diagnóstico por imagem , Curvaturas da Coluna Vertebral/diagnóstico por imagem , Adulto , Idoso , Feminino , Humanos , Cifose/diagnóstico por imagem , Lordose/diagnóstico por imagem , Masculino , Pessoa de Meia-Idade , Reprodutibilidade dos Testes
8.
Qual Health Res ; 30(1): 3-22, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-31631748

RESUMO

Advances in health care mean that we can now treat diseases that once cut lives short. However, the increase in life expectancy has not been matched by improvements in quality of life. The World Health Organization warns us that all countries should prepare to meet the challenges of an aging population and this is integral to the United Nations 2030 Agenda for Sustainable Development. This may require a shift in attitude toward aging. We aimed to use meta-ethnography to explore the experience of adults living beyond the age of 80. Our conceptual model illuminates the phenomenon of connection in older age and reflects on the paradox of time: ephemeral, yet interminable. Our findings encourage us to reflect on the influence of enlightenment philosophies that underpin the desire for autonomy at all costs. Our study challenges the stereotypes of old age and has the potential to influence people's perspectives toward aging.


Assuntos
Atitude , Envelhecimento Saudável , Qualidade de Vida/psicologia , Idoso de 80 Anos ou mais , Envelhecimento , Antropologia Cultural , Envelhecimento Saudável/psicologia , Humanos , Expectativa de Vida
9.
Trials ; 20(1): 732, 2019 Dec 16.
Artigo em Inglês | MEDLINE | ID: mdl-31842977

RESUMO

BACKGROUND: Optimising the management of peri-operative pain and recovery following knee replacement has been identified as a patient priority. Current pain relief strategies use opiate-based analgesia; however, up to 50% of patients experience significant side effects. Local anaesthetic incisional infiltration is one alternative. The length of the duration of action is a major limiting factor of current local anaesthetic techniques. Liposomal bupivacaine has been reported to be effective for up to 72 h. This randomised controlled trial will evaluate the clinical and cost effectiveness of liposomal bupivacaine. METHODS: SPAARK is a patient-blinded, multi-centre, active comparator, superiority, two-arm, parallel-group randomised controlled trial. Five hundred patients undergoing knee replacement will be recruited and randomised to liposomal bupivacaine plus bupivacaine hydrochloride or bupivacaine hydrochloride alone. The co-primary outcomes are the Quality of Recovery 40 measured at 72 h post-surgery and also cumulative pain measured daily using a 0-10 visual analogue scale for the first 3 days following surgery. Secondary outcomes include cumulative opioid consumption, fitness for discharge, functional outcomes assessed using the Oxford Knee Score and American Knee Society Score, the EuroQol five dimensions instrument and complications. A cost utility analysis is also planned. DISCUSSION: The clinical effectiveness and cost effectiveness of liposomal bupivacaine have yet to be evaluated in the National Health Service, making this trial appropriate and timely. TRIAL REGISTRATION: ISRCTN registry, ISRCTN54191675. Registered on 14 November 2017.


Assuntos
Anestésicos Locais/administração & dosagem , Artroplastia do Joelho , Bupivacaína/administração & dosagem , Osteoartrite do Joelho/cirurgia , Dor Pós-Operatória/prevenção & controle , Anestésicos Locais/efeitos adversos , Anestésicos Locais/economia , Artroplastia do Joelho/efeitos adversos , Artroplastia do Joelho/economia , Bupivacaína/efeitos adversos , Bupivacaína/economia , Análise Custo-Benefício , Custos de Medicamentos , Estudos de Equivalência como Asunto , Humanos , Lipossomos , Estudos Multicêntricos como Assunto , Osteoartrite do Joelho/diagnóstico , Dor Pós-Operatória/diagnóstico , Dor Pós-Operatória/economia , Dor Pós-Operatória/etiologia , Método Simples-Cego , Fatores de Tempo , Resultado do Tratamento , Reino Unido
10.
BMJ Open ; 9(11): e031599, 2019 11 21.
Artigo em Inglês | MEDLINE | ID: mdl-31753882

RESUMO

OBJECTIVES: Effects of the UK Department of Health's national Enhanced Recovery After Surgery (ERAS) Programme on outcomes after primary hip replacement. DESIGN: Natural experimental study using interrupted time series to assess the changes in trends before, during and after ERAS implementation (April 2009 to March 2011). SETTING: Surgeries in the UK National Joint Registry were linked with Hospital Episode Statistics containing inpatient episodes from National Health Service trusts in England and patient reported outcome measures. PARTICIPANTS: Patients aged ≥18 years from 2008 to 2016. MAIN OUTCOME MEASURES: Regression coefficients of monthly means of length of hospital stay, bed day cost, change in Oxford Hip Scores (OHS) 6 months post-surgery, complications 6 months post-surgery and revision rates 5 years post-surgery. RESULTS: 438 921 primary hip replacements were identified. Hospital stays shortened from 5.6 days in April 2008 to 3.6 in December 2016. There were also improvements in bed day costs (£7573 in April 2008 to £5239 in December 2016), positive change in self-reported OHS from baseline to 6 months post-surgery (17.7 points in April 2008 to 22.9 points in December 2016), complication rates (4.1% in April 2008 to 1.7% March 2016) and 5 year revision rates (5.9 per 1000 implant-years (95% CI 4.8 to 7.2) in April 2008 to 2.9 (95% CI 2.2 to 3.9) in December 2011). The positive trends in all outcomes started before ERAS was implemented and continued during and after the programme. CONCLUSIONS: Patient outcomes after hip replacement have improved over the last decade. A national ERAS programme maintained this improvement but did not alter the existing rate of change.


Assuntos
Artroplastia de Quadril , Recuperação Pós-Cirúrgica Melhorada , Análise de Séries Temporais Interrompida , Medidas de Resultados Relatados pelo Paciente , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Inglaterra , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Sistema de Registros , País de Gales
11.
BMJ Open ; 9(10): e025357, 2019 10 03.
Artigo em Inglês | MEDLINE | ID: mdl-31585967

RESUMO

OBJECTIVES: We have previously developed and validated the Arthritis Research UK Musculoskeletal Health Questionnaire (MSK-HQ) for use across musculoskeletal care pathways, showing encouraging psychometric test results. The objective of this study was to determine the responsiveness of MSK-HQ following MSK treatments and to determine the minimally important change (MIC). SETTING: We collected data in four cohorts from community physiotherapy and secondary-care orthopaedic hip, knee and shoulder clinics. PARTICIPANTS: 592 individuals were recruited; 210 patients treated with physiotherapy for a range of MSK conditions in primary care; 150 patients undergoing hip replacement, 150 patients undergoing knee replacement and 82 undergoing shoulder surgery in secondary care. OUTCOME MEASURES: Preoperative data were collected including the MSK-HQ, European Quality of Life-5D (EQ-5D) and the OHS, OKS or OSS in each joint-specific group. The same scores, together with anchor questions, were collected postintervention at 3 months for the physiotherapy group and 6 months for all others. Following COnsensus-based Standards for the selection of health status Measurement INstruments (COSMIN) guidelines, responsiveness was assessed using correlation between scores and the MIC was calculated for the entire cohort using receiver operating characteristic curve analysis. RESULTS: The MSK-HQ demonstrated strong correlation (R=0.73) with EQ-5D across the entire cohort and with each of the joint-specific Oxford scores (hip R=0.87, knee R=0.92 and shoulder R=0.77). Moderate correlation was seen between MSK-HQ and EQ-5D across each individual group (R value range 0.60-0.68), apart from the hip group where correlation was strong (R=0.77). The effect size with MSK-HQ was 0.93, in the entire cohort, double that measured with EQ-5D (0.43). In all subgroups, MSK-HQ measured a greater treatment effect compared with EQ-5D. The MIC is 5.5 (95% CI 2.7 to 8.3). CONCLUSION: Our study demonstrates that the MSK-HQ questionnaire is responsive to change across a range of musculoskeletal conditions, supporting its use as a generic MSK measurement instrument.


Assuntos
Doenças Musculoesqueléticas/terapia , Inquéritos e Questionários/estatística & dados numéricos , Adulto , Idoso , Artroplastia de Quadril , Artroplastia do Joelho , Feminino , Humanos , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Modalidades de Fisioterapia , Período Pós-Operatório , Período Pré-Operatório , Curva ROC , Articulação do Ombro/cirurgia , Resultado do Tratamento
12.
Health Technol Assess ; 23(44): 1-318, 2019 08.
Artigo em Inglês | MEDLINE | ID: mdl-31456562

RESUMO

BACKGROUND: A total of 25,000 people in the UK have osteoporotic vertebral fracture (OVF). Evidence suggests that physiotherapy may have an important treatment role. OBJECTIVE: The objective was to investigate the clinical effectiveness and cost-effectiveness of two different physiotherapy programmes for people with OVF compared with a single physiotherapy session. DESIGN: This was a prospective, adaptive, multicentre, assessor-blinded randomised controlled trial (RCT) with nested qualitative and health economic studies. SETTING: This trial was based in 21 NHS physiotherapy departments. PARTICIPANTS: The participants were people with symptomatic OVF. INTERVENTIONS: Seven sessions of either manual outpatient physiotherapy or exercise outpatient physiotherapy compared with the best practice of a 1-hour single session of physiotherapy (SSPT). MAIN OUTCOME MEASURES: Outcomes were measured at 4 and 12 months. The primary outcomes were quality of life and muscle endurance, which were measured by the disease-specific QUALEFFO-41 (Quality of Life Questionnaire of the European Foundation for Osteoporosis - 41 items) and timed loaded standing (TLS) test, respectively. Secondary outcomes were (1) thoracic kyphosis angle, (2) balance, evaluated via the functional reach test (FRT), and (3) physical function, assessed via the Short Physical Performance Battery (SPPB), 6-minute walk test (6MWT), Physical Activity Scale for the Elderly, a health resource use and falls diary, and the EuroQol-5 Dimensions, five-level version. RESULTS: A total of 615 participants were enrolled, with 216, 203 and 196 randomised by a computer-generated program to exercise therapy, manual therapy and a SSPT, respectively. Baseline data were available for 613 participants, 531 (86.6%) of whom were women; the mean age of these participants was 72.14 years (standard deviation 9.09 years). Primary outcome data were obtained for 69% of participants (429/615) at 12 months: 175 in the exercise therapy arm, 181 in the manual therapy arm and 173 in the SSPT arm. Interim analysis met the criteria for all arms to remain in the study. For the primary outcomes at 12 months, there were no significant benefits over SSPT of exercise [QUALEFFO-41, difference -0.23 points, 95% confidence interval (CI) -3.20 to 1.59 points; p = 1.000; and TLS test, difference 5.77 seconds, 95% CI -4.85 to 20.46 seconds; p = 0.437] or of manual therapy (QUALEFFO-41, difference 1.35 points, 95% CI -1.76 to 2.93 points; p = 0.744; TLS test, difference 9.69 seconds (95% CI 0.09 to 24.86 seconds; p = 0.335). At 4 months, there were significant gains for both manual therapy and exercise therapy over SSPT in the TLS test in participants aged < 70 years. Exercise therapy was superior to a SSPT at 4 months in the SPPB, FRT and 6MWT and manual therapy was superior to a SSPT at 4 months in the TLS test and FRT. Neither manual therapy nor exercise therapy was cost-effective relative to a SSPT using the threshold of £20,000 per quality-adjusted life-year. There were no treatment-related serious adverse events. CONCLUSIONS: This is the largest RCT to date assessing physiotherapy in participants with OVFs. At 1 year, neither treatment intervention conferred more benefit than a single 1-hour physiotherapy advice session. The focus of future work should be on the intensity and duration of interventions to determine if changes to these would demonstrate more sustained effects. TRIAL REGISTRATION: Current Controlled Trials ISRCTN49117867. FUNDING: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 44. See the NIHR Journals Library website for further project information.


Assuntos
Terapia por Exercício , Fraturas por Osteoporose/terapia , Modalidades de Fisioterapia , Fraturas da Coluna Vertebral/terapia , Idoso , Análise Custo-Benefício/economia , Feminino , Humanos , Masculino , Qualidade de Vida/psicologia , Inquéritos e Questionários , Avaliação da Tecnologia Biomédica , Reino Unido
13.
BMJ ; 364: l185, 2019 02 07.
Artigo em Inglês | MEDLINE | ID: mdl-30733197

RESUMO

OBJECTIVE: To compare arthroscopic hip surgery with physiotherapy and activity modification for improving patient reported outcome measures in patients with symptomatic femoroacetabular impingement (FAI). DESIGN: Two group parallel, assessor blinded, pragmatic randomised controlled trial. SETTING: Secondary and tertiary care centres across seven NHS England sites. PARTICIPANTS: 222 participants aged 18 to 60 years with symptomatic FAI confirmed clinically and with imaging (radiography or magnetic resonance imaging) were randomised (1:1) to receive arthroscopic hip surgery (n=112) or a programme of physiotherapy and activity modification (n=110). Exclusion criteria included previous surgery, completion of a physiotherapy programme targeting FAI within the preceding 12 months, established osteoarthritis (Kellgren-Lawrence grade ≥2), and hip dysplasia (centre-edge angle <20 degrees). INTERVENTIONS: Participants in the physiotherapy group received a goal based programme tailored to individual patient needs, with emphasis on improving core stability and movement control. A maximum of eight physiotherapy sessions were delivered over five months. Participants in the arthroscopic surgery group received surgery to excise the bone that impinged during hip movements, followed by routine postoperative care. MAIN OUTCOME MEASURES: The primary outcome measure was the hip outcome score activities of daily living subscale (HOS ADL) at eight months post-randomisation, with a minimum clinically important difference between groups of 9 points. Secondary outcome measures included additional patient reported outcome measures and clinical assessment. RESULTS: At eight months post-randomisation, data were available for 100 patients in the arthroscopic hip surgery group (89%) and 88 patients in the physiotherapy programme group (80%). Mean HOS ADL was 78.4 (95% confidence interval 74.4 to 82.3) for patients randomised to arthroscopic hip surgery and 69.2 (65.2 to 73.3) for patients randomised to the physiotherapy programme. After adjusting for baseline HOS ADL, age, sex, and study site, the mean HOS ADL was 10.0 points higher (6.4 to 13.6) in the arthroscopic hip surgery group compared with the physiotherapy programme group (P<0.001)). No serious adverse events were reported in either group. CONCLUSIONS: Patients with symptomatic FAI referred to secondary or tertiary care achieve superior outcomes with arthroscopic hip surgery than with physiotherapy and activity modification. TRIAL REGISTRATION: ClinicalTrials.gov NCT01893034.


Assuntos
Artroscopia/métodos , Terapia por Exercício/métodos , Impacto Femoroacetabular/cirurgia , Articulação do Quadril/cirurgia , Atividades Cotidianas , Adolescente , Adulto , Inglaterra , Feminino , Impacto Femoroacetabular/reabilitação , Articulação do Quadril/fisiopatologia , Humanos , Masculino , Pessoa de Meia-Idade , Medidas de Resultados Relatados pelo Paciente , Resultado do Tratamento , Adulto Jovem
14.
Physiotherapy ; 105(1): 76-83, 2019 03.
Artigo em Inglês | MEDLINE | ID: mdl-30241701

RESUMO

OBJECTIVE: To determine the reliability and validity of the Figure of 8 Walk test (F8W) for older people after knee replacement surgery in the home setting. DESIGN: Observational repeated measures. SETTING: A specialist orthopaedic hospital and participants homes. PARTICIPANTS: Seventy-four older adults aged over 55 years one year following knee replacement surgery participated in two assessments more than one week apart. MAIN OUTCOME MEASURE: The time to complete, steps, boundary limits and smoothness score from the Figure of 8 Walk test (F8W), the time to complete the Timed Up and Go (TUG) test and the time to complete the Timed Walk Test (TWT). RESULTS: Overall, on 95% of occasions, the difference between the measurements for intra-rater reliability were within 1.8second of the two test times. The difference between the measurements for inter-rater reliability were found to be narrower than for intra-rater reliability with scores within 1.2second overall on 95% of occasions. The time to perform the F8W was highly correlated to the Timed Up and Go (overall sample r=0.921) and the variability spread within narrow limits (-0.8 to 0.8 z-scores). This was also true for the Timed Walk Test (overall sample r=0.834) with a narrow limit of variability on almost all of the observations (-1.16 to 1.16 z-scores). CONCLUSIONS: The F8W test has good reliability and validity when used in either a clinical or home setting for patients around one year following knee replacement surgery.


Assuntos
Artroplastia do Joelho/reabilitação , Teste de Caminhada/métodos , Idoso , Idoso de 80 Anos ou mais , Avaliação da Deficiência , Feminino , Serviços de Assistência Domiciliar , Humanos , Masculino , Pessoa de Meia-Idade , Equilíbrio Postural , Reprodutibilidade dos Testes , Teste de Caminhada/normas
15.
Trials ; 19(1): 638, 2018 Nov 19.
Artigo em Inglês | MEDLINE | ID: mdl-30454051

RESUMO

BACKGROUND: About 15% of patients fail to achieve a satisfactory clinical outcome following knee replacement, which may indicate the existing model of rehabilitation after surgery is possibly not the most efficacious. The COmmunity-based Rehabilitation after Knee Arthroplasty (CORKA) trial evaluates the effects of a new multi-component community-based rehabilitation programme following knee replacement compared with usual care. METHODS/DESIGN: The CORKA trial is a multi-centre, single-blind, two-arm randomised controlled trial. The primary outcome is the Late Life Function and Disability Instrument (LLFDI) overall function score measured at 12 months post-randomisation which will be analysed using a linear mixed effects model. Secondary outcomes are measured at 6 and 12 months post-randomisation and include the LLFDI frequency and limitation total dimension scores, the Oxford Knee Score, the Knee injury and Osteoarthritis Outcome Score quality of life subscale, the Physical Activity Scale for the Elderly, the EuroQol EQ-5D-5L, and several measurements of physical function. Full details of the planned analysis approaches for the primary and secondary outcomes are described here, as are the descriptive statistics which will be reported. This is an update to the CORKA protocol which has already been published in this journal. DISCUSSION: This paper provides details of the planned statistical analyses for this trial and will reduce the risks of outcome reporting bias and data-driven results. TRIAL REGISTRATION: ISRCTN registry, 13517704 . Registered on 12 February 2015. FUNDING/SPONSOR: The trial is funded by the National Institute for Health Research Health Technology Assessment programme under its commissioned research programme (HTA 12/196/08). The trial sponsor is the University of Oxford.


Assuntos
Artroplastia do Joelho/reabilitação , Artroplastia do Joelho/estatística & dados numéricos , Serviços de Saúde Comunitária/estatística & dados numéricos , Articulação do Joelho/cirurgia , Osteoartrite do Joelho/reabilitação , Osteoartrite do Joelho/cirurgia , Artroplastia do Joelho/efeitos adversos , Fenômenos Biomecânicos , Interpretação Estatística de Dados , Avaliação da Deficiência , Humanos , Articulação do Joelho/fisiopatologia , Modelos Estatísticos , Estudos Multicêntricos como Assunto/estatística & dados numéricos , Osteoartrite do Joelho/diagnóstico , Osteoartrite do Joelho/fisiopatologia , Ensaios Clínicos Controlados Aleatórios como Assunto/estatística & dados numéricos , Recuperação de Função Fisiológica , Método Simples-Cego , Fatores de Tempo , Resultado do Tratamento , Reino Unido
16.
J Hosp Palliat Nurs ; 20(5): 433-439, 2018 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-30188434

RESUMO

Moral distress occurs when a nurse knows the right action but is impeded from taking that right action because of institutional constraints. Caring for patients who are dying might evoke distress, including moral distress. The distress from a difficult clinical situation is likely to permeate other areas of practice. In this article, 2 cases are used as a means to distinguish moral distress from other distress arising from clinical situations. Opportunities to alleviate distress include increasing knowledge, improved communication, enhanced collaboration, and development of institutional supports.


Assuntos
Cuidadores/psicologia , Conforto do Paciente/métodos , Transtornos de Estresse Pós-Traumáticos/terapia , Idoso , Ética em Enfermagem , Humanos , Masculino , Transtornos de Estresse Pós-Traumáticos/psicologia , Estresse Psicológico/psicologia , Estresse Psicológico/terapia
17.
J Orthop ; 15(2): 658-662, 2018 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-29881215

RESUMO

Background: When compared to total hip arthroplasty (THA), hip resurfacing arthroplasty (HRA) is usually undertaken in younger, more active patients with hip osteoarthritis. Previous research has noted that patients are able to return to pre-operative activity levels, with many even increasing their activity post HRA, but patterns in post-operative recovery have been less well investigated. Materials and Methodology: A randomised controlled trial dataset was analysed to explore activity levels attained after HRA. Data was collected on 80 male patients. The primary outcome of focus was the University of California, Los Angeles (UCLA) Activity Index, with follow-up at 6 weeks, 16 weeks and 1 year. Results: Mean UCLA at baseline was 5.4 (SD; 2.1) which, after an initial fall to 4.7 (SD; 1.6, p = 0.008) at 6 weeks, increased at both the 16 week and 1 year follow ups (p < 0.001), with a final mean activity index of 7.2 (SD; 1.7). Mode UCLA at 1 year was 7 or 8, representing patients who are regularly taking part in activities such as cycling and golf. Conclusion: Following HRA, patients can achieve significant improvements in activity measured using the UCLA Activity Index. Activity levels have been shown to initially decrease following HRA, with improvement throughout the first postoperative year. The results of this study provide clinicians with a simple tool to help patients visualise their post-operative recovery. This may have implications when managing patient expectations of post-operative activity level in both HRA and large head THA populations.

18.
Arch Phys Med Rehabil ; 99(11): 2230-2237, 2018 11.
Artigo em Inglês | MEDLINE | ID: mdl-29709523

RESUMO

OBJECTIVES: (1) To determine evidence-based guidance for the length of time to return to specific valued functional and leisure activities after knee arthroplasty (KA). (2) To determine what patients feel are the most important functional or leisure activities to recover after KA. (3) To collect information about patients' expectations and compare them to the actual time it takes to return. DESIGN: Prospective longitudinal cohort observational survey. SETTING: Specialist orthopedic hospital. PARTICIPANTS: Patients (N=99) with osteoarthritis or rheumatoid arthritis (mean=69.9y [range 44-88]) listed for total knee arthroplasty (TKA) or unicompartmental knee arthroplasty. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Valued activities list (VAL) used to select activities patients expect to return to and report the actual time taken to return. RESULTS: Participants in unicompartmental knee arthroplasty group returned to the 6 most popular valued activities (walking >1km, stair climbing, housework, driving, gardening, and kneeling) 8%-33% more quickly than TKA group, and they were satisfied with performing these activities sooner on average (4%-18%) than the TKA group. The percentage of participants satisfied at 12 months postsurgery ranged from 96% returning to housework to 36% returning to kneeling. The Wilcoxon signed-rank test was used to compare the expected time and the actual time to return: Housework (Z=-5.631, P<.05, effect size=0.64) and swimming (Z=-3.209, P<.05, effect size=0.59) were quicker than expected, and walking >1 km (Z=-2.324, P<.05, effect size=0.27) was slower than expected. CONCLUSIONS: A more tailored and personalized approach with consideration of prior level of activity and comorbidities must be taken into account and adequately discussed to help bridge the gap between the expected and actual recovery time.


Assuntos
Artroplastia do Joelho/reabilitação , Satisfação do Paciente/estatística & dados numéricos , Recuperação de Função Fisiológica , Volta ao Esporte/estatística & dados numéricos , Fatores de Tempo , Adulto , Idoso , Idoso de 80 Anos ou mais , Artrite Reumatoide/cirurgia , Feminino , Humanos , Joelho/fisiopatologia , Atividades de Lazer , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Osteoartrite do Joelho/cirurgia , Período Pós-Operatório , Estudos Prospectivos
19.
Physiotherapy ; 104(2): 224-231, 2018 06.
Artigo em Inglês | MEDLINE | ID: mdl-29361297

RESUMO

OBJECTIVE: The UKUFF trial was a three-way parallel group randomised trial comparing surgical and non-surgical treatments for people with rotator cuff tears of their shoulder. High crossover between arms in the UKUFF led to the original trial design being reconfigured; 'Rest then Exercise' was halted. This study explored why participants recruited did not remain within allocated treatment arms and explored crossover and surgical decision making. DESIGN: A qualitative phenomenological approach. PARTICIPANTS: Purposive sampling (n=18) included participants randomised to 'Rest then Exercise' arm considered least likely to proceed to surgery but who had surgery, plus participants from all arms not having surgery. METHODS: In-depth, semi-structured interviews were recorded and transcribed. Field-notes, memos, member-checking and a reflexive diary were used. DATA ANALYSES: In accordance with Interpretative Phenomenological Analysis. Peer review, code-recode audits and constant comparison occurred throughout. RESULTS: 1. Impact of symptoms and diagnosis: these influenced crossover; long durations of severe pain and failed conservative treatment increased eagerness for surgery. 2. Perceptions and expectations of treatment: surgery provided hope for participants, especially when "Rest then Exercise" was perceived as having previously failed. Surgeons were perceived to believe "tears need repairing". 3. Professionals know best: autonomy and communication: patients deciding not to have surgery had to actively leave the surgical waiting list. Increasing age, carer role, self-employment, co-morbidity and improving symptoms were reasons described for declining surgery. CONCLUSIONS: Most participants had failed conservative treatment before trial entry and described strong preferences regarding treatment. Trials should demonstrate patient and clinician equipoise but participants' rarely described equipoise. If conservative treatments are usually provided sequentially in clinical practice, it may be inappropriate to include them as comparators in surgical trials. This is a qualitative study and not eligible for trial registration since it was carried out independently of the UKUFF trial (UKUFF ISRCTN97804283 Date assigned 29/06/2007).


Assuntos
Tomada de Decisões , Pacientes Desistentes do Tratamento , Lesões do Manguito Rotador/terapia , Estudos Cross-Over , Feminino , Humanos , Entrevistas como Assunto , Masculino , Cooperação do Paciente , Percepção , Pesquisa Qualitativa , Projetos de Pesquisa , Lesões do Manguito Rotador/cirurgia , Reino Unido
20.
Disabil Rehabil ; 40(16): 1914-1920, 2018 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-28478692

RESUMO

PURPOSE: Small reductions in body weight can decrease osteoarthritic knee pain. Intuitively this should provide a strong incentive for weight-loss. However many people undergoing knee joint replacement (KJR) are categorised as obese. Gender theories can help us to understand differential responses to illness and therefore make an important contribution to rehabilitation. We aimed to explore barriers to weight loss in a group of older men with osteoarthritis. MATERIALS AND METHODS: We conducted 12 in-depth interviews, before and 1 year after surgery, with six obese men listed for KJR. Analysis was influenced by constructivist grounded theory. We abstracted conceptual themes from the data through constant comparison. RESULTS: We identified the following themes: (1) I am big and healthy and don't need to lose weight; (2) being this size isn't good for me; (3) men don't have to worry about that sort of thing; (4) I am not as active as I used to be; (5) I have worked hard all my life; (6) what is the point in trying anyway? CONCLUSIONS: Gendered narratives can make it challenging for men to lose weight. Healthcare professionals cannot ignore the influence of gender on rehabilitation and should consider gender specific strategies. Implications for rehabilitation Men may not associate being overweight with being unhealthy. Men may take pride in being in good shape and may respond better to weight loss strategies that focus on fitness not body size. Men may link weight gain with decrease in activity levels rather than overeating. Health care professionals should challenge the assumption that weight loss will follow surgery. Health care professionals cannot ignore the influence of gender on the success of rehabilitation.


Assuntos
Dieta Redutora , Obesidade/dietoterapia , Osteoartrite do Joelho/terapia , Idoso , Atitude Frente a Saúde , Teoria Fundamentada , Humanos , Entrevistas como Assunto , Masculino , Pessoa de Meia-Idade , Obesidade/complicações , Osteoartrite do Joelho/complicações , Fatores Sexuais , Perda de Peso
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