"I was considering surgery because I believed that was how it was treated": a qualitative study on willingness for joint surgery after completion of a digital management program for osteoarthritis.

OBJECTIVE: To explore, using a qualitative approach, reasons for patients' continued willingness or their shift in willingness for total joint replacement (TJR) surgery, following participation in Joint Academy, a Swedish, digital, non-surgical treatment program for osteoarthritis (OA). DESIGN: Nineteen patients with hip or knee OA were interviewed after finishing their first 6 weeks in the treatment program, using a semi-structured interview guide. The interviews were transcribed verbatim and analyzed using a systematic text condensation method. RESULTS: Analysis of the interview data revealed three main categories of reasons provided for the participants' decisions regarding surgery: 1) Various reasons for participating in Joint Academy with three sub-categories: (a) longstanding pain affects daily life, (b) last chance for improvement and (c) mandatory treatment to be eligible for total joint replacements (TJR); 2) Willingness for TJR following treatment, which included four sub-categories: (a) surgery - the last resort, (b) reduced pain and improved functioning, (c) no perceived improvements after treatment, and (d) trust in healthcare providers; and 3) Expectations of TJR. The shift in willingness towards or away from TJR was mainly due to the perceived success of Joint Academy in improving their functioning. CONCLUSION: Several patients reconsidered their options and had changed their attitude to TJR after participation in a digital program aimed at reducing OA symptoms and improving functioning. These results highlight the importance of providing patients with adequate information about non-surgical management options to facilitate shared decision-making, and possibly reduce the need for surgery.

Measurement properties of the Body Awareness Scale Movement Quality (BAS MQ) in persons on the autism spectrum: A preliminary Rasch analysis.

BACKGROUND: Persons on the autism spectrum exhibit poorer body awareness than neurotypical persons. Since movement quality may be regarded as an expression of body awareness, assessment of movement quality is important. Sound assessments of measurement properties are essential if reliable decisions about body awareness interventions for persons on the autism spectrum are to be made, but there is insufficient research. OBJECTIVE: To assess measurement properties of the Body Awareness Scale Movement Quality (BAS MQ) in an autism and a neurotypical reference group. METHODS: Persons on the autism spectrum (n=108) and neurotypical references (n=32) were included. All were assessed with BAS MQ. Data were analyzed according to the Rasch model. RESULTS: BAS MQ was found to have acceptable unidimensionality, supported by the fit statistics. The hierarchical ordering showed that coordination ability was the most difficult, followed by stability and relating. Response category functioning worked as intended for 19 out of 23 items. There were few difficult items, which decreased targeting. Reliability measures were good. BAS MQ discriminated between the autism and the reference groups, with the autism group exhibiting poorer movement quality, reflecting clinical observations and previous research. CONCLUSIONS: BAS MQ was found to have acceptable measurement properties, though suffering from problems with targeting item difficulty to person ability for persons on the autism spectrum. The BAS MQ may, along with experienced movement quality, contribute to clinically relevant information of persons on the autism spectrum, although we encourage refinements and further analyses to improve its measurement properties.

Danish translation and psychometric testing of the Rivermead Mobility Index.

OBJECTIVES: The Rivermead Mobility Index (RMI) is widely used in several neurological conditions including multiple sclerosis (MS), but its psychometric properties have not been documented in Scandinavia. Therefore, the aim of the study was to translate RMI from UK English into Danish and conduct an initial psychometric testing of the Danish RMI. MATERIALS AND METHODS: The Danish translation conducted by the forward-backward method was first field-tested regarding user-friendliness and relevance. It was then psychometrically tested among 40 outpatients with MS regarding unidimensionality (corrected item-total correlations, adherence to an assumed Guttman response pattern), reliability, and construct validity. RESULTS: Field testing found the Danish RMI relevant and user-friendly. Corrected item-total correlations were ≥0.47 and item responses fitted the Guttman pattern. There was a 47.5% ceiling effect, and reliability was 0.91. Correlations supported construct validity. CONCLUSION: The Danish RMI is user-friendly, unidimensional, reliable, and valid. The results correspond to those previously reported with the original UK RMI version. Ceiling effects are limiting but sample related. Larger samples representing a wider variety of MS severities are needed for firmer evaluation of the Danish RMI.

Relationship between ulcer healing after hyperbaric oxygen therapy and transcutaneous oximetry, toe blood pressure and ankle-brachial index in patients with diabetes and chronic foot ulcers.

AIMS/HYPOTHESIS: The randomised, double-blind, placebo-controlled Hyperbaric Oxygen Therapy (HBOT) in Diabetic Patients with Chronic Foot Ulcers (HODFU) study showed beneficial effect of HBOT. As this treatment is expensive and time-consuming, being able to select patients for therapy would be very useful. The aim of this study was to evaluate whether circulatory variables could help in predicting outcome of HBOT. METHODS: All HODFU study participants who completed therapy, predefined as receiving at least 36 out of 40 scheduled HBOT/placebo sessions, were included in this study (n = 75). Baseline transcutaneous oximetry (TcPO2), toe blood pressure (TBP) and ankle-brachial index (ABI) were measured. Ulcer healing rate was registered at the 9-month follow-up visit. An ulcer was considered healed when it was completely epithelialised and remained so at the 12-month follow-up. RESULTS: In the HBOT group TcPO2 were significantly lower for patients whose ulcer did not heal as compared with those whose ulcers healed. A significantly increased healing frequency was seen with increasing TcPO(2) levels in the HBOT group (TcPO2/healing rate: <25 mmHg/0%; 26-50 mmHg/50%; 51-75 mmHg/73%; and >75 mmHg/100%). No statistically significant relation between the level of TBP or ABI and healing frequency was seen. CONCLUSIONS/INTERPRETATION: Our results indicate that TcPO2 in contrast to ABI and TBP correlates to ulcer healing following HBOT. We suggest HBOT as a feasible adjunctive treatment modality in diabetic patients with chronic non-healing foot ulcers when basal TcPO2 at the dorsum of the foot is above 25 mmHg. TRIAL REGISTRATION: NCT00953186 FUNDING: Mrs Thelma Zoegas Foundation and Faculty of Medicine, Lund University.

Has aerobic exercise effect on pain perception in persons with migraine and coexisting tension-type headache and neck pain? A randomized, controlled, clinical trial.

BACKGROUND: A large subset of persons with migraine suffers from coexisting tension-type headache and neck pain which may adversely affect the prognosis of migraine. Aerobic exercise has been shown to decrease migraine burden in these persons. Therefore, the aim of this study was to investigate whether the effect of aerobic exercise in persons with migraine and coexisting tension-type headache and neck pain can be explained by changes in pain perception. METHOD: Seventy consecutively recruited persons with migraine and coexisting tension-type headache and neck pain were randomized into exercise group or control group. Aerobic exercise consisted of bike/cross-trainer/brisk walking for 45 min, three times/week for 3 months. Controls continued their usual daily activities. Pericranial tenderness, pain thresholds, supra-thresholds and temporal summation were assessed at baseline, after treatment and at follow-up (6 months from baseline). RESULTS: Fifty-two persons with migraine and coexisting tension-type headache and neck pain completed the study. Aerobic exercise did not induce consistent changes in nociceptive pathways measured by pericranial tenderness, pressure pain thresholds and sensitivity to electrical stimulation. CONCLUSION: The effect of aerobic exercise cannot be explained by measurable effects on the pain modulation system. Thus, the positive effect on migraine burden may rather be explained by positive alteration of avoidance behaviour. Aerobic exercise can be recommended as a safe and inexpensive migraine treatment strategy. SIGNIFICANCE: This study adds further knowledge about the positive effect of aerobic exercise for persons with migraine and coexisting tension-type headache and neck pain. This effect cannot be measured by changes in pain modulation, but may rather be explained by positive alteration of avoidance behaviour.

A prospective study: hyperbaric oxygen therapy in diabetics with chronic foot ulcers.

Research suggests that hyperbaric oxygen therapy may have beneficial effects on ulcer healing and amputation rates in diabetic patients. This paper describes the design of a study that is evaluating its effects on chronic diabetic foot ulcers.

Hyperbaric oxygen treatment of healthy volunteers with u.v.-irradiated blister wounds.

Healthy male volunteers were wounded by skin blistering, excision of the blister roof and u.v.-irradiation of the dermal wound bed. The lesions, painlessly inflicted on one forearm, were occluded, and no systemic therapy was given (n = 7). Ten days later the procedure was repeated contralaterally, and this time hyperbaric oxygen (HBO) therapy was given (1 h at 283 kPa in a 'multi-place' chamber) beginning 1.5 h, 10.5 h and 21.5 h after injury. The maximum 'length' of the lesions - including the surrounding oedema zone - differed throughout the experiment when comparisons were made on a daily basis (P less than 0.005 on day 1). The values were lower after HBO treatment, the difference being maximal on day 1 when it was 41 per cent. The hyperaemia at the periphery of the lesions, assessed with a mechanical laser Doppler linear scanner, was less in the HBO-treated group on days 3, 4, and 5 (P less than 0.05 on day 3). Centrally within the wound the mean Doppler values were lower after HBO-treatment for the duration of the experiment, but the differences were not significant for comparisons made on a daily basis. The exudation rates decreased after HBO treatment (P less than 0.05 on days 2-6). The end-points of epithelialization (5.1 days (HBO group) vs. 5.7 days) did not differ significantly. Thus, HBO had beneficial effects on this superficial dermal lesion. Oedema and exudation decreased, as did the peripheral hyperaemia, but the rate of epithelialization was not accelerated.

Skin suction blister wound exposed to u.v. irradiation: a burn wound model for use in humans.

The effects of exposing blister wounds to u.v. irradiation were assessed in 14 male volunteers, on whose forearms blister wounds (diameter 5 mm, suction set at 200 mmHg below atmospheric for 2 h 15 min, blister roof cut at base), and irradiated blister wounds (as above, in addition u.v. irradiation given selectively for 30 min from a distance of 10 cm), were produced. In non-u.v.-irradiated wounds, flow cessation, assessed by video microscopy (n = 6), was observed in a small proportion of the papillary loop vessels. The oedema adjacent to the wound was poorly developed. Laser Doppler linear scans (n = 8) demonstrated a pronounced hyperaemia in the wound bed and also in the adjacent skin, the reaction subsiding over a few days. The exudation rate, determined by weighing the hydrocolloid dressings applied to the wound, was maximal on day 1 and then rapidly decreased. Epithelialization, assessed evaporimetrically as the time taken for reinstatement of the epidermal water barrier, was complete in 5.1 days. In the u.v.-irradiated wounds the blood flow had ceased in all the papillary loop vessels by day 1, and increased oedema, exudation and hyperaemia at the wound edges were observed. Epithelialization was not significantly retarded by the irradiation injury. After 6 months, slight discolouration of the skin was occasionally observed, but no cosmetically disturbing scars. This benign and standardized wound model in humans--based on a combination of a mechanical suction injury and a superficial radiation burn--may prove to be useful, for instance when studying the effects of burns treatment.

Hyperbaric oxygen reduced size of chronic leg ulcers: a randomized double-blind study.

To evaluate the effect of hyperbaric oxygen therapy on chronic wound healing, 16 otherwise healthy patients who had nondiabetic, chronic leg ulcers with no large vessel disease were included in a double-blind study. Patients were grouped according to age and then randomly assigned to two groups breathing either air or oxygen at 2.5 atmospheres of absolute pressure for 90 minutes 5 days per week for a total of 30 treatments. The wound area was copied onto transparent film covering the wound and then measured using only one matching wound from each patient. The mean decrease of the wound areas at weeks 2, 4, and 6 in the oxygen group were 6 percent (SD +/- 14), 22 percent (SD +/- 13), and 35.7 percent (SD +/- 17), respectively, and in the air group, 2.8 percent (SD +/- 11), 3.7 percent (SD +/- 11), and 2.7 percent (SD +/- 11), respectively, giving a p value less than 0.05 at week 4, and a p value less than 0.001 at week 6 between the groups using the Mann-Whitney U test. These data indicate that hyperbaric oxygen therapy may be used as a valuable adjunct to conventional therapies when nondiabetic wounds do not heal.

Malnutrition and risk of falling among elderly without home-help service--a cross sectional study.

OBJECTIVES: The aim of this study was to explore the frequency of malnutrition risk and associated risk of falling, social and mental factors among elderly without home-help service. The aim was also to explore factors associated with risk of falling. DESIGN: A cross-sectional design was used. SETTING: Elderly persons own homes. PARTICIPANTS: Data were collected during preventive home visits to 565 elderly (age range 73-90 years) without home-help service. Those with complete SCREEN II forms were included in the study (n = 465). MEASUREMENTS: MEASUREMENTS included rating scales regarding malnutrition risk (SCREEN II) and risk of falling (Downton). In addition, single-items: general health, satisfaction with life, tiredness, low-spiritedness, worries/anxiety and sleeping were used. RESULTS: According to the SCREEN II, 35% of the sample had no malnutrition risk, 35% had moderate risk and 30% had high malnutrition risk. In an ordinal regression analysis, increased malnutrition risk was associated with being a woman living alone (OR 4.63), male living alone (OR 6.23), lower age (OR 0.86), poorer general health (OR 2.03-5.01), often/always feeling tired (OR 2.38), and an increased risk of falling (OR 1.21). In a linear regression analysis, risk of falling was associated with higher age (B 0.020), not shopping independently (B 0.162), and low meat consumption (B 0.138). CONCLUSION: There are complex associations between malnutrition risk and the gender-cohabitation interaction, age, general health, tiredness, and risk of falling. In clinical practice comprehensive assessments to identify those at risk of malnutrition including associated factors are needed. These have to be followed by individual nutritional interventions using a holistic perspective which may also contribute to reducing the risk of falling.

A leisure-time frame of reference based on a literature analysis.

The aims of this study were, through literature analyses, to identify the concept 'leisure time,' to design a model of leisure time and to study the empirical methods used in research literature on leisure time. The data for this article consisted of occupational therapy literature including 48 articles found through a search of the MEDLINE and PsychLIT databases for the period 1975-1989. The methods used for identifying and coding these data based on a set of questions presented by Guba and Lincoln (1985). For discovering the empirical methods used in the material, the work of Ostrow and Caplan (1985) was followed. The data analysis led to the development of a frame of reference of leisure time as used in occupational therapy literature. This model consists of the following dimensions: time, intrinsic motivation, free choice of activity, capability, structure of social and culture environment, leisure-time activity engaged in, goals, pleasure for pleasure's sake, diversion, recreation, relaxation, self-fulfillment, influence on individual, leisure role, leisure behavior, and satisfied harmonious person.

Passive drug diffusion via standardized skin mini-erosion; methodological aspects and clinical findings with new device.

PURPOSE: To develop a clinical alternative to drug administration by injection or infusion. METHODS: A simple, mechanical device (Cellpatch) enables both the formation of a standardized small epidermal bleb and exposure of the circular base of the bleb to drug. The epidermis is split off by suctioning without bleeding or discomfort in a layer superficial to dermal capillaries and nociceptor nerves. Transdermal invasivity is thus avoided. Absorption of dextran test drug in aqueous solution vs molecular weight (3 kDa-70 kDa) and erosion area (3 kDa, diameter: 3-10 mm) were studied in healthy volunteers. The feasibility of using Morphine cellpatch (cell filled with 20 mg/ml morphine hydrochloride, aqueous solution, erosion diameter 6 mm) for post-operative pain relief was studied in two different patient groups; the Cellpatch was removed after 48 hours. Plasma morphine concentrations were determined at intervals. RESULTS: Dextrans of all sizes were efficiently absorbed transdermally, although absorption decreased with increasing molecular weight. The degree of absorption was directly related to the area of the mini-erosion. There were no sign of dose-dumping even with the largest erosions. The Cellpatch performed well in the demanding conditions of the postoperative unit, and was considered easy to use. Pharmacokinetically, the postoperative morphine delivery was related to that of a continuous infusion, with variability and dose in the same range as a continuous morphine infusion used clinically for providing basal pain relief. There were no bacterial growth in the morphine cells at 48 h. Reepithelialization of the erosion was rapid. CONCLUSIONS: The feasibility of administering drugs in a wide size range by passive diffusion through a standardized skin mini-erosion was demonstrated; the rate of absorption decreased with increasing molecular weight. The small area of the erosion restricts and controls the concentration driven diffusion of drug into the circulation. As a consequence of the favorable findings, three placebo-controlled clinical studies using Morphine cellpatch for postoperative pain relief are currently underway.