Anne Christie

Physical Therapy Interventions for Patients With Osteoarthritis of the Knee: An Overview of Systematic Reviews

Patients with osteoarthritis of the knee are commonly treated by physical therapists. Practice should be informed by updated evidence from systematic reviews. The purpose of this article is to summarize the evidence from systematic reviews on the effectiveness of physical therapy for patients with knee osteoarthritis. Systematic reviews published between 2000 and 2007 were identified by a comprehensive literature search. We graded the quality of evidence across reviews for each comparison and outcome. Twenty-three systematic reviews on physical therapy interventions for patients with knee osteoarthritis were included. There is high-quality evidence that exercise and weight reduction reduce pain and improve physical function in patients with osteoarthritis of the knee. There is moderate-quality evidence that acupuncture, transcutaneous electrical nerve stimulation, and low-level laser therapy reduce pain and that psychoeducational interventions improve psychological outcomes. For other interventions and outcomes, the quality of evidence is low or there is no evidence from systematic reviews.

Effectiveness of Nonpharmacological and Nonsurgical Interventions for Patients With Rheumatoid Arthritis: An Overview of Systematic Reviews

Conclusions based on systematic reviews of randomized controlled trials are considered to provide the highest level of evidence about the effectiveness of an intervention. This overview summarizes the available evidence from systematic reviews on the effects of nonpharmacological and nonsurgical interventions for rheumatoid arthritis (RA). Systematic reviews of studies of patients with RA (aged >18 years) published between 2000 and 2007 were identified by comprehensive literature searches. Methodological quality was independently assessed by 2 authors, and the quality of evidence was summarized by explicit methods. Pain, function, and patient global assessment were considered primary outcomes of interest. Twenty-eight systematic reviews were included in this overview. High-quality evidence was found for beneficial effects of joint protection and patient education, moderate-quality evidence was found for beneficial effects of herbal therapy (gamma-linolenic acid) and low-level laser therapy, and low-quality evidence was found for the effectiveness of the other interventions. The quality of evidence for the effectiveness of most nonpharmacological and nonsurgical interventions in RA is moderate to low.

Exploring Tai Chi in rheumatoid arthritis: a quantitative and qualitative study

BackgroundRheumatoid arthritis (RA) is a chronic, inflammatory and systemic disease which affects the musculoskeletal system. Exercise programmes are reported to improve physical functioning in patients with RA. Tai Chi is a traditional Chinese martial art which combines slow and gentle movements with mental focus. The purpose of this study was to study in which way Tai Chi group exercise impacted on disease activity, physical function, health status and experience in RA patients, applying quantitative and qualitative methods.MethodsFifteen patients with RA (13 females, age 33-70 years) were recruited from a rheumatology department into a single group study. The patients were instructed in Tai Chi exercise twice weekly for 12 weeks. Assessments at baseline, 12 weeks, and 12 weeks follow-up were performed with a wide range of measures, including disease activity, self-reported health status, physical performance tests (Walking in Figure of Eight, Timed-Stands Test, and Shoulder Movement Impairment Scale). Qualitative data were obtained from a focus group interview conducted after completed intervention with taping and verbatim transcription. Review of the transcripts identified themes important to patients practicing Tai Chi.ResultsWithin the group, Tai Chi practice lead to improved lower-limb muscle function at the end of intervention and at 12 weeks follow-up. Qualitative analyses showed that patients experienced improved physical condition, confidence in moving, balance and less pain during exercise and in daily life. Other experience included stress reduction, increased body awareness, confidence in moving and indicated that Tai Chi was a feasible exercise modality in RA.ConclusionsImproved muscle function in lower limbs was also reflected when patient experiences with Tai Chi were studied in depth in this explorative study. The combination of qualitative and quantitative research methods shows that Tai Chi has beneficial effects on health not related to disease activity and standardised health status assessment, and may contribute to an understanding of how Tai Chi exerts its effects.Trial registrationNCT00522054

Effectiveness of Nonpharmacological and Nonsurgical Interventions for Hip Osteoarthritis: An Umbrella Review of High-Quality Systematic Reviews

An increasing number of systematic reviews are available regarding nonpharmacological and nonsurgical interventions for hip osteoarthritis (OA). The objectives of this article are to identify high-quality systematic reviews on the effect of nonpharmacological and nonsurgical interventions for hip OA and to summarize available high-quality evidence for these treatment approaches. The authors identified and screened 204 reviews. Two independent reviewers using a previously pilot-tested quality assessment form assessed the full text of 58 reviews. Six reviews were of sufficient high quality and could be included for further analyses. There was moderate-quality evidence that acupuncture and diacerein have no effect on pain and function. There was low-quality evidence that strengthening exercises and avocado/soybean unsaponifiables reduce pain and that diacerein decreases radiographic OA progression. There was insufficient high-quality evidence regarding nonpharmacological and nonsurgical interventions for hip OA, and further primary studies and reviews are needed.

Methodological properties of six shoulder disability measures in patients with rheumatic diseases referred for shoulder surgery

The aim of this study was to explore the methodological properties in 6 commonly used shoulder disability measures (Dash, Spadi, Oxford, the Constant score, Shoulder Function Assessment Scale, Bostroms shoulder movement impairment scale) in patients with inflammatory or degenerative diseases referred for shoulder surgery. One-hundred and six patients completed the measures preoperatively. Fifty-five (51.9%) were not able to carry out the assessment of the strength component of the Constant score. Pearson correlation coefficients between the measures varied between 0.22 and 0.87. The lowest correlation coefficients were found between performance-based and self-report measures. All measures, except the Dash, were able to differentiate significantly between patients who were more and less severely affected. Performance-based measures differentiated better (effect size, 0.68- 0.87) than self-report measures (effect size, 0.21-0.61) between the 2 patient groups. Performance-based and self-report assessments provide complementary information about shoulder status and should not be used interchangeably.

Identification of shoulder-specific patient acceptable symptom state in patients with rheumatic diseases undergoing shoulder surgery.

STUDY DESIGN Clinical measurement study with a longitudinal design. OBJECTIVE Estimate Patient Acceptable Symptom State (PASS) thresholds in six shoulder outcome measures and two pain scales. METHODS Patients with rheumatic diseases undergoing shoulder surgery were assessed at baseline and one-year follow-up (with Bostrom Shoulder Movement Impairment Scale, Constant, Disability of the Arm, Shoulder and Hand [DASH], Oxford Shoulder Score [Oxford], Shoulder Function Assessment Scale, Shoulder Pain and Disability Index [Spadi], and two visual analog pain scales [VAS]). PASS thresholds were estimated using the 75th percentile and the receiver operating characteristic curve approach. RESULTS One hundred patients were included; 74 (74%) patients considered their shoulder function to be acceptable (PASS+), which was significantly associated with being female, odds ratio (OR) 4.54, and having better functional status (Health Assessment Questionnaire), OR 0.17 (p<0.05). Activity-related pain (VAS), the Oxford, and the Spadi showed best discriminative accuracy for PASS. All measures estimated changes exceeding the minimal clinical important difference. CONCLUSION The Oxford and the Spadi showed better discriminant ability for PASS than the more commonly used Constant score and the DASH. The PASS thresholds for pain showed that patients accepted less pain at rest than during activity, underlining the importance of assessing both aspects of pain. LEVEL OF EVIDENCE 3. Diagnostic study.

Beneficial and harmful effects of shoulder arthroplasty in patients with rheumatoid arthritis: results from a Cochrane review

OBJECTIVE To assess beneficial and harmful effects of arthroplasty in the shoulder joint in patients with RA. METHODS A systematic review within the framework of the Cochrane Collaboration identified randomized controlled trials (RCTs), controlled clinical trials and case series (included for assessment of complications) published between 1995 and 2008. Articles considered potentially relevant were retrieved in full text and assessed independently by two authors. Risk of bias and level of evidence were assessed according to the established criteria. RESULTS One RCT (26 shoulders) compared cemented and uncemented humeral stem fixation during arthroplasty, reporting no significant differences between groups at 2-year follow-up (low-quality evidence). Nineteen case series (1155 shoulders) reported component loosening requiring revision at 5%, infections at 2% and minor complications at 7% (very low-quality evidence). The retrospective case series had several limitations related to methodological quality and standards of reporting. CONCLUSION At present, there is very little research evidence supporting decisions about shoulder joint arthroplasty in patients with RA.

Patients with rheumatoid arthritis feel better after exercises in warm water than after similar exercises on land

Question To compare the effects of individualised exercises in a heated pool to similar exercises on land in people with rheumatoid arthritis (RA). Design Randomised controlled trial with concealed allocation and assessor blinding. Setting Hospital rheumatology clinic in Birmingham, UK. Participants 115 adult patients with RA meeting American College of Rheumatology criteria, invited to participate on referral for physiotherapy, by invitation in clinics, or by mail. Fifty-seven patients were randomised to water-based exercises and 58 to land-based exercises. Interventions Water-based exercises were performed in 35°C water in sessions with up to four patients. Land-based exercises were performed in sessions with up to six patients. Both groups performed joint mobility, muscle strength, and functional activities, tailored to each individuals ability. Both exercise programs consisted of weekly 30-min sessions for six weeks. Patients were not required to do exercises between treatment sessions but could do so if they chose. Outcomes The primary outcome was self-rated overall effect of treatment, measured on the day treatment was completed on a 7-point scale ranging from 1 (very much worse) to 7 (very much better). Secondary outcomes included a visual analogue scale of pain, the health assessment questionnaire (HAQ), ten metre walk speed, and the EuroQol-5D questionnaire. Secondary outcomes were also collected at 3 months post treatment. Results At end of treatment 87% (40/46) of the patients treated with water-based exercise felt much better or very much better. This proportion of patients was significantly greater than the 47.5% (19/40) of patients in the land-based group with the same ratings (relative risk=1.8, 95% confidence interval 1.3 to 2.6). Sensitivity analyses showed that this result was robust to different assumptions. There were no significant differences between groups in the change in pain, HAQ, ten metre walk speed, or EuroQol-5D either on the day treatment was completed or at 3 months follow-up. Conclusion Patients with RA are more likely to report feeling much better or very much better immediately after treatment if they are treated with exercises in a heated pool compared to similar exercises on land. The duration of this perceived benefit is unclear.

Aquatic Exercises were Associated with an Acceptable State of Symptoms in Patients with Inflammatory Rheumatic Diseases: Results from a Study with Interrupted Time‐Series Design

AIM OF STUDY The aim of this study was two-fold: to compare symptoms and daily activity in patients with inflammatory rheumatic diseases across periods with and without aquatic exercises, and to examine whether the patients reached an acceptable state of symptoms during the periods with aquatic exercises. METHODS Thirty-six patients reported pain, fatigue, stiffness and ability to carry out daily activities across periods with and without aquatic exercises. The study has an interrupted time-series design and variables were collected with text messages on mobile phones twice a week over a period of 35 weeks. RESULTS There was a significant reduction in pain, fatigue, stiffness and enhanced level of daily activity (p > 0.05) during periods of aquatic exercises compared to periods without. Further, a significantly higher proportion of patients reached an acceptable state for both pain and fatigue during periods with aquatic exercises. CONCLUSIONS Living with an inflammatory rheumatic disease is a lifelong challenge. Pain and fatigue are considered major obstacles for daily functioning and adequate self-management strategies are requested. Based on the high proportion of patients reporting to be in an acceptable state of both pain and fatigue during periods with aquatic exercises, the intervention should be regarded as an important self-management tool rather than a treatment option assuming long-lasting effects. Copyright

OP0095-HPR Why Use Pen and Paper in Data Collection when you can Use a Mobile Phone? - Comparison of the Two Methods

Background Optimal monitoring of disease course and individual fluctuation in patients with rheumatic diseases requires both frequent and real-time assessment of relevant outcomes. Traditionally, patient-reported outcomes (PROs) have been collected using questionnaires completed with pen and paper (P&P). However, as a measurement tool in more frequent data collection, the P&P method is impractical and P&P registrations are not always filled in at the intended time (1). In contrast, data collected with text messages (SMS) on mobile telephones are time stamped and thus real-time assessments. This precludes retrospective reporting of data with regard to real time. Mobile phone ownership is rapidly increasing worldwide, making it a well-suited tool for frequent data collection and real-time assessments of PROs. Objectives To compare daily registrations of PROs assessed with SMS messages and P&P forms with regard to scores, variation of scores and feasibility of methods. Methods Pain, fatigue, stiffness and ability to carry out daily activities were assessed daily on a numeric rating scale (NRS, 0 to 10, 0 = best). Every other day the scales were reported on SMS and every other day on P&P forms for a total of 28 consecutive days. When receiving the SMS message, the patients scored each of the four variables and separated the scores with a period. A correct SMS response could for instance be: “1.5.7.3”. Data from the SMS responses were electronically transferred to a secure data server. Completed P&P forms were mailed using postage prepaid envelopes, and data from the forms were entered manually into the statistical software package. Variations, expressed as the pooled standard deviation or as the average range between the maximum and minimum scores for the two formats were compared with paired sample t-tests or Wilcoxon Signed Rank Test. Results Twenty-one patients with various rheumatic diseases, mean (SD) age 49.7 (12.2) years, 70 % female and 90 % with disease duration > 6 years, were included. The mean scores of the four variables did not differ significantly between the SMS and the P&P formats, and the variations were comparable (p>0.05)(table). Agreements between the two formats, illustrated by Bland-Altman plots for all four variables, were acceptable. Overall, the SMS data sets were more complete than the P&P data sets with 10.4% versus 28.6% missing. When asked for preference of format, 85 % preferred the SMS format while 15 % were indifferent to type of format. None of the patients preferred the P&P format. Conclusions Collection of PROs provides more complete data sets on mobile phones than on paper questionnaires. The two formats are comparable with regard to scores and variation of scores. Our results encourage the use of text messages in frequent data collection aiming at real-time assessments. References Lane SJ, Heddle NM, Arnold E, Walker I. A review of randomized controlled trials comparing then effectiveness of hand held computers with paper methods of data collection. BMC Med Inform Decis Mak. 2006;6:23 Disclosure of Interest None Declared