Annette Swinkels

Self-management of fatigue in rheumatoid arthritis: a randomised controlled trial of group cognitive-behavioural therapy

Objectives To investigate the effect of group cognitive behavioural therapy (CBT) for fatigue self-management, compared with groups receiving fatigue information alone, on fatigue impact among people with rheumatoid arthritis (RA). Methods Two-arm, parallel randomised controlled trial in adults with RA, fatigue ≥6/10 (Visual Analogue Scale (VAS) 0–10, high bad) and no recent change in RA medication. Group CBT for fatigue self-management comprised six (weekly) 2 h sessions, and consolidation session (week 14). Control participants received fatigue self-management information in a 1 h didactic group session. Primary outcome at 18 weeks was the impact of fatigue measured using two methods (Multi-dimensional Assessment of Fatigue (MAF) 0–50; VAS 0–10), analysed using intention-to-treat analysis of covariance with multivariable regression models. Results Of 168 participants randomised, 41 withdrew before entry and 127 participated. There were no major baseline differences between the 65 CBT and 62 control participants. At 18 weeks CBT participants reported better scores than control participants for fatigue impact: MAF 28.99 versus 23.99 (adjusted difference −5.48, 95% CI −9.50 to −1.46, p=0.008); VAS 5.99 versus 4.26 (adjusted difference −1.95, 95% CI −2.99 to −0.90, p<0.001). Standardised effect sizes for fatigue impact were MAF 0.59 (95% CI 0.15 to 1.03) and VAS 0.77 (95% CI 0.33 to 1.21), both in favour of CBT. Secondary outcomes of perceived fatigue severity, coping, disability, depression, helplessness, self-efficacy and sleep were also better in CBT participants. Conclusions Group CBT for fatigue self-management in RA improves fatigue impact, coping and perceived severity, and well-being. Trial registration: ISRCTN 32195100

Does Aquatic Exercise Relieve Pain in Adults With Neurologic or Musculoskeletal Disease? A Systematic Review and Meta-Analysis of Randomized Controlled Trials

OBJECTIVE To evaluate the literature on the effectiveness of aquatic exercise in relieving pain in adults with neurologic or musculoskeletal disease. DATA SOURCES A systematic literature search of 14 databases was examined for research on aquatic exercise over the period January 1980 to June 2006. STUDY SELECTION Randomized controlled trials (RCTs) that included adults with neurologic or musculoskeletal disease, pain as an outcome measure, and exercise in water were included. DATA EXTRACTION Information on the participants, interventions, and outcomes was extracted from the included studies. Quality appraisal was assessed using the Scottish Intercollegiate Guidelines Network criteria for RCTs. DATA SYNTHESIS Nineteen studies met the inclusion criteria; 8 were of moderate to low risk of bias, and 5 of these had data suitable for meta-analyses. This showed that aquatic exercise has a small posttreatment effect in relieving pain compared with no treatment (P=.04; standardized mean difference [SMD], -.17; 95% confidence interval [CI], -.33 to -.01), but it is not possible to draw a firm conclusion because of the lack of consistency of evidence across studies. Comparable pain-relieving effects were found between aquatic and land-based exercise (P=.56; SMD=.11; 95% CI, -.27 to .50). CONCLUSIONS There is sound evidence that there are no differences in pain-relieving effects between aquatic and land exercise. Compared with no treatment, aquatic exercise has a small pain-relieving effect; however, the small number of good-quality studies and inconsistency of results means that insufficient evidence limits firm conclusions. Future studies should aim for focused research questions on specific aquatic exercise techniques, using robust methodologic designs and detailed reporting of temperature, depth, and care setting.

A prospective observational study of falling before and after knee replacement surgery

BACKGROUND knee arthritis is a risk factor for falling. Increasing numbers of people are receiving total knee arthroplasty (TKA) but the natural history of falling before and after TKA is unknown. OBJECTIVE to prospectively monitor falls in pre- and post-operative TKA patients and to identify independent risk factors for post-operative falling. DESIGN a prospective observational study with a 1-year follow-up. PARTICIPANTS community-dwelling older people recruited from a regional orthopaedic centre. METHODS consecutive patients added to the TKA waiting list who completed monthly falls diaries, pre-operatively and 1 year post-operatively. Data on knee status (WOMAC: pain, stiffness and function), balance confidence (the Activities Balance Confidence Scale-UK-ABC-UK) and mood (Geriatric Depression Scale-GDS) were collected at quarterly intervals. RESULTS ninety-nine patients received a primary TKA. 24.2% fell in the last pre-operative quarter (24 patients reported 44 falls) and this decreased to 11.7-11.8% in the first four post-operative quarters. 45.8% of people who fell pre-operatively fell again in the first post-operative year. Higher pre-operative GDS scores and a history of falling were significant independent predictors of post-operative falling. CONCLUSION a recent history of falling is common in people undergoing TKA and approximately 45% of patients fall again in the year following surgery. Patients being considered for TKA should be asked about falls history and undergo falls risk assessment and intervention.

Evidence-based practice in health and social care: where are we now?

This paper explores evidence-based practice (EBP) in health and social care in the UK from the individual perspectives of professionals in physiotherapy, midwifery, nursing and social care. The present interest in EBP emerges as a natural derivative of contemporary economic, social and political trends and concerns. There is optimism and broad acceptance of the overall philosophy of EBP and each profession demonstrates a concerted organisational attempt to bridge the research--practice divide. This includes the interpretation of research outcomes in the form of practice guidelines, protocols and standards. However, adherence to these is poor and resistance to EBP is growing. This is attributed to practical and philosophical tensions common to all of the professions. These include the continued dominance of randomised controlled trials (RCTs) in the hierarchy of evidence. RCTs often fail to capture the multi-faceted individualistic nature of health and social care interactions or the development of qualitative methodologies within the professions. Concern is expressed that professional autonomy and the art of practice will be eroded by the enforcement of guidelines and protocols. EBP is currently located within individual professions rather than the broader context of interprofessional practice. The future of EBP is dependent, at least in part, on educational initiatives, organisational commitment and support, patient/client involvement and the development of a broader interprofessional perspective.

Pelvic floor exercises for erectile dysfunction.

Associate Editor

“They didn't tell us, they made us work it out ourselves”: Patient perspectives of a cognitive–behavioral program for rheumatoid arthritis fatigue†

Fatigue is an overwhelming rheumatoid arthritis (RA) symptom caused by interacting clinical and psychosocial factors. Cognitive–behavioral therapy (CBT) addresses links between thoughts, feelings, and behaviors and uses cognitive restructuring to facilitate behavior changes. In a randomized controlled trial, a group CBT program for RA fatigue improved fatigue impact, severity, and perceived coping, as well as mood and quality of life. The aim of this study was to explore the patient perspective of the program and the impact of behavior changes.

Physical performance tests, self-reported outcomes, and accidental falls before and after total knee arthroplasty: An exploratory study

This longitudinal, observational study explored the relationship between physical performance tests, self-reported outcomes, and accidental falling, before and after total knee arthroplasty (TKA). Thirty-seven patients were randomly selected from a larger study of falling before and after surgery conducted at a UK National Health Service Orthopaedic Unit. Physical performance tests were the Berg Balance Score (BBS), Timed Up and Go (TUG), and Hand Grip Strength (HGS). Self-reported outcomes incorporated the Western Ontario and McMasters Osteoarthritis Index (WOMAC), Activities Balance Confidence Scale (ABC-UK), Geriatric Depression Scale (GDS), and accidental falls. Paired pre- and postoperative data were available on 22 patients. A total of 22.7% patients fell before and after TKA. Postoperative improvement in BBS and TUG was found in 41% and 50% of patients, respectively, HGS did not change. BBS showed a consistent moderate-to-strong association with other physical tests both before and after surgery; TUG (rs −0.76; rs −0.90), maximal HGS (r 0.49; r 0.48), and self-report measures; ABC-UK (r 0.52; r 0.74), WOMAC stiffness (r −0.53; r −0.48), and WOMAC function (r −0.56; r −0.45). Although self-report questionnaires are an efficient, cost-effective approach to outcome assessment in TKA, there is a growing case for inclusion of physical performance tests. The Berg Balance Score may be a useful addition to outcome assessment in patients with TKA.

Within-day and day-to-day intrarater reliability of ultrasonographic measurements of acromion-greater tuberosity distance in healthy people

Shoulder subluxation is subjectively assessed by a palpable increase in the distance between the acromion and the humerus. Diagnostic ultrasound has potential for objective assessment of this distance. We used portable ultrasound to measure the distance between the acromion and greater tuberosity (acromion-greater tuberosity [AGT] distance) and tested the intrarater reliability in healthy individuals prior to testing on stroke patients. Thirty-two healthy participants aged 51–85 years (mean 64.2±10.5) were recruited. Seated participants were scanned by a physiotherapist trained in shoulder ultrasound. Measurements were recorded on day 1 and again within 2 weeks. Reliability was assessed by intraclass correlation coefficients. The mean AGT distance was 1.68±0.41 cm for the left and 1.78±0.40 cm for the right shoulder. Within-day intrarater reliability coefficients were 0.99 and 0.98 for the left and right shoulders, respectively. Corresponding values for day-to-day reliability were 0.96 and 0.97. Portable diagnostic ultrasound is a quick and reliable method of assessing AGT distance in healthy individuals when measured by the same examiner.

Reliability and Validity of Ultrasonographic Measurements of Acromion-Greater Tuberosity Distance in Poststroke Hemiplegia

OBJECTIVES The primary aim of this study was to assess the intrarater reliability of ultrasonographic measurements of acromion-greater tuberosity (AGT) distance in patients with stroke using portable ultrasound. A secondary aim was to determine the discriminant validity of the ultrasonographic technique by comparison of AGT distance measurements of stroke-affected and unaffected shoulders. DESIGN Test-retest design. SETTING Two local National Health Service hospitals in the South West of England. PARTICIPANTS Patients with first-time stroke (N=26; 16 men, 10 women; mean age ± SD, 71±10y) with 1-sided weakness who gave informed consent were recruited. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Portable diagnostic ultrasound was used to record measurements on day 1 and again within a fortnight. Bedside measurements were undertaken by a single physical therapist with patients seated upright in a standard hospital chair. Intraclass correlation coefficients (ICCs) and standard errors of measurement were used to assess reliability. Minimum detectable change (MDC90) scores were used to estimate the magnitude of change that is likely to exceed measurement error. Repeated-measures analysis of variance (ANOVA) was used to assess discriminant validity. RESULTS Mean ± SD AGT distances on the stroke-affected side and unaffected side were 2.3±0.6cm and 1.9±0.3cm, respectively. ICC for within-day reliability was .98 for the affected shoulder and .95 for the unaffected shoulder. Corresponding values for between-day reliability were .94 and .76. The standard error of measurement for both affected and unaffected shoulders was less than 0.2cm. Within-day MDC90 for the affected shoulder and the unaffected shoulder was ±0.2cm and ±0.1cm, respectively. Repeated-measures ANOVA showed a significant difference between mean AGT distance for the affected and unaffected shoulders. CONCLUSIONS Ultrasonographic measurement of AGT distance demonstrates both intrarater reliability and discriminant validity and has the potential to assess shoulder subluxation in patients with stroke. Research into interrater reliability and concurrent validity of ultrasonographic measurements of AGT distance in patients with stroke is required.

A critical review of shoulder subluxation and its association with other post-stroke complications

Abstract Objectives: Shoulder subluxation affects up to 81% of patients with stroke and has been the subject of clinical research studies for decades. Despite this, its role in upper limb recovery is poorly understood. Subluxation has been linked to other post-stroke complications such as pain, restricted range of motion, poor motor recovery and reflex sympathetic dystrophy. The aim of the present study is to synthesise research findings on the association between subluxation and other post-stroke complications. Methods: A critical review of the relevant literature was undertaken. Results: The association between shoulder subluxation and post-stroke complications is equivocal. The majority of studies were found to have methodological limitations such as heterogeneous patient recruitment criteria, small sample sizes, lack of a standardised definition of subluxation and the use of varied and insensitive clinical measures of assessment. Discussion: Although the association between subluxation and post-stroke complications is uncertain, when present in combination, these complications could have a significant impact on upper limb function. Early rehabilitation programmes which target shoulder muscle function may be the best approach to the prevention of secondary complications and the facilitation of motor recovery in the upper limb. Future longitudinal studies with more homogenous samples are needed. These should consider assessing patients at multiple times and follow them up for at least 1 year. The use of prediction models would allow understanding of a causal association between subluxation and other post-stroke complications. This would inform the effective rehabilitation of upper limb dysfunction in patients with stroke.