Cornelia H. M. van den Ende

Occupational Therapy for Stroke Patients A Systematic Review

Background and Purpose— Occupational therapy (OT) is an important aspect of stroke rehabilitation. The objective of this study was to determine from the available literature whether OT interventions improve outcome for stroke patients. Methods— An extensive search in MEDLINE, CINAHL, EMBASE, AMED, and SCISEARCH was performed. Studies with controlled and uncontrolled designs were included. Seven intervention categories were distinguished and separately analyzed. If a quantitative approach (meta-analysis) of data analysis was not appropriate, a qualitative approach (best-evidence synthesis), based on the type of design, methodological quality, and significant findings of outcome and/or process measures, was performed. Results— Thirty-two studies were included in this review, of which 18 were randomized controlled trials. Ten randomized controlled trials had a high methodological quality. For the comprehensive OT intervention, the pooled standardized mean difference for primary activities of daily living (ADL) (0.46; CI, 0.04 to 0.88), extended ADL (0.32; CI, 0.00 to 0.64), and social participation (0.33; CI, 0.03 to 0.62) favored treatment. For the training of skills intervention, some evidence for improvement in primary ADL was found. Insufficient evidence was found to indicate that the provision of splints is effective in decreasing muscle tone. Conclusions— This review identified small but significant effect sizes for the efficacy of comprehensive OT on primary ADL, extended ADL, and social participation. These results correspond to the outcome of a systematic review of intensified rehabilitation for stroke patients. The amount of evidence with respect to specific interventions, however, is limited. More research is needed to enable evidence-based OT for stroke patients.

The Scleroderma Patient-centered Intervention Network (SPIN) Cohort: protocol for a cohort multiple randomised controlled trial (cmRCT) design to support trials of psychosocial and rehabilitation interventions in a rare disease context

Introduction Psychosocial and rehabilitation interventions are increasingly used to attenuate disability and improve health-related quality of life (HRQL) in chronic diseases, but are typically not available for patients with rare diseases. Conducting rigorous, adequately powered trials of these interventions for patients with rare diseases is difficult. The Scleroderma Patient-centered Intervention Network (SPIN) is an international collaboration of patient organisations, clinicians and researchers. The aim of SPIN is to develop a research infrastructure to test accessible, low-cost self-guided online interventions to reduce disability and improve HRQL for people living with the rare disease systemic sclerosis (SSc or scleroderma). Once tested, effective interventions will be made accessible through patient organisations partnering with SPIN. Methods and analysis SPIN will employ the cohort multiple randomised controlled trial (cmRCT) design, in which patients consent to participate in a cohort for ongoing data collection. The aim is to recruit 1500–2000 patients from centres across the world within a period of 5 years (2013–2018). Eligible participants are persons ≥18 years of age with a diagnosis of SSc. In addition to baseline medical data, participants will complete patient-reported outcome measures every 3 months. Upon enrolment in the cohort, patients will consent to be contacted in the future to participate in intervention research and to allow their data to be used for comparison purposes for interventions tested with other cohort participants. Once interventions are developed, patients from the cohort will be randomly selected and offered interventions as part of pragmatic RCTs. Outcomes from patients offered interventions will be compared with outcomes from trial-eligible patients who are not offered the interventions. Ethics and dissemination The use of the cmRCT design, the development of self-guided online interventions and partnerships with patient organisations will allow SPIN to develop, rigourously test and effectively disseminate psychosocial and rehabilitation interventions for people with SSc.

Prognosis of limitations in activities in osteoarthritis of the hip or knee: a 3-year cohort study

UNLABELLED van Dijk GM, Veenhof C, Spreeuwenberg P, Coene N, Burger BJ, van Schaardenburg D, van den Ende CH, Lankhorst GJ, Dekker J, on behalf of the CARPA Study Group. Prognosis of limitations in activities in osteoarthritis of the hip or knee: a 3-year cohort study. OBJECTIVE To describe the course of limitations in activities in elderly patients with osteoarthritis (OA) of the hip or knee over a follow-up period of 3 years, and to identify prognostic factors of the course of limitations in activities, focusing on body functions, comorbidity, and cognitive functioning. DESIGN A longitudinal cohort study with 3 years of follow-up. Measurements were conducted annually. Statistical analyses included t tests, univariate regression analyses, and multivariate regression analyses. SETTING Rehabilitation centers and hospitals (Departments of Orthopedics, Rheumatology, and Rehabilitation) in The Netherlands. PARTICIPANTS Patients (N=237) with hip or knee OA. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Patient-perceived change, self-reported limitations in activities measured by the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and observed limitations in activities (timed walking test). Prognostic factors: demographic data, clinical data, body function (pain, muscle strength, range of motion [ROM]), comorbidity, and cognitive functioning (cognitive decline, memory, attention). RESULTS Self-reported limitations in activities measured by the WOMAC improved slightly after 3-year follow-up. In knee OA, reduced ROM at 1-year follow-up (beta=.120), increased pain at 1-year follow-up (beta=-.177), and higher morbidity count (beta=-.180) predicted worsening of self-reported limitations in activities. In hip OA, reduced ROM at 1-year follow-up (beta=.201 for hip external rotation and beta=.144 for knee extension), increased pain at 1-year follow-up (beta=-.134), higher morbidity count (beta=-.220), or the presence of moderate to severe cardiac disease (beta=-.214) and poorer cognitive functioning (beta=.181) predicted worsening of self-reported limitations in activities. Performance-based limitations in activities measured by the timed walking test did not change after 3 years of follow-up. In knee OA, decreased muscle strength at 1-year follow-up (beta=-.272) and higher morbidity count (beta=.199) predicted worsening of performance-based limitations in activities. In hip OA, better ROM (beta=.182), higher morbidity count (beta=.232), or the presence of moderate to severe cardiac and eye-ear-nose-throat disease (beta=.210 and beta=.188, respectively) and older age (beta=.355) predicted worsening of performance-based limitations in activities. CONCLUSIONS Overall, at the group level, limitations in activities of patients with OA of the hip or knee recruited from hospitals and rehabilitation centers seem fairly stable during the first 3 years of follow-up. However, at the level of individual patients, considerable variation occurs. Prognostic factors for worsening of limitations in activities include increased pain, reduced ROM, and decreased muscle strength at 1-year follow-up; higher morbidity count; and to a lesser extent poor cognitive functioning.

Evidence of the efficacy of occupational therapy in different conditions: an overview of systematic reviews

Objective: To summarize the research evidence available from systematic reviews of the efficacy of occupational therapy (OT) for practitioners, researchers, purchasing organizations and policy-makers. Data source: The search for systematic reviews was conducted in PubMed and the Cochrane Library (October 2004). Methods: The reviews included were those that utilized a systematic search for evidence with regard to OT for specific patient groups. Data were summarized for patient group, interventions, outcome domains, type of study designs included, method of data synthesis and conclusions. Results: Fourteen systematic reviews were included. Three reviews related to rheumatoid arthritis, four reviewed stroke and four focused on elderly people. Reviews of Parkinsons disease, multiple sclerosis, Huntingtons disease, cerebral palsy and mental illnesses were also identified. The reviews of rheumatoid arthritis, stroke and elderly people showed evidence of the efficacy of OT in increasing functional abilities. Positive results were presented for quality of life and social participation in elderly people and stroke respectively. The efficacy of OT in all other patient groups is unknown due to insufficient evidence. Conclusion: This summary shows that elderly people and people with stroke or rheumatoid arthritis can expect to benefit from comprehensive OT. Evidence of the efficacy of specific interventions is sparse and should be addressed in future research. The evidence that does exist should be incorporated into OT practice.

Beating osteoARThritis: Development of a stepped care strategy to optimize utilization and timing of non-surgical treatment modalities for patients with hip or knee osteoarthritis

Inadequacies in health care practices have been reported despite existing guidelines to manage hip or knee osteoarthritis. To facilitate guideline implementation and improve utilization of non-surgical treatment options a care strategy should be developed. This study describes the development of an evidence-based, multidisciplinary, patient-centered, stepped care strategy. A national, multidisciplinary, steering group developed the strategy in three phases: (1) consensus among steering group members (first draft); (2) written consultation of 23 representatives of patient organizations and professional associations involved in osteoarthritis care (second draft); (3) consensus of the final draft after discussion in two rounds during a conference with representatives from the different disciplines. The final stepped care strategy presents, in three tiers, the optimal order for non-surgical treatment modalities. It recommends that more advanced options should only be considered if options listed in previous steps failed to produce satisfactory results. Hence, the first step treatment options can be offered to all patients but may also be provided through self care (education, life style advice, and acetaminophen). The second step (exercise therapy, dietary therapy, and non-steroidal anti-inflammatory drugs) and third step treatment options (multidisciplinary care, intra-articular injections, and transcutaneous electrical nerve stimulation) can be considered for people with persisting complaints. Trough a consensus procedure, we succeeded to develop a multidisciplinary, patient-centered, stepped care strategy based on national guidelines. This strategy provides a framework for health care providers and patients with hip or knee osteoarthritis to discuss the optimal timing of the various treatment options.

The cost effectiveness of behavioural graded activity in patients with osteoarthritis of hip and/or knee

Objective: To evaluate whether exercise treatment based on behavioural graded activity comprising booster sessions is a cost-effective treatment for patients with osteoarthritis of the hip and/or knee compared with usual care. Methods: An economic evaluation from a societal perspective was carried out alongside a randomised trial involving 200 patients with osteoarthritis of the hip and/or knee. Outcome measures were pain, physical functioning, self-perceived change and quality of life, assessed at baseline, 13, 39 and 65 weeks. Costs were measured using cost diaries for the entire follow-up period of 65 weeks. Cost and effect differences were estimated using multilevel analysis. Uncertainty around the cost-effectiveness ratios was estimated by bootstrapping and graphically represented on cost-effectiveness planes. Results: 97 patients received behavioural graded activity, and 103 patients received usual care. At 65 weeks, no differences were found between the two groups in improvement with respect to baseline on any of the outcome measures. The mean (95% confidence interval) difference in total costs between the groups was −€773 (−€2360 to €772)—that is, behavioural graded activity resulted in less cost but this difference was non-significant. As effect differences were small, a large incremental cost-effectiveness ratio of €51 385 per quality adjusted life year was found for graded activity versus usual care. Conclusions: This study provides no evidence that behavioural graded activity is either more effective or less costly than usual care. Yielding similar results to usual care, behavioural graded activity seems an acceptable method for treating patients with osteoarthritis of the hip and/or knee.

Disease-related and psychosocial factors associated with depressive symptoms in patients with systemic sclerosis, including fear of progression and appearance self-esteem

OBJECTIVE The prevalence of depressive symptoms is high in patients with systemic sclerosis (SSc, scleroderma). This study was conducted to determine which disease-related and psychosocial factors are associated with depressive symptoms, independent of sociodemographic factors. METHODS In total, 215 patients with SSc completed questionnaires on sociodemographics, physical functioning (HAQ-DI), pain (VAS), fatigue (CIS), psychosocial characteristics (CISS, ICQ, PRQ, ASE, FoP-Q-SF) and depressive symptoms (CES-D). Disease characteristics (disease duration, disease subtype, modified Rodnan Skin Score) were collected. Hierarchical linear regression analyses were conducted to assess associations with depressive symptoms. RESULTS The mean CES-D score was 12.9 (SD=9.7) and the prevalence of patients scoring>= 16 and>=19 were 32.1% and 25.1%, respectively. The variance explained by sociodemographics and disease characteristics was negligible (R(2)≤.09). Fatigue and pain were independently associated with depressive symptoms (R(2) change=.35). After adding psychological factors (R(2) change=.21), satisfaction with social support, emotion-focused coping and helplessness were also significantly associated with depressive symptoms. Higher fear of progression was associated with more depressive symptoms (P≤.01), and appearance self-esteem showed a marginally significant association (P=.08). CONCLUSION Depressive symptoms were common in the present sample of patients with SSc and were independently associated with pain, fatigue, social support, emotion-focused coping, helplessness and fear of progression. Results suggest that, in addition to assessment of disease characteristics, attention should be given also to psychosocial factors found to be associated with depressive symptoms. For the development and trialling of psychological interventions, fear of progression could be an important target.

Active involvement and long-term goals influence long- term adherence to behavioural graded activity in patients with osteoarthritis: a qualitative study

QUESTION Why do some patients who have received a behavioural graded activity program successfully integrate the activities into their daily lives and others do not? DESIGN Qualitative study. PARTICIPANTS 12 patients were selected according to the model of deliberate sampling for heterogeneity, based on their success with the intervention as assessed on the Patient Global Assessment. INTERVENTION Behavioural graded activity. OUTCOME MEASURES Data from 12 interviews were coded and analysed using the methods developed in grounded theory. The interviews covered three main themes: aspects related to the content of behavioural graded activity, aspects related to experience with the physiotherapist, and aspects related to characteristics of the participant. RESULTS Interview responses suggest that two factors influence long-term adherence to exercise and activity.First, initial long-term goals rather than short-term goals seem to relate to greater adherence to performing activities in the long term. Second, active involvement by participants in the intervention process seems to relate to greater adherence to performing activities in the long term. CONCLUSION Although involvement of patients in the intervention process is already part of behavioural graded activity, it would be beneficial to emphasise the importance of active involvement by patients right from the start of the intervention. Furthermore, to increase the success of behavioural graded activity, physiotherapists should gain a clear understanding of the patients initial motives in undergoing intervention.

Joint‐pain comorbidity, health status, and medication use in hip and knee osteoarthritis: A cross‐sectional study

To determine the prevalence of joint‐pain comorbidities in individuals with hip or knee osteoarthritis (OA) and to assess the differences in the characteristics of people with and without joint‐pain comorbidities.

Compliance with the guidelines for acute ankle sprain for physiotherapists is moderate in the Netherlands: an observational study

QUESTION What is the compliance with guidelines for acute ankle sprain for physiotherapists? DESIGN Survey of random sample of physiotherapists. PARTICIPANTS 400 physiotherapists working in extramural health care in the Netherlands. OUTCOME MEASURES Questions covered attitude towards guidelines in general, familiarity with the guidelines for acute ankle sprain,compliance with the guidelines, advantages and disadvantages of the guidelines, and factors relating to compliance with the guidelines. RESULTS The majority of the physiotherapists were familiar with the content of the guidelines to some degree and 66%applied it to more than half of their patients with acute ankle sprain. The recommendations to determine both the prognosis and the necessity of treatment by using the function score were the least followed. Some physiotherapists thought the function score was not completely clear, which may have been a barrier for implementation. Factors relating positively to compliance were a positive attitude towards guidelines in general, and having colleagues who implemented the guidelines for acute ankle sprain. CONCLUSION Although compliance with the guidelines for acute ankle sprain was fair/moderate, compliance may be enhanced by improving clarity of the function score, including it in the short version and improving the attitude of physiotherapists towards guidelines in general.