J. Dekker

Effectiveness of exercise therapy: A best-evidence summary of systematic reviews

The purpose of this project was to summarise the available evidence on the effectiveness of exercise therapy for patients with disorders of the musculoskeletal, nervous, respiratory, and cardiovascular systems. Systematic reviews were identified by means of a comprehensive search strategy in 11 bibliographic databases (08/2002), in combination with reference tracking. Reviews that included (i) at least one randomised controlled trial investigating the effectiveness of exercise therapy, (ii) clinically relevant outcome measures, and (iii) full text written in English, German or Dutch, were selected by two reviewers. Thirteen independent and blinded reviewers participated in the selection, quality assessment and data-extraction of the systematic reviews. Conclusions about the effectiveness of exercise therapy were based on the results presented in reasonable or good quality systematic reviews (quality score > or = 60 out of 100 points). A total of 104 systematic reviews were selected, 45 of which were of reasonable or good quality. Exercise therapy is effective for patients with knee osteoarthritis, sub-acute (6 to 12 weeks) and chronic (> or = 12 weeks) low back pain, cystic fibrosis, chronic obstructive pulmonary disease, and intermittent claudication. Furthermore, there are indications that exercise therapy is effective for patients with ankylosing spondylitis, hip osteoarthritis, Parkinsons disease, and for patients who have suffered a stroke. There is insufficient evidence to support or refute the effectiveness of exercise therapy for patients with neck pain, shoulder pain, repetitive strain injury, rheumatoid arthritis, asthma, and bronchiectasis. Exercise therapy is not effective for patients with acute low back pain. It is concluded that exercise therapy is effective for a wide range of chronic disorders.

Predictors of outcome in neck and shoulder symptoms: a cohort study in general practice

Study Design. An observational prospective cohort study in general practice. Objectives. To describe the clinical course and to identify predictors of recovery, changes in pain intensity, and changes in functional disability in patients with neck or shoulder symptoms at 3- and 12-month follow-up. Summary of Background Data. Knowledge on the clinical course and predictors of outcome in neck and shoulder symptoms is limited. Such knowledge would facilitate treatment decisions and may help to inform patients about their prognosis. Methods. Four hundred and forty-three patients who consulted their general practitioner with neck or shoulder symptoms participated in the study. Baseline scores of pain and disability, symptom characteristics, sociodemographic and psychological factors, social support, physical activity, general health, and comorbidity were investigated as possible predictors of recovery, changes in pain intensity, and changes in functional disability using multiple regression analyses. Results. The recovery rate was low; 24% of the patients reported recovery at 3 months and 32% reported recovery at 12-month follow-up. Duration of the symptoms before consulting the GP and a history of neck or shoulder symptoms increased the probability of an unfavorable outcome. Furthermore, less vitality and more worrying were consistently associated with poorer outcome after 3 and 12 months. The area under the receiver-operator characteristic curve for the model predicting recovery was 0.8 at 3 months and 0.75 at 12 months. The explained variance of the models on pain and functional disability ranged from 43 to 54%. Conclusions. The results found in this study indicate that besides clinical characteristics, psychological factors also predict the outcome of neck and shoulder symptoms.

Comorbidity, limitations in activities and pain in patients with osteoarthritis of the hip or knee

BackgroundThis study aims to contribute to the knowledge of the influence of comorbidity in OA. The objectives of the study were (i) to describe the prevalence of comorbidity and (ii) to describe the relationship between comorbidity (morbidity count, severity and the presence of specific diseases) and limitations in activities and pain in elderly patients with knee or hip OA using a comprehensive inventory of comorbidity.MethodsA cross-sectional cohort study was conducted, in which 288 elderly patients with hip or knee osteoarthritis were included. Apart from demographic and clinical data, information about comorbidity, limitations in activities (WOMAC, SF-36 and timed walking test) and pain (VAS) was collected by questionnaires and tests. Statistical analyses included descriptive statistics, multivariate regression techniques, t-tests and one-way ANOVA.ResultsAlmost all patients suffered from at least one comorbid disease, with cardiac diseases, diseases of eye, ear, nose, throat and larynx, other urogenital diseases and endocrine/metabolic diseases being most prevalent. Morbidity count and severity index were associated with more limitations in activities and with more pain. The presence of most of the moderate or severe diseases and obesity was associated with limitations in activities or with pain.ConclusionThe results of this study emphasize the importance of comorbidity in the rehabilitation of elderly patients with osteoarthritis of the hip or knee. Clinical practitioners should be aware of the relationship of comorbidity with functional problems in OA patients.

Comparison of the responsiveness of the Harris Hip Score with generic measures for hip function in osteoarthritis of the hip

Objective: To compare responsiveness of the Harris Hip Score with generic measures (that is, the Short Form-36 (SF-36), and a test of walking speed and pain during walking) in patients with osteoarthritis (OA) of the hip. Method: The first 75 cases within the population of a randomised clinical trial on manual therapy and exercise therapy were selected for secondary analysis. Experienced (self reported) recovery by the patients after treatment (five weeks) was used as an external criterion for clinically relevant improvement. Responsiveness was evaluated by comparing responsiveness ratios and receiver operating characteristic curves. Results: The responsiveness ratio for the Harris Hip Score was high (1.70) compared with walking speed (0.45), pain during walking (0.66), and the subscales of the SF-36—“bodily pain” (0.42) and “physical functioning” (0.36). The area under the curve also was highest for the Harris Hip Score (0.92) compared with walking speed (0.71), pain during walking (0.73), and the SF-36 subscales—bodily pain and physical functioning (both 0.66). Conclusion: The Harris Hip Score is more responsive than the test of walking speed, pain, and subscales for function of the SF-36 in patients with OA of the hip. The Harris Hip Score seems to be a suitable instrument to evaluate change in hip function in patients with OA of the hip.

Proprioception in knee osteoarthritis: a narrative review

OBJECTIVE To give an overview of the literature on knee proprioception in knee osteoarthritis (OA) patients. METHOD A literature search was performed and reviewed using the narrative approach. RESULTS (1) Three presumed functions of knee proprioception have been described in the literature: protection against excessive movements, stabilization during static postures, and coordination of movements. (2) Proprioceptive accuracy can be measured in different ways; correlations between these methods are low. (3) Proprioceptive accuracy in knee OA patients seems to be impaired when compared to age-matched healthy controls. Unilateral knee OA patients may have impaired proprioceptive accuracy in both knees. (4) Causes of impaired proprioceptive accuracy in knee OA remain unknown. (5) There is currently no evidence for a role of impaired proprioceptive accuracy in the onset or progression of radiographic osteoarthritis (ROA). (6) Impaired proprioceptive accuracy could be a risk factor for progression (but not for onset) of both knee pain and activity limitations in knee OA patients. (7) Exercise therapy seems to be effective in improving proprioceptive accuracy in knee OA patients. CONCLUSIONS Recent literature has shown that proprioceptive accuracy may play an important role in knee OA. However, this role needs to be further clarified. A new measurement protocol for knee proprioception needs to be developed. Systematic reviews focusing on the relationship between impaired proprioceptive accuracy, knee pain and activity limitations and on the effect of interventions (in particular exercise therapy) on proprioceptive accuracy in knee OA are required. Future studies focusing on causes of impaired proprioceptive accuracy in knee OA patients are also needed, taking into account that also the non-symptomatic knee may have proprioceptive impairments. Such future studies may also provide knowledge of mechanism underlying the impact of impaired proprioceptive accuracy on knee pain and activity limitations.

Structural joint changes, malalignment, and laxity in osteoarthritis of the knee

Objective: To assess the relationship between (i) structural joint changes (i.e. joint space narrowing and osteophyte formation) and laxity and (ii) joint malalignment and laxity in osteoarthritis (OA) of the knee. Methods: A cross‐sectional study was carried out on 35 outpatients with osteoarthritis of the knee. Weight‐bearing radiographs of the knees were used to assess joint space narrowing (JSN) and osteophyte formation. Knee joint laxity was assessed using a device that measures the angular deviation of the knee in the frontal plane (varus–valgus laxity). Malalignment was assessed using a goniometer. All analyses were performed using knees as units of analysis (i.e. 70 knees). Results: The mean laxity of 70 knees was 8.0±4.1°. Knees with minute JSN were significantly more lax than knees with no JSN. There was no significant relationship between osteophyte formation and laxity. Malaligned knees were significantly more lax than aligned knees. Conclusion: Both joint space narrowing and malalignment are related to laxity. These results support the premise that biomechanical factors play a role in the degeneration of the osteoarthritic knee joint.

Reproducibility of plantar pressure measurements in patients with chronic arthritis: a comparison of one-step, two-step, and three-step protocols and an estimate of the number of measurements required.

Background: Plantar pressure measurement may be a helpful evaluation tool in patients with foot complaints. Determination of dynamic pressure distribution under the foot may give information regarding gait, progress of disorders, and the effect of treatment. However, for these measurements to have clinical application, reproducibility, consistency, and accuracy must be ascertained. We compared the reproducibility of measurements among one-step, two-step, and three-step protocols for data collection in patients with arthritis. In addition, the number of measurements needed for a consistent average was determined for the protocol that was found to be the most reproducible. Methods: Twenty patients with foot complaints secondary to arthritis participated in the study. Each patient was tested with a pressure platform system using two of the three testing protocols. Reproducibility of contact time and maximal peak pressure were assessed. Intraclass Correlation Coefficients (ICC) were calculated for measurement results among protocols. In stage two of the study, the number of measurements needed for a consistent average was determined by calculating the first three measurements, the first five measurements, and then all seven measurements for both feet. ICC of three, five, and seven measurements were compared. The two-step protocol (13 patients), which was found in stage one of the study to be the most reproducible, was used for this determination. Results: Reproducibility was found to be reasonable or good for all three measurement protocols. The mean values of contact time for the one-step protocol were found to be higher than the mean values of contact time for the two-step or three-step protocols in both feet. The differences between the one-step and three-step protocols were statistically significant for the left foot only. The mean peak pressure did not show statistically-significant differences among the three protocols. The one-step and three-step protocols were not used for stage two of the study. Using the two-step protocol, three measurements were found to be sufficient for obtaining a consistent average. Conclusions: The results of our study indicated that the one-step, two-step, and three-step protocols of collecting plantar pressure measurements in patients with foot complaints secondary to chronic arthritis were all similar. However, the use of the two-step protocol is recommended over the one-step and three-step protocols; the one-step protocol produced a longer stance phase that did not resemble normal walking and when comparing the two-step and three-step protocols, the two-step protocol was less time consuming and less strenuous for patients with painful feet.

Prevalence of Hand Symptoms, Impairments and Activity Limitations in Rheumatoid Arthritis in Relation to Disease Duration

OBJECTIVE To determine the prevalence of hand and wrist symptoms and impairments, and the resulting activity limitations in relation to disease duration in patients with rheumatoid arthritis. DESIGN AND PATIENTS A cross-sectional study included 200 consecutive patients with rheumatoid arthritis in 4 categories of disease duration: 2-4, 4-6, 6-8 and ≥ 8 years. Patients were asked about the presence of various hand and wrist symptoms, and underwent a standardized physical examination. To evaluate activity limitations, patients completed the Disabilities of the Arm Shoulder and Hand questionnaire and scored their limitations on a Numerical Rating Scale (0 = no to 10 = maximum limitation). RESULTS Of all patients, 94% suffered from at least one symptom, and 67% had at least one impairment, mostly from the earliest stages onwards. The median standardized Disabilities of the Arm Shoulder and Hand score (interquartile range) was 26.7 (10.8-42.5). The mean Numerical Rating Scale score for activity limitations was 2.99 (standard deviation 2.50) in the dominant hand and 2.59 (standard deviation 2.49) in the non-dominant hand. CONCLUSION A high prevalence of hand and wrist symptoms and impairments is often already present after 2 years of disease duration. We recommend that physicians specifically screen for these symptoms and impairments, starting 2 years after the diagnosis of rheumatoid arthritis.

Rehabilitation of stroke patients with apraxia: the role of additional cognitive and motor impairments.

Purpose : The present study investigated which additional cognitive and motor impairments were present in stroke patients with apraxia and which of these factors influenced the effects of treatment. Method : A group of 33 patients with apraxia were treated according to the guidelines of a therapy programme based on teaching patients strategies to compensate for the presence of apraxia. Patients were treated at occupational therapy departments in general hospitals, rehabilitation centres and nursing homes. The outcome of the strategy training was studied in a pre-post test design; measurements were conducted at baseline and after 12 weeks of therapy. The pretreatment scores of the patients with apraxia were compared to normscores and scores of a control group of patients without apraxia ( n = 36) to investigate which impairments are present. The following variables were analysed in order to determine which factors influence outcome: additional neuropsychological deficits (comprehension of language, cognitive impairments due to dementia, neglect and short term memory), level of motor functioning, severity of apraxia and performance on activities of daily living (ADL), and some relevant patient characteristics (gender, age, type of stroke, time since stroke, and location of treatment). Results : The results showed that the presence of apraxia is associated with the presence of additional cognitive and motor impairments. The successful outcome of strategy training was not negatively influenced by cognitive comorbidity. The outcome seemed to be more prominent in patients who were more severely impaired at the start of rehabilitation in terms of the degree of motor impairments, the severity of apraxia and the initial ADL dependence. The ADL observations, however, displayed a ceiling effect, which was taken into account in discussing the results. Demographic variables, especially age, did not predict the outcome of treatment. Conclusions : We suggest that the effect of this training is stronger in more severely disabled patients. However, neither the presence of additional cognitive impairments nor the severity of motor problems nor old age should be an indication for refraining from treating apraxia.

Determinants of range of joint motion in patients with early symptomatic osteoarthritis of the hip and/or knee: an exploratory study in the CHECK cohort

OBJECTIVE Reduced range of motion (ROM) is supposed to be a characteristic feature of osteoarthritis (OA). Because little is known about determinants of ROM, the objective of the present study was to explore the association between demographic, articular, and clinical factors and ROM in patients with early symptomatic knee and/or hip OA. DESIGN Baseline data of 598 participants of the Cohort Hip and Cohort Knee (CHECK) study were used in this cross-sectional study. METHODS Separate analyses were performed for participants with knee and participants with hip symptoms. Active knee flexion, and hip internal rotation, external rotation, flexion, adduction, and abduction were assessed using a goniometer. Participants underwent a standardised physical and radiographic examination, and completed a questionnaire. Exploratory regression analyses were performed to explore the association between ROM and demographic [i.e., age, gender, body mass index (BMI)], articular [i.e., osteophytosis, joint space narrowing (JSN)], and clinical (i.e., pain, stiffness) factors. RESULTS In patients with early symptomatic knee OA, osteophytosis, bony enlargement, crepitus, pain, and higher BMI were associated with lower knee flexion. JSN was associated with lower ROM in all planes of motion. In addition, osteophytosis, flattening of the femoral head, femoral buttressing, pain, morning stiffness, male gender, and higher BMI were found to be associated with lower hip ROM in two planes of motion. CONCLUSION Features of articular degeneration are associated with lower knee ROM and lower hip ROM in patients with early OA. Pain, stiffness, higher BMI, and male gender are associated with lower ROM as well.