Karine Toupin April

American College of Rheumatology 2012 recommendations for the use of nonpharmacologic and pharmacologic therapies in osteoarthritis of the hand, hip, and knee.

To update the American College of Rheumatology (ACR) 2000 recommendations for hip and knee osteoarthritis (OA) and develop new recommendations for hand OA.

A qualitative study on the term CAM: is there a need to reinvent the wheel?

BackgroundAs complementary and alternative medicine (CAM) has developed extensively, uncertainty about the appropriateness of the terms CAM and other CAM-related terms has grown both in the research and practice communities. Various terms and definitions have been proposed over the last three decades, highlighting how little agreement exits in the field. Contextual use of current terms and their respective definitions needs to be discussed and addressed.MethodsRelying upon the results of a large international Delphi survey on the adequacy of the term CAM, a focus group of 13 international experts in the field of CAM was held. A forum was also set up for 28 international experts to discuss and refine proposed definitions of both CAM and integrative healthcare (IHC) terms. Audio recordings of the meeting and forum discussion threads were analyzed using interpretive description.ResultsMultiple terms to describe the therapies, products, and disciplines often referred to as CAM, were considered. Even though participants generally agreed there is a lack of optimal definitions for popular CAM-related umbrella terms and that all terms that have so far been introduced are to some extent problematic, CAM and IHC remained the most popular and accepted terms by far. The names of the specific disciplines were also deemed adequate in certain contexts. Focus group participants clarified the context in which those three terms are appropriate. Existing and emergent definitions of both CAM and integrative healthcare terms were discussed.ConclusionsCAM and other related terms could be used more effectively, provided they are used in the proper context. It appears difficult for the time being to reach a consensus on the definition of the term CAM due to the uncertainty of the positioning of CAM in the contemporary healthcare systems. While umbrella terms such as CAM and IHC are useful in the context of research, policy making and education, relevant stakeholders should limit the use of those terms.

Access and perceived need for physical and occupational therapy in chronic arthritis

Purpose. Physical and occupational therapy are beneficial for persons with chronic arthritis; however, access is problematic. The goal was to examine issues related to access to these services for patients with chronic arthritis. Methods. We used two data sources: 1) questionnaires sent to a random sample of 600 family physicians and to all 85 rheumatologists in the province of Quebec; and 2) interviews of 211 patients with physician-confirmed chronic arthritis recruited from 34 primary care settings in Quebec. Results. Only 11.5% of family physicians and 31.7% of rheumatologists referred patients with rheumatoid arthritis (RA) to rehabilitation, whereas 60.4% of family doctors referred patients with osteoarthritis. Only 26.1% of patients felt that they required rehabilitation and this was associated with lower self-efficacy (OR: 0.84, 95% CI: 0.72, 0.99) and higher educational level (OR: 2.10, 95% CI: 1.01, 4.36). Conclusion. Family physicians are less likely to refer patients with RA to therapy. Only about a quarter of patients with chronic arthritis treated in primary care perceived the need for these services. Efforts to improve arthritis care should address education of physicians and patients regarding the benefits of rehabilitation and there should be efforts to increase therapy resources in order to enhance access.

Update of Strategies to Translate Evidence from Cochrane Musculoskeletal Group Systematic Reviews for Use by Various Audiences

For rheumatology research to have a real influence on health and well-being, evidence must be tailored to inform the decisions of various audiences. The Cochrane Musculoskeletal Group (CMSG), one of 53 groups of the not-for-profit international Cochrane Collaboration, prepares, maintains, and disseminates systematic reviews of treatments for musculoskeletal diseases. While systematic reviews provided by the CMSG fill a major gap in meeting the need for high-quality evidence syntheses, our work does not end at the completion of a review. The term “knowledge translation” (KT) refers to the activities involved in bringing research evidence to various audiences in a useful form so it can be used to support decision making and improve practices. Systematic reviews give careful consideration to research methods and analysis. Because the review is often long and detailed, the clinically relevant results may not be apparent or in the optimal form for use by patients and their healthcare practitioners. This paper describes 10 formats, many of them new, for ways that evidence from Cochrane Reviews can be translated with the intention of meeting the needs of various audiences, including patients and their families, practitioners, policy makers, the press, and members of the public (the “5 Ps”). Current and future knowledge tools include summary of findings tables, patient decision aids, plain language summaries, press releases, clinical scenarios in general medical journals, frequently asked questions (Cochrane Clinical Answers), podcasts, Twitter messages, Journal Club materials, and the use of storytelling and narratives to support continuing medical education. Future plans are outlined to explore ways of improving the influence and usefulness of systematic reviews by providing results in formats suitable to our varied audiences.

The State of Research on Complementary and Alternative Medicine in Pediatric Rheumatology

This article reviews available evidence on complementary and alternative medicine in pediatric rheumatology. Despite its common use in pediatric rheumatology (34%-92%), there is still uncertainty as to its efficacy and safety. Although results are promising for some treatments such as massage, acupuncture, mind-body interventions (eg, guided imagery and meditative breathing), and some natural health products (eg, calcium supplements and Tripterygium wilfordii), there is a need for high-quality trials investigating the long-term effects and underlying mechanisms of these therapies as well as research on their use in this population of patients.

Measurement Properties of Questionnaires Assessing Complementary and Alternative Medicine Use in Pediatrics: A Systematic Review

Objective Complementary and alternative medicine (CAM) is commonly used by children, but estimates of that use vary widely partly due to the range of questionnaires used to assess CAM use. However, no studies have attempted to appraise measurement properties of these questionnaires. The aim of this systematic review was to critically appraise and summarize measurement properties of questionnaires of CAM use in pediatrics. Study design A search strategy was implemented in major electronic databases in March 2011 and conference websites, scientific journals and experts were consulted. Studies were included if they mentioned a questionnaire assessing the prevalence of CAM use in pediatrics. Members of the team independently rated the methodological quality of the studies (using the COSMIN checklist) and measurement properties of the questionnaires (using the Terwee and Cohen criteria). Results A total of 96 CAM questionnaires were found in 104 publications. The COSMIN checklist showed that no studies reported adequate methodological quality. The Terwee criteria showed that all included CAM questionnaires had indeterminate measurement properties. According to the Cohen score, none were considered to be a well-established assessment, two approached the level of a well-established assessment, seven were promising assessments and the remainder (n = 87) did not reach the score’s minimum standards. Conclusion None of the identified CAM questionnaires have been thoroughly validated. This systematic review highlights the need for proper validation of CAM questionnaires in pediatrics, which may in turn lead to improved research and knowledge translation about CAM in clinical practice.

Leisure in children and adolescents with juvenile idiopathic arthritis: a systematic review.

The aim of this systematic review is to describe participation in social and physical leisure activities among children and adolescents with JIA, as well as identify potential determinants of leisure participation. Methods Electronic databases were systematically searched for articles published up until June 2013 pertaining to participation in leisure activities among youth with JIA and other rheumatic diseases. Studies were included if they measured involvement in either social or physical leisure activities. Selection and quality appraisal of articles were completed independently by two authors. Results Eight hundred and ninety-three articles were found through electronic and reference search. One hundred and nine full articles were reviewed to assess for eligibility. Twelve articles met inclusion criteria and findings were reviewed. Most focused on describing participation in physical rather than social activities. Results suggest that youth with JIA participated less in both social and physical leisure activities as compared to healthy peers, and those with JIA did not meet national recommendations for physical activity. Potential determinants of leisure participation were socio-demographic (age, sex), anthropometric (height, weight) and disease-related (JIA subtype, disease duration, pain, number of swollen or painful joints, stiffness, fatigue, well-being) factors. Conclusion Characterization of leisure activity remains limited and mostly focused on physical activity in JIA. Assessment of more comprehensive outcome measures is warranted to obtain a better description of leisure in this population. Evidence of the influence of contextual factors as potential determinants of involvement in leisure among children with pediatric rheumatologic diseases is needed.

A survey of Canadian regulated complementary and alternative medicine schools about research, evidence-based health care and interprofessional training, as well as continuing education

BackgroundWhile some effort has been made to integrate complementary and alternative medicine (CAM) information in conventional biomedical training, it is unclear whether regulated Canadian CAM schools’ students are exposed to research activities and continuing education, or whether topics such as evidence-based health care and interprofessional collaboration (IPC) are covered during their training. Since these areas are valued by the biomedical training field, this may help to bridge the attitudinal and communication gaps between these different practices. The aim of this study was to describe the training offered in these areas and gather the perceptions of curriculum/program directors in regulated Canadian CAM schools.MethodsA two-phase study consisting of an electronic survey and subsequent semi-structured telephone interviews was conducted with curriculum/program (C/P) directors in regulated Canadian CAM schools. Questions assessed the extent of the research, evidence-based health care, IPC training and continuing education, as well as the C/P directors’ perceptions about the training. Descriptive statistics were used to describe the schools’, curriculum’s and the C/P directors’ characteristics. Content analysis was conducted on the interview material.ResultsTwenty-eight C/P directors replied to the electronic survey and 11 participated in the interviews, representing chiropractic, naturopathy, acupuncture and massage therapy schools. Canadian regulated CAM schools offered research and evidence-based health care training as well as opportunities for collaboration with biomedical peers and continuing education to a various extent (58% to 91%). Although directors were generally satisfied with the training offered at their school, they expressed a desire for improvements. They felt future CAM providers should understand research findings and be able to rely on high quality research and to communicate with conventional care providers as well as to engage in continuing education. Limited length of the curriculum was one of the barriers to such improvements.ConclusionsThese findings seem to reinforce the directors’ interest and the importance of integrating these topics in order to ensure best CAM practices and improve communication between CAM and conventional providers.

Models of Care for addressing chronic musculoskeletal pain and health in children and adolescents

Chronic musculoskeletal pain among children and adolescents is common and can negatively affect quality of life. It also represents a high burden on the health system. Effective models of care for addressing the prevention and management of pediatric musculoskeletal pain are imperative. This chapter will address the following key questions: (1) Why are pediatric-specific models of pain care needed? (2) What is the burden of chronic musculoskeletal pain among children and adolescents? (3) What are the best practice approaches for early identification and prevention of chronic musculoskeletal pain in children and adolescents? (4) What are the recommended strategies for clinical management of chronic pain, including pharmacological, physical, psychological and complementary, and alternative approaches? (5) What are the most effective strategies for implementing models of pain care across different care settings? (6) What are the research priorities to improve models of care for children and adolescents with chronic musculoskeletal pain?

Development and Alpha-testing of a Stepped Decision Aid for Patients Considering Nonsurgical Options for Knee and Hip Osteoarthritis Management.

Objective. To develop an innovative stepped patient decision aid (StDA) comparing the benefits and harms of 13 nonsurgical treatment options for managing osteoarthritis (OA) and to evaluate its acceptability and effects on informed decision making. Methods. Guided by the Ottawa Decision Support Framework and the International Patient Decision Aid Standards, the process involved (1) developing a decision aid with evidence on 13 nonsurgical treatments from the 2012 American College of Rheumatology OA clinical practice guidelines; and (2) interviewing patients with OA and healthcare providers to test its acceptability and effects on knowledge and decisional conflict. Results. The StDA helped make the decision explicit, and presented evidence on 13 OA treatments clustered into 5 steps or levels according to their benefits and harms. Probabilities of benefits and harms were presented using pictograms of 100 faces formatted to allow comparisons across sets of options. It also included a values clarification exercise and knowledge test. Feedback was obtained from 49 patients and 7 healthcare providers. They found that the StDA presented evidence in a clear manner, and helped patients clarify their values and make an informed decision. Some participants found that there was too much information and others said that there was not enough on each treatment option. Conclusion. This innovative StDA allows patients to consider both the evidence and their values for multiple options. The findings are being used to revise and plan future evaluation. The StDA is an example of how research evidence in guidelines can be implemented in practice.