Laura A. Passalent

Exercise in Ankylosing Spondylitis: Discrepancies Between Recommendations and Reality

Objective. To determine the type and extent of exercise used by an ankylosing spondylitis (AS) cohort and to examine patients’ perceptions of exercise. Recommendations for the management of AS identify exercise as the cornerstone of comprehensive management. Methods. An exercise inventory questionnaire and the Exercise Benefits and Barriers Scale (EBBS) were administered to patients attending the AS clinic of a large teaching hospital. Benefits and barriers subscales of the EBBS were analyzed to identify the perceived benefits of, and barriers to, exercise. Higher benefits scores (range 29–116) indicate a more positive perception of exercise. Higher barriers scores (range 14–56) indicate a greater perception of barriers to exercise. Results. Sixty-one patients with AS completed the questionnaires. Mean age was 38.0 years, and mean disease duration was 14.7 years. Walking (3 times/week) and stretching (3 times/week) were the most commonly reported types of exercise and were reported in 35.0% and 32.8%, respectively. The mean benefits EBBS score was 87.1 ± 12.5. The most frequently reported benefits of exercise were that it “increases my level of physical fitness” (96.4%) and “improves functioning of my cardiovascular system” (96.4%). The mean barriers EBBS score was 29.2 ± 5.3, and the most frequently reported barrier to exercise was that it “tires me” (71.4%). Conclusion. Patients with AS perceive the benefits of exercise, with average EBBS benefits scores comparable to historical controls with similar conditions. Despite positive perceptions, the majority of patients with AS did not report participating in exercise on a frequent basis.

Physiotherapy for ankylosing spondylitis: evidence and application.

Purpose of reviewAnkylosing spondylitis (AS) is a disease that tends to affect younger individuals, many of whom are in the prime of their lives; therefore, incorporating the most up-to-date evidence into physiotherapy practice is critical. The purpose of this review is to update the most recent evidence related to physiotherapy intervention for AS and highlight the application of the findings to current physiotherapy research and clinical practice. Recent findingsThe results of this review add to the evidence supporting physiotherapy as an intervention for AS. The emphasis continues to be on exercise as the most studied physiotherapy modality, with very few studies examining other physiotherapy modalities. Results of the studies reviewed support the use of exercise, spa therapy, manual therapy and electrotherapeutic modalities. In addition, the results of this review help to understand who might benefit from certain interventions, as well as barriers to management. SummaryA review of recently published articles has resulted in a number of studies that support the body of literature describing physiotherapy as an effective form of intervention for AS. In order to continue to build on the existing research, further examination into physiotherapy modalities, beyond exercise-based intervention, needs to be explored.

Wait Times for Publicly Funded Outpatient and Community Physiotherapy and Occupational Therapy Services: Implications for the Increasing Number of Persons with Chronic Conditions in Ontario, Canada

BACKGROUND Timely access to publicly funded health services has emerged as a priority policy issue across the continuum of care from hospitals to the home and community sector. The purpose of this study was to examine wait lists and wait times for publicly funded outpatient and community occupational therapy (OT) and physical therapy (PT) services. METHODS A mailed self-administered questionnaire was sent in December 2005 to all publicly funded sites across Ontario that deliver outpatient or community OT or PT services (N = 374). Descriptive statistics were used to describe the study sample and to examine wait lists and wait times by setting and client condition. RESULTS Overall response rate was 57.2% (n = 214). More than 10,000 people were reported to be waiting for OT or PT services across Ontario. Of these, 16% (n = 1,664) were waiting for OT and 84% (n = 8,842) for PT. Of those waiting for OT, 59% had chronic conditions and half were waiting for home care rehabilitation services. Of those waiting for PT, 73% had chronic conditions and 81% were waiting at hospital outpatient departments. CONCLUSIONS Individuals with chronic conditions experience excessive wait times for outpatient and community OT and PT services in Ontario, particularly if they are waiting for services in hospital outpatient departments.

Development, Sensibility, and Reliability of the Toronto Axial Spondyloarthritis Questionnaire in Inflammatory Bowel Disease

Objective. There is an unacceptable delay in the diagnosis of axial spondyloarthritis (axSpA) in its early stages among patients at high risk, in particular those with inflammatory bowel disease (IBD). Our objectives were to develop a sensible and reliable questionnaire to identify undetected axSpA among patients with IBD. Methods. Literature was reviewed for item generation in the Toronto axSpA Questionnaire on IBD (TASQ-IBD). Sensibility of the questionnaire was assessed among healthcare professionals and patients. This assessment was related to purpose and framework (clinical function, clinical justification, and clinical applicability), face validity, comprehensiveness [oligo-variability (limiting the questionnaire to important items) and transparency], replicability, content validity, and feasibility. The test-retest reliability study was administered to 77 patients with established IBD and axSpA. Kappa agreement coefficients and absolute agreement were calculated for items. Results. Three domains included IBD, inflammatory back symptoms, and extraaxial features. The entry criterion required a patient to have IBD and back pain or stiffness that ever persisted for ≥ 3 months. Iterative sensibility assessment involved 16 items and a diagram of the back. Kappa coefficients ranged from 0.81–1.00 for each item. Absolute agreement across all items ranged from 91% to 100%. Conclusion. TASQ-IBD is a newly developed, sensible, and reliable case-finding questionnaire to be administered to patients with IBD who have ever had chronic back pain or stiffness persisting for ≥ 3 months. It should facilitate identification and timely referral of patients with IBD to rheumatologists and minimize the delay in diagnosis of axSpA. Consequently, it should assess the prevalence of axSpA in IBD.

The FIM™ as a measure of change in function after discharge from inpatient rehabilitation: a Canadian perspective.

Purpose. To examine the FIM™ as an outcome measure at follow-up following discharge from inpatient rehabilitation. Methods. Secondary analysis of the National Rehabilitation Reporting System (NRS) data from 13 facilities across Canada that collected follow-up data between 2001 and 2006. The study sample included all NRS records with a hospital length of stay of at least 3 days, for individuals 18 years and older. Outcomes included: mean total, motor and cognitive FIM™ scores at admission, discharge, and follow-up; change in FIM™ scores from admission to discharge and from discharge to follow-up; correlation between FIM™ scores at admission, discharge and follow-up, and predictors of the change in FIM™ scores between discharge and follow-up. Results. The majority of the change in FIM™ scores is seen between admission and discharge with the higher FIM scores maintained, if not increased slightly, between discharge and follow-up. Discharge and follow-up total FIM™ scores are highly correlated indicating that collection of the follow-up FIM™ may not provide additional information that justifies the expense of data collection after a patient has been discharged from inpatient rehabilitation. Conclusions. The use of more appropriate rehabilitation follow-up outcomes needs to be considered.

Geographic information systems (GIS): an emerging method to assess demand and provision for rehabilitation services.

Abstract Purpose: To illustrate the application of geographic information systems (GIS) as a tool to assess rehabilitation service delivery by presenting results from research recently conducted to assess demand and provision for community rehabilitation service delivery in Ontario, Canada. Methods: Secondary analysis of data obtained from existing sources was used to establish demand and provision profiles for community rehabilitation services. These data were integrated using GIS software. Results: A number of descriptive maps were produced that show the geographical distribution of service provision variables (location of individual rehabilitation health care providers and location of private and publicly funded community rehabilitation clinics) in relation to the distribution of demand variables (location of the general population; location of specific populations (i.e. residents age 65 and older) and distribution of household income). Conclusions: GIS provides a set of tools for describing and understanding the spatial organization of the health of populations and the distribution of health services that can aid the development of health policy and answer key research questions with respect to rehabilitation health services delivery. Implications for Rehabilitation It is important to seek out alternative and innovative methods to examine rehabilitation service delivery. GIS is a computer-based program that takes any data linked to a geographically referenced location and processes it through a software system that manages, analyses and displays the data in the form of a map, allowing for an alternative level of analysis. GIS provides a set of tools for describing and understanding the spatial organization of population health and health services that can aid the development of health policy and answer key research questions with respect to rehabilitation health services delivery.

Analysis of the Effect of the Oral Contraceptive Pill on Clinical Outcomes in Women with Ankylosing Spondylitis

Objective. There are unexplained sex-specific changes in the clinical expression of ankylosing spondylitis (AS). We sought to examine the potential effect of exogenous estrogen in the form of oral contraceptive pills (OCP) on AS initiation and severity. Methods. This cross-sectional study consisted of women with AS from the membership of the Spondylitis Association of America. Measures of disease severity included use of biological agents and hip replacement surgery, while Bath AS Functional Index (BASFI) scores served as a surrogate marker of disability. Information was obtained using a patient questionnaire on patient demographics, OCP use, pregnancy history, AS duration, medication use, and hip replacement. Results. There were 571 women with AS who participated in our study, consisting of 448 OCP ever-users and 123 non-OCP users. The mean age of OCP users was 42.7 yrs (± 11.5) and of non-OCP users, 48.4 yrs (± 12.1). No difference was noted in the age at initial onset of back pain. However, OCP users were significantly younger at the time of diagnosis of AS (36.5 yrs vs 39.1 yrs, p = 0.02). There were no significant differences between the 2 groups in tumor necrosis factor inhibitor or opioid use, BASFI scores, pregnancy complications, or hip surgery. Conclusion. The use of exogenous estrogens in the form of OCP is not associated with a measurable effect on initiation or severity of AS. Biologic and social factors may contribute to earlier diagnosis of AS in OCP users. This is the largest study to date investigating the potential effect of exogenous estrogens in women with AS.

Availability and Structure of Ambulatory Rehabilitation Services: A Survey of Hospitals with Designated Rehabilitation Beds in Ontario, Canada

PURPOSE To determine the degree to which ambulatory physical therapy (PT), occupational therapy (OT), and speech language pathology (SLP) services are available in hospitals with designated rehabilitation beds (DRBs) in Ontario, and to explore the structure of delivery and funding among services that exist. METHODS Questions regarding ambulatory services were included in the System Integration and Change (SIC) survey sent to all hospitals participating in the Hospital Report 2005: Rehabilitation initiative. RESULTS The response rate was 75.9% (41 of 54 hospitals). All hospitals surveyed provide some degree of ambulatory rehabilitation services, but the nature of these services varies according to rehabilitation client groups (RCGs). The majority of hospitals continue to deliver services through their employees rather than by contracting out or by creating for-profit subsidiary clinics, but an increasing proportion is accessing private sources to finance ambulatory services. CONCLUSIONS Most hospitals with DRBs provide some degree of ambulatory rehabilitation services. Privatization of delivery is not widespread in these facilities.

The patient perspective: arthritis care provided by Advanced Clinician Practitioner in Arthritis Care program-trained clinicians

Objective To assess patient satisfaction with the arthritis care services provided by graduates of the Advanced Clinician Practitioner in Arthritis Care (ACPAC) program. Materials and methods This was a cross-sectional evaluation using a self-report questionnaire for data collection. Participants completed the Patient–Doctor Interaction Scale, modified to capture patient–practitioner interactions. Participants completed selected items from the Group Health Association of America’s Consumer Satisfaction Survey, and items capturing quality of care, appropriateness of wait times, and a comparison of extended-role practitioner (ERP) services with previously received arthritis care. Results A total of 325 patients seen by 27 ERPs from 15 institutions completed the questionnaire. Respondents were primarily adults (85%), female (72%), and living in urban areas (79%). The mean age of participants was 54 years (range 3–92 years), and 51% were not working. Patients with inflammatory (51%) and noninflammatory conditions (31%) were represented. Mean (standard deviation) Patient–Practitioner Interaction Scale subscale scores ranged from 4.50 (0.60) to 4.63 (0.48) (1 to 5 [greater satisfaction]). Overall satisfaction with the quality of care was high (4.39 [0.77]), as was satisfaction with wait times (referral to appointment, 4.27 [0.86]; in clinic, 4.24 [0.91]). Ninety-eight percent of respondents felt the arthritis care they received was comparable to or better than that previously received from other health care professionals. Conclusion Patients were very satisfied with and amenable to arthritis care provided by graduates of the ACPAC program. Our findings provide early support for the deployment and integration of ACPAC ERPs into the Ontario health care system and should inform future evaluation at the patient level.

Evaluation of perceived collaborative behaviour amongst stakeholders and clinicians of a continuing education programme in arthritis care.

Abstract Successful implementation of new extended practice roles which transcend conventional boundaries of practice entails strong collaboration with other healthcare providers. This study describes interprofessional collaborative behaviour perceived by advanced clinician practitioner in arthritis care (ACPAC) graduates at 1 year beyond training, and relevant stakeholders, across urban, community and remote clinical settings in Canada. A mixed-method approach involved a quantitative (survey) and qualitative (focus group/interview) evaluation issued across a 4-month period. ACPAC graduates work across heterogeneous settings and are on teams of diverse size and composition. Seventy per cent perceived their team as actively working in an interprofessional care model. Mean scores on the Bruyère Clinical Team Self-Assessment on Interprofessional Practice subjective subscales were high (range: 3.66–4.26, scale: 1–5 = better perception of team’s interprofessional practice), whereas the objective scale was lower (mean: 4.6, scale: 0–9 = more interprofessional team practices). Data from focus groups (ACPAC graduates) and interviews (stakeholders) provided further illumination of these results at individual, group and system levels. Issues relating to ACPAC graduate role recognition, as well as their deployment, integration and institutional support, including access to medical directives, limitation of scope of practice, remuneration conflicts and tenuous funding arrangements were barriers perceived to affect role implementation and interprofessional working. This study offers the opportunity to reflect on newly introduced roles for health professionals with expectations of collaboration that will challenge traditional healthcare delivery.