N.L.U. van Meeteren

Preoperative therapeutic programme for elderly patients scheduled for elective abdominal oncological surgery: a randomized controlled pilot study

Objective: Investigation of the feasibility and preliminary effect of a short-term intensive preoperative exercise programme for elderly patients scheduled for elective abdominal oncological surgery. Design: Single-blind randomized controlled pilot study. Setting: Ordinary hospital in the Netherlands. Subjects: Forty-two elderly patients (>60 years). Interventions: Patients were randomly assigned to receive a short-term intensive therapeutic exercise programme to improve muscle strength, aerobic capacity, and functional activities, given in the outpatient department (intervention group; n =22), or home-based exercise advice (control group; n=20). Main measures: Parameters of feasibility, preoperative functional capacity and postoperative course. Results: The intensive training programme was feasible, with a high compliance and no adverse events. Respiratory muscle endurance increased in the preoperative period from 259 ± 273 to 404 ± 349 J in the intervention group and differed significantly from that in the control group (350 ± 299 to 305 ± 323 J; P<0.01). Timed-Up-and-Go, chair rise time, LASA Physical Activity Questionnaire, Physical Work Capacity and Quality of Life (EORTC-C30) did not reveal significant differences between the two groups. There was no significant difference in postoperative complications and length of hospital stay between the two groups. Conclusion: The intensive therapeutic exercise programme was feasible and improved the respiratory function of patients due to undergo elective abdominal surgery compared with home-based exercise advice.

Measuring patients' perceptions on their functional abilities: validation of the Haemophilia Activities List

Summary.  Recently, the Haemophilia Activities List (HAL), a haemophilia‐specific self‐assessment questionnaire to assess a patients self‐perceived functional ability, was introduced and a limited pilot study warranted its further development. The present study finalizes the HAL and assesses the convergent and construct validity, as well as the internal consistency of its definitive version. Three questionnaires (HAL, Dutch‐Arthritis Impact Measurement Scales 2 and the Impact on Participation and Autonomy questionnaire) were completed by 127 patients with severe haemophilia (<1% clotting activity), as well as four performance tests (button test, 50 metre walking test, timed‐up‐and‐go test and figure‐8 walking test). After removal of 15 non‐informative items from the provisional HAL, three components within the questionnaire were identified (upper extremity activities, basic lower extremity activities and complex lower extremity activities). The internal consistency of these components was high (Cronbachs α = 0.93–0.95), as was internal consistency for the seven domains of the HAL (α = 0.61–0.96). The convergent validity of the HAL when compared to the other two questionnaires was good (r = 0.47–0.84). The construct validity of the HAL when compared to the four performance tests was generally lower (r = 0.23–0.77). The final version of the HAL has good internal consistency and convergent validity and gives the clinician insight into a patients self‐perceived ability to perform activities of daily life. It is likely that self‐assessment instruments (questionnaires) and performance tests consider different concepts of functional health status and it is therefore recommended that both types are included when clinicians assess a patients functional abilities.

Preoperative therapeutic exercise in frail elderly scheduled for total hip replacement: a randomized pilot trial

Objective: To evaluate the feasibility and preliminary effectiveness of therapeutic exercise before total hip replacement in frail elderly. Design: A single-blind, randomized clinical pilot trial. Setting: Outpatient physiotherapy department. Subjects: Frail elderly with hip osteoarthritis awaiting total hip replacement. Interventions: A short (3—6 weeks) tailor-made, therapeutic exercise programme was compared with usual care. Main measures: Feasibility was assessed through patient satisfaction, adherence, occurrence of adverse events and the number of eligible non-volunteers. Preliminary preoperative effectiveness was assessed with performance and self-reported measures of pain, functioning, physical activity and quality of life. Postoperatively we measured functional recovery and length of hospital stay. Results: Sixty-two eligible patients were approached of whom 21 (mean age 76 years) agreed to participate. Exercisers (n = 10), rated the intervention as very good 8.9 (8—10) (10-point rating scale). No serious adverse events occurred. Forty-one (66%) eligible patients did not participate, mainly because of logistic considerations, resulting in selection bias. The intervention group (trainings sessions participated 91%) showed relevant preoperative improvements on the chair-rise time (delta —2.9 seconds; 95% confidence interval (CI) —6.2 to 0.4) and timed-up-and-go (delta —4.4 seconds; 95% CI —9.3 to 0.5). Postoperatively, no significant differences were seen. Conclusions: A short, tailor-made, exercise programme is well tolerated and appreciated in elderly patients awaiting total hip replacement. However, a larger randomized clinical trial in the same setting is not warranted, because of the high number of eligible non-volunteers.

Clinimetric instruments to assess functional health status in patients with haemophilia: a literature review

Summary.  The World Federation of Hemophilia scoring system (WFH‐1) evaluates primarily body functions and structures, whereas assessment of the whole area of functional health status is considered nowadays to be a better measure. In addition, the WFH‐1 lacks psychometric properties (reliability, validity and sensitivity to change). This study aimed to gain insight into the clinimetric assessment of functional health status in patients with haemophilia by way of a systematic literature search. A standardized literature search and selection was performed on the databases of CINAHL (1982–2001), Medline (1966–2001), and PubMed (January–July 2001). Clinimetric instruments applied in the selected articles were classified based on the international classification of functioning, disability, and health (ICF) and analysed for their psychometric properties. In 19 articles published between 1979 and 2001, 34 clinimetric instruments were used to assess functional health status. Instruments were classified as measuring the ICF components body structure and function (n = 17), activities (12) and participation (4). Reliability was measured in four articles on three different instruments, the validity (construct) of the instruments for patients with haemophilia was reported in six articles on five instruments, and sensitivity to change in three articles on three instruments. The populations under study varied in number (7–9 35), mean age (21.6–50.8 years), and in the distribution of haemophilia severity. Reports on the evaluation of functional health status in patients with haemophilia are increasing. Further research on the psychometric properties of the instruments is warranted in more groups of patients with haemophilia. Development of the new core set of clinimetric instruments, the WFH‐2, might benefit from this strategy.

Feasibility and preliminary effectiveness of preoperative therapeutic exercise in patients with cancer: A pragmatic study

The aim of this pilot study is to determine the feasibility and preliminary effectiveness of an individually designed preoperative therapeutic exercise program (PreTEP), in patients recently diagnosed with cancer and awaiting elective surgery. The purpose is to improve their physical fitness levels during this waiting period with the intention of decreasing postoperative morbidity. A preexperimental pilot study was performed at the University Medical Center Utrecht, The Netherlands. Thirty-nine patients diagnosed with cancer, scheduled for elective abdominal/thoracic surgery, were referred to a multidisciplinary preoperative screening. Fifteen patients (38%) participated in PreTEP. Participants were satisfied and motivated during the period of training (on average 5 weeks) in which they attended 84% of the sessions. Cardiorespiratory fitness (Åstrand-test) and muscle strength (Handheld Dynamometry) increased significantly, from 25 to 33 mL/kg/min, respectively (p<0.01; 95% confidence interval [CI]=−0.011 to −0.004) and from 894 Newton (N) to 961 N (p<0.01; 95% CI=−94.53 to −39.0). No adverse events occurred during the training period. PreTEP was shown to be feasible, safe, and well-tolerated and appreciated by participants. Despite the relatively short period of training, physical fitness improved in all participants.

Validity of health status measurement with the Dutch Arthritis Impact Measurement Scale 2 in individuals with severe haemophilia

The aim of this study was to investigate the validity of the Dutch Arthritis Impact Measurement Scales 2 (D‐AIMS2). Hence, D‐AIMS2 data of individuals with severe haemophilia were correlated with clinical and perceived health‐related quality of life data. Patients with severe haemophilia, who visit the Van Creveldkliniek on a regular basis, were administered the D‐AIMS2. In addition, health‐related quality of life was measured by the Sickness Impact Profile (SIP). As clinical indices, range of movement (which was converted into Joint Alignment and Motion scores) and muscle strength were recorded during the routine visit. Extensive descriptive and correlational (linear) analyses between corresponding datasets were performed. Thirty‐one individuals with severe haemophilia were included. Their scores on the D‐AIMS2 demonstrated moderate to very high internal consistency for scales and components (Cronbach’s α=0.62–0.92). The physical health components of the D‐AIMS2 and the SIP were significantly correlated (Pearson’s r=0.53; P < 0.05). The psychological health and social interaction components of the D‐AIMS2 did not correlate significantly with the psychosocial component of the SIP. The physical health component of the D‐AIMS2 correlated significantly with the clinical data for the lower extremities (r=0.52 and r =−0.45; P < 0.05). These data support the reliability and validity of the physical aspects of the D‐AIMS2 in patients with severe haemophilia. The next step should be to extend the investigation of psychometric qualities of this health‐related questionnaire in a larger population.

The use of a disability model in haemophilia research

Summary.  Most haemophilia research is medically orientated. However, assessment of the impact of disease on the individual is different when viewed from a rehabilitation perspective. Several models are available to explore functioning and health from this perspective. The disablement process (DP) is such a model, and the aim of this study was to introduce this process in haemophilia research to see whether this type of research could lead to meaningful data. Forty‐three adult patients with severe haemophilia participated in this study in which the three ‘main pathway’ domains of the DP (impairments, functional limitations and disability) and two additional factors (intra‐individual and risk factors) were addressed. Three questionnaires (HAL, Dutch‐AIMS2 and IPA) were incorporated, and Pettersson scores for 21 patients were retrieved. Step‐wise and hierarchical regression analysis was used to assess relationship between the various domains. Arthropathy explained 48% of the variance in functional limitations and nearly 25% of the variance in disability. Functional limitations explained 54% of the variance in disability. Patients identified pain as an important aspect of health which addressed 22% and 13% of the variance in functional limitations and disability respectively. Age was correlated with arthropathy (r = 0.85; P < 0.001), whereas psychological health correlated with pain (r = 0.67; P < 0.001). Both variables were also correlated with functional limitations and disability. Analyses adjusting for the effects of age and psychological health were subsequently performed resulting in more insight in the associations within the DP. The use of the DP in haemophilia research proved to be useful.

Assessing functional health status in adults with haemophilia: towards a preliminary core set of clinimetric instruments based on a literature search in Rheumatoid Arthritis and Osteoarthritis

Summary.  People with haemophilia experience a progressive deterioration of their functional health status. Regular clinical assessment of functional health status provides insight into their process of disablement. As such, the development of a core‐set of measurement tools is warranted. The aim of this study was to gather data to prepare a (preliminary) core set of clinically relevant and feasible instruments to assess the functional health status of adults with haemophilia, and to indicate their psychometric qualities. Therefore, clinimetric instruments frequently used in two haemophilia‐resembling diseases (Rheumatoid Arthritis and Osteoarthritis) were reviewed from the literature. An extensive search in Medline yielded 13 relevant review articles, incorporating a total of 182 instruments, of which 40 were appropriate for haemophilia. Of these 40 instruments 3 measure body structures, 13 body functions, 19 activities (of which 5 are performance based and 14 self‐report based), and 3 measure participation. This classification is based on the International Classification of Functioning, Disability and Health. Detailed information regarding the psychometrics (reliability, validity and responsiveness) of four instruments is described fully in the literature, whereas the psychometrics of the majority of the other instruments are only partly described. The results of this literature study may contribute to the formation of a (preliminary) core set of clinimetric instruments to assess the functional health status of adults with haemophilia. Decisions on the final core set should be held within the Musculoskeletal Committee of the World Federation of Haemophilia.

The utility of the Dutch Arthritis Impact Measurement Scales 2 for assessing health status in individuals with haemophilia: a pilot study.

The aim of this pilot study was to examine the usefulness of the Dutch version of the Arthritis Impact Measurement Scales 2 (D‐AIMS2)in assessing the health status of Dutch individuals with haemophilia. Sixty‐eight individuals with mild, moderate, and severe haemophilia attending our clinic for their annual check‐up participated. They first completed the Canadian Occupational Performance Measure (COPM). The D‐AIMS2 was filled in afterwards at home. With the COPM, individuals rated their specific problematic activities of daily life (ADL), as well as the severity and importance of each problem. The D‐AIMS2 is a comprehensive, self‐administered questionnaire that evaluates functional health status. Fifty‐seven individuals completed and returned the D‐AIMS2. Reliability analysis demonstrated good internal consistency for the scales (Cronbach’s α=0.76–1.00), as well as for the components (α=0.80–0.88), except for the component ‘social interaction’ (α=0.44). Criterion validity of the D‐AIMS2 was assessed by comparison with COPM outcomes; 80% of the problematic ADLs were included in the questionnaire, 20% were missing. Correlations between the D‐AIMS2 components ‘physical health’ and ‘symptoms’ with predicted scores of those individuals by a highly experienced physiotherapist (r=0.63 and 0.53, respectively) substantiated its concurrent validity. Based on these results we concluded that the D‐AIMS2, with minor adjustments, can be an appropriate tool for assessing the health status of Dutch haemophilia patients.

Recovery of function after sciatic nerve crush lesion in rats selected for diverging locomotor activity in the open field

The relation between recovery of function following a sciatic nerve crush lesion and an individual behavioural characteristic, the locomotor activity in an open field, was investigated in rats. Ten high-active (HA) and ten low-active (LA) rats were selected from a stock of sixty male, random-bred Wistar rats, by measuring travelled distance in an open field. Subsequently, both HA and LA rats underwent an unilateral sciatic nerve crush. Recovery of motor function revealed no significant differences between both groups, whereas recovery of sensory function in HA rats was significantly more rapid than in the LA rats (P < 0.01). These observations suggest the existence of a relationship between individual behavioural characteristics, and the sensory recovery of nerve function following crush lesion in rats.