Yasmin Ahamed

A physiotherapist-delivered, combined exercise and pain coping skills training intervention for individuals with knee osteoarthritis: a pilot study.

BACKGROUNDnOsteoarthritis (OA) of the knee is associated with a number of physical and psychological impairments. Unfortunately, very few treatment strategies are capable of addressing both types of impairments concurrently. We performed a pilot, randomized controlled, proof of principle trial investigating the feasibility and effects of an intervention combining physical exercise and pain coping skills training (PCST).nnnMETHODSnTwenty patients with a clinical and radiographical diagnosis of tibiofemoral OA were randomized to receive either 10 weeks of physiotherapist supervised exercises (lower limb strengthening and walking) combined with non-directive counseling (NDC) or the same exercise program delivered concurrently with PCST. Primary outcomes included self-reported pain and pain coping, while secondary outcomes included self efficacy and self-reported physical function.nnnRESULTSnTen participants were randomized to each group and both groups exhibited significant improvements in isometric knee strength, self-reported knee pain and physical function, self efficacy for control of pain management and other arthritis symptoms. Only those in the exercise + PCST group reported statistically significant improvements in pain control coping and rational thinking. No between-group differences existed in any outcome (0.07 < p < 0.98). Based on our findings, 63 participants per group would be needed for future large-scale studies using similar outcome measures and design.nnnCONCLUSIONSnOur study showed that an intervention that combines exercise and PCST within the same treatment session and delivered by specially-trained physiotherapists is feasible and can improve both physical and psychological outcomes in individuals with knee OA.nnnLEVEL OF EVIDENCEnLevel II Clinical Trials Registry number: ACTRN12609000623291.

Physical Therapist-Delivered Pain Coping Skills Training and Exercise for Knee Osteoarthritis: Randomized Controlled Trial.

To investigate whether a 12‐week physical therapist–delivered combined pain coping skills training (PCST) and exercise (PCST/exercise) is more efficacious and cost effective than either treatment alone for knee osteoarthritis (OA).

A physiotherapist-delivered integrated exercise and pain coping skills training intervention for individuals with knee osteoarthritis: a randomised controlled trial protocol

BackgroundKnee osteoarthritis (OA) is a prevalent chronic musculoskeletal condition with no cure. Pain is the primary symptom and results from a complex interaction between structural changes, physical impairments and psychological factors. Much evidence supports the use of strengthening exercises to improve pain and physical function in this patient population. There is also a growing body of research examining the effects of psychologist-delivered pain coping skills training (PCST) particularly in other chronic pain conditions. Though typically provided separately, there are symptom, resource and personnel advantages of exercise and PCST being delivered together by a single healthcare professional. Physiotherapists are a logical choice to be trained to deliver a PCST intervention as they already have expertise in administering exercise for knee OA and are cognisant of the need for a biopsychosocial approach to management. No studies to date have examined the effects of an integrated exercise and PCST program delivered solely by physiotherapists in this population. The primary aim of this multisite randomised controlled trial is to investigate whether an integrated 12-week PCST and exercise treatment program delivered by physiotherapists is more efficacious than either program alone in treating pain and physical function in individuals with knee OA.Methods/designThis will be an assessor-blinded, 3-arm randomised controlled trial of a 12-week intervention involving 10 physiotherapy visits together with home practice. Participants with symptomatic and radiographic knee OA will be recruited from the community in two cities in Australia and randomized into one of three groups: exercise alone, PCST alone, or integrated PCST and exercise. Randomisation will be stratified by city (Melbourne or Brisbane) and gender. Primary outcomes are overall average pain in the past week measured by a Visual Analogue Scale and physical function measured by the Western Ontario and McMaster Universities Osteoarthritis Index subscale. Secondary outcomes include global rating of change, muscle strength, functional performance, physical activity levels, health related quality of life and psychological factors. Measurements will be taken at baseline and immediately following the intervention (12 weeks) as well as at 32 weeks and 52 weeks to examine maintenance of any intervention effects. Specific assessment of adherence to the treatment program will also be made at weeks 22 and 42. Relative cost-effectiveness will be determined from health service usage and outcome data.DiscussionThe findings from this randomised controlled trial will provide evidence for the efficacy of an integrated PCST and exercise program delivered by physiotherapists in the management of painful and functionally limiting knee OA compared to either program alone.Trial registrationAustralian New Zealand Clinical Trials Registry reference number: ACTRN12610000533099

Characterising cortical density in the mid-tibia: intra-individual variation in adolescent girls and boys

Background: Inter-individual differences in cortical bone volumetric density (CoD), such as those related to sex, are a product of differences in remodelling rates. While cortical bone is often treated as a uniform tissue, remodelling rates also vary within individual bones. This level of adaptation has largely been overlooked in analyses of peripheral quantitative computed tomography (pQCT) images. Further, such variation in CoD has never been assessed in growing bones. We hypothesised that CoD varied significantly within the same cross-section of the mid-tibia of adolescents. We further hypothesised that due to the profound impact of oestrogen on remodelling, this variation would be different between sexes. Methods: Subjects were 183 adolescents (99 girls and 84 boys) in grade 6 and 7 with a mean age of 12.1 years. We used age at peak height velocity to adjust for maturational differences between sexes. Image data from a mid-tibia pQCT scan of each subject were assessed regionally within eight sectors distributed about the cortex and aligned by the anterior tibial crest. We used a repeated measures general linear model to assess intra-individual variation in CoD while controlling for differences in ethnicity, maturity, height, weight, physical activity level and total cross-sectional bone area (ToA). Results: Sector based variation in CoD was significant (p<0.001), with the anterior cortex having lower density than the posterior cortex. The largest percentage difference (anterior vs posteromedial sectors) was 12.2%. A significant sector*sex interaction (pu200a=u200a0.018) was detected; however, its impact was relatively small with girls having 1.1–3.6% denser bones than boys depending on the sector (2.7% average difference). Conclusions: The magnitude of the variation in CoD across sectors within individuals of both sex was far greater than the mean differences between the sexes. This finding indicates that the microstructural variation within the mid-tibia is detectable by pQCT and its magnitude suggests an important level of adaptation to loading.

Can Physical Therapists Deliver a Pain Coping Skills Program? An Examination of Training Processes and Outcomes

Background Physical therapists are well established as providers of treatments for common, painful, and disabling conditions, such as knee osteoarthritis (OA). Thus, they are well placed to deliver treatments that integrate physical and psychosocial elements. Attention is usually given to outcomes of such programs, but few studies have examined the processes and outcomes of training physical therapists to deliver such treatments. Objective The aim of this study was to describe the processes in training physical therapists: (1) to deliver a standardized pain coping skills treatment and (2) to evaluate the effectiveness of that training. Design This study was an analysis of data relating to therapist performance in a randomized clinical trial. Methods Eleven physical therapists were trained to deliver a 10-session pain coping skills training program for people with knee OA as part of a randomized controlled trial (N=222). The initial training was provided in a workshop format and included extensive, ongoing supervision by a psychologist and rigorous use of well-defined performance criteria to assess competence. Adherence to the program, ratings of performance, and use of advanced skills were all measured against these criteria in a sample (n=74, 10%) of the audio recordings of the intervention sessions. Results Overall, the physical therapists achieved a very high standard of treatment delivery, with 96.6% adherence to the program and mean performance ratings all in the satisfactory range. These results were maintained throughout the intervention and across all sessions. Limitations Only 10% of the delivered sessions were analyzed, and the physical therapists who took part in the study were a self-selected group. Conclusions This study demonstrated that a systematic approach to training and accrediting physical therapists to deliver a standardized pain coping skills program can result in high and sustained levels of adherence to the program. Training fidelity was achieved in this group of motivated clinicians, but the supervision provided was time intensive. The data provide a promising indicator of greater potential for psychologically informed practice to be a feature of effective health care.

Establishing a pragmatic framework to optimise health outcomes in heart failure and multimorbidity (ARISE-HF): A multidisciplinary position statement.

Background Multimorbidity in heart failure (HF), defined as HF of any aetiology and multiple concurrent conditions that require active management, represents an emerging problem within the ageing HF patient population worldwide. Methods To inform this position paper, we performed: 1) an initial review of the literature identifying the ten most common conditions, other than hypertension and ischaemic heart disease, complicating the management of HF (anaemia, arrhythmias, cognitive dysfunction, depression, diabetes, musculoskeletal disorders, renal dysfunction, respiratory disease, sleep disorders and thyroid disease) and then 2) a review of the published literature describing the association between HF with each of the ten conditions. From these data we describe a clinical framework, comprising five key steps, to potentially improve historically poor health outcomes in this patient population. Results We identified five key steps (ARISE-HF) that could potentially improve clinical outcomes if applied in a systematic manner: 1) Acknowledge multimorbidity as a clinical syndrome that is associated with poor health outcomes, 2) Routinely profile (using a standardised protocol — adapted to the local health care system) all patients hospitalised with HF to determine the extent of concurrent multimorbidity, 3) Identify individualised priorities and person-centred goals based on the extent and nature of multimorbidity, 4) Support individualised, home-based, multidisciplinary, case management to supplement standard HF management, and 5) Evaluate health outcomes well beyond acute hospitalisation and encompass all-cause events and a person-centred perspective in affected individuals. Conclusions We propose ARISE-HF as a framework for improving typically poor health outcomes in those affected by multimorbidity in HF.

Reexamining the Surfaces of Bone in Boys and Girls During Adolescent Growth: A 12-Year Mixed Longitudinal pQCT Study.

We revisit Stanley Garns theory related to sex differences in endocortical and periosteal apposition during adolescence using a 12‐year mixed longitudinal study design. We used peripheral quantitative computed tomography to examine bone parameters in 230 participants (110 boys, 120 girls; aged 11.0 years at baseline). We assessed total (Tt.Ar, mm2), cortical (Ct.Ar, mm2), and medullary canal area (Me.Ar, mm2), Ct.Ar/Tt.Ar, cortical bone mineral density (Ct.BMD, mg/cm3), and polar strength‐strain index (SSIp, mm3) at the tibial midshaft (50% site). We used annual measures of height and chronological age to identify age at peak height velocity (APHV) for each participant. We compared annual accrual rates of bone parameters between boys and girls, aligned on APHV using a linear mixed effects model. At APHV, boys demonstrated greater Tt.Ar (ratio = 1.27; 95% confidence interval [CI] 1.21, 1.32), Ct.Ar (1.24 [1.18, 1.30]), Me.Ar (1.31 [1.22, 1.40]), and SSIp (1.36 [1.28, 1.45]) and less Ct.Ar/Tt.Ar (0.98 [0.96, 1.00]) and Ct.BMD (0.97 [0.96, 0.97]) compared with girls. Boys and girls demonstrated periosteal bone formation and net bone loss at the endocortical surface. Compared with girls, boys demonstrated greater annual accrual rates pre‐APHV for Tt.Ar (1.18 [1.02, 1.34]) and Me.Ar (1.34 [1.11, 1.57]), lower annual accrual rates pre‐APHV for Ct.Ar/Tt.Ar (0.56 [0.29, 0.83]) and Ct.BMD (–0.07 [–0.17, 0.04]), and similar annual accrual rates pre‐APHV for Ct.Ar (1.10 [0.94, 1.26]) and SSIp (1.14 [0.98, 1.30]). Post‐APHV, boys demonstrated similar annual accrual rates for Ct.Ar/Tt.Ar (1.01 [0.71, 1.31]) and greater annual accrual rates for all other bone parameters compared with girls (ratio = 1.23 to 2.63; 95% CI 1.11 to 3.45). Our findings support those of Garn and others of accelerated periosteal apposition during adolescence, more evident in boys than girls. However, our findings challenge the notion of greater endocortical apposition in girls, suggesting instead that girls experience diminished endocortical resorption compared with boys.

Impact of Nurse-Led, Multidisciplinary Home-Based Intervention on Event-Free Survival Across the Spectrum of Chronic Heart Disease: Composite Analysis of Health Outcomes in 1226 Patients From 3 Randomized Trials

Background— We sought to determine the overall impact of a nurse-led, multidisciplinary home-based intervention (HBI) adapted to hospitalized patients with chronic forms of heart disease of varying types. Methods and Results— Prospectively planned, combined, secondary analysis of 3 randomized trials (1226 patients) of HBI were compared with standard management. Hospitalized patients presenting with heart disease but not heart failure, atrial fibrillation but not heart failure, and heart failure, as well, were recruited. Overall, 612 and 614 patients, respectively, were allocated to a home visit 7 to 14 days postdischarge by a cardiac nurse with follow-up and multidisciplinary support according to clinical need or standard management. The primary outcome of days-alive and out-of-hospital was examined on an intention-to-treat basis. During 1371 days (interquartile range, 1112–1605) of follow-up, 218 patients died and 17u2009917 days of hospital stay were recorded. In comparison with standard management, HBI patients achieved significantly prolonged event-free survival (90.1% [95% confidence interval, 88.2–92.0] versus 87.2% [95% confidence interval, 85.1–89.3] days-alive and out-of-hospital; P=0.020). This reflected less all-cause mortality (adjusted hazard ratio, 0.67; 95% confidence interval, 0.50–0.88; P=0.005) and unplanned hospital stay (median, 0.22 [interquartile range, 0–1.3] versus 0.36 [0–2.1] days/100 days follow-up; P=0.011). Analyses of the differential impact of HBI on all-cause mortality showed significant interactions (characterized by U-shaped relationships) with age (P=0.005) and comorbidity (P=0.041); HBI was most effective for those aged 60 to 82 years (59%–65% of individual trial cohorts) and with a Charlson Comorbidity Index Score of 5 to 8 (36%–61%). Conclusions— These data provide further support for the application of postdischarge HBI across the full spectrum of patients being hospitalized for chronic forms of heart disease. Clinical Trial Registration— URL: http://www.anzctr.org.au. Unique identifiers: 12610000221055, 12608000022369, 12607000069459.

Current and projected burden of heart failure in the Australian adult population: A substantive but still ill-defined major health issue

BackgroundComprehensive epidemiological data to describe the burden of heart failure (HF) in Australia remain lacking despite its importance as a major health issue. Herewith, we estimate the current and future burden of HF in Australia using best available data.MethodsAustralian-specific and the most congruent international epidemiological and health utilisation data were applied to the Australian population (adults agedu2009≥u200945xa0years, 8.9 of 22.7 million total population in 2014) on an age and sex-specific basis. We estimated the current incident and prevalent cases of clinically overt/symptomatic HF (predominately those with reduced ejection fraction), hospital activity (diagnosis of HF as a primary or secondary reason for admission) and health care costs in 2014 and future prevalence and burden of HF projected to 2030.ResultsWe estimated that over 61,000 (6.9 per 1000 person-years) adult Australians agedu2009≥u200945xa0years (58xa0% women) are diagnosed with HF with clinically overt signs and symptoms every year. On a conservative basis, 480,000 (6.3xa0%, 95xa0% CI 2.6 to 10.0xa0%) Australians (66xa0% men) are now affected by the syndrome withu2009>u2009150,000 hospitalisations in excess of 1 million days in hospital per annum. The annual cost of managing HF in the community is approximately

Multimorbidity and the risk of all cause 30-day readmission in the setting of multidisciplinary management of chronic heart failure: A retrospective analysis of 830 hospitalized patients in Australia

900 million and nearly