Comparison of patients in three different rehabilitation settings after knee or hip arthroplasty: a natural observational, prospective study.

BACKGROUND: Patients after primary hip or knee replacement surgery can benefit from postoperative treatment in terms of improvement of independence in ambulation, transfers, range of motion and muscle strength. After discharge from hospital, patients are referred to different treatment destination and modalities: intensive inpatient rehabilitation (IR), cure (medically prescribed stay at a convalescence center), or ambulatory treatment (AT) at home. The purpose of this study was to 1) measure functional health (primary outcome) and function relevant factors in patients with hip or knee arthroplasty and to compare them in relation to three postoperative management strategies: AT, Cure and IR and 2) compare the post-operative changes in patient's health status (between preoperative and the 6 month follow-up) for three rehabilitation settings. METHODS: Natural observational, prospective two-center study with follow-up. Sociodemographic data and functional mobility tests, Timed Up and Go (TUG) and Iowa Level of Assistance Scale (ILOAS) of 201 patients were analysed before arthroplasty and at the end of acute hospital stay (mean duration of stay: 9.7 days +/- 3.9). Changes in health state were measured with the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) before and 6 months after arthroplasty. RESULTS: Compared to patients referred for IR and Cure, patients referred for AT were significantly younger and less comorbid. Patients admitted to IR had the highest functional disability before arthroplasty. Before rehabilitation, mean TUG was 40.0 s in the IR group, 33.9 s in the Cure group, and 27.5 s in the AT group, and corresponding mean ILOAS was 16.0, 13.0 and 12.2 (50.0 = worst). At the 6 months follow-up, the corresponding effect sizes of the WOMAC global score were 1.32, 1.87, and 1.51 (>0 means improvement). CONCLUSIONS: Age, comorbidity and functional disability are associated with referral for intensive inpatient rehabilitation after hip or knee arthroplasty and partly affect health changes after rehabilitation.

[Salutogenic concepts in the rehabilitation of osteoarthritis]. / Salutogenetische Konzepte bei der Rehabilitation von Arthrose.

BACKGROUND: The treatment strategies for osteoarthritis (OA) are well known from numerous studies. One of the challenges is long-term patient compliance to the recommended therapies without supervision. OBJECTIVE: To examine the ability of salutogenic concepts to improve rehabilitative management of OA. MATERIALS AND METHODS: Review article introducing salutogenic concepts and their empiric evidence, focussing on Antonovsky's sense of coherence (SOC). RESULTS: The SOC consists of the three components comprehensibility, manageability and meaningfulness. SOC can be quantified by SOC-13, a self-reported measurement with 13 items. Associations of the SOC with different dimensions of health (in particular with Short Form 36, SF-36) are known from cross-sectional studies. Most studies showed a stronger correlation of the mental than the physical health dimensions of SF-36 with SOC-13. This result is consistent with baseline examinations of hip and knee OA patients before rehabilitation. At the 6-month follow-up, correlations between SOC and the changes of the SF-36 scores were weak. A salutogenically orientated instruction for self-management of symptoms in cancer patients showed significant improvement in SOC. CONCLUSION: Increasing SOC can lead to health improvements on many levels, e.g. self-efficacy, reduction of fear, coping, education, resources and compliance to treatment. Empirical proof that interventional measures increasing SOC can improve the health of OA patients is currently unavailable.

[Treatment of chronic pain in Switzerland: scientific evidence]. / Behandlung chronischer Schmerzen in der Schweiz: wissenschaftliche Evidenz.

Chronic pain is often seen in the lower back region (lumbar spine). It usually influences different aspects of health and wellbeing, is often treated inadequately and causes important economic costs. Various biopsychosocial factors influence chronic pain and the outcome of medical treatment. This has lead to multidisciplinary treatment strategies. The scientific evaluation of interdisciplinary inpatient pain management programs in Switzerland shows moderate to large changes in various health dimensions in subjects with chronic non-specific back pain, fibromyalgia, chronic widespread pain, and after whiplash injury. These short- to mid-term results are confirmed by international scientific evidence. The effects of an interdisciplinary pain management program are higher than those of the standard rehabilitation. Complementary, subgroup-specific pain treatment could optimize these results.

[Western Ontario shoulder instability index (WOSI): translation and cross-cultural adaptation for use by German speakers]. / "Western Ontario Shoulder Instability Index" (WOSI) : Ubersetzung und transkulturelle Anpassung für den deutschsprachigen Gebrauch.

BACKGROUND: Outcome assessment after orthopaedic interventions is becoming more and more important. However, there are no disease-specific instruments for patient self-assessment of shoulder instability. The goal of our study was to translate and test the Western Ontario Shoulder Instability Index (WOSI) using a standardised approach. The guidelines of the American Association of Orthopedic Surgeons were used for the translation and cross-cultural adaptation process. MATERIAL AND METHOD: Understanding was tested in 20 healthy subjects, and reliability and validity were quantified in 30 patients with shoulder instability. The quality of the translated version was described using the criteria of homogeneity, reliability, and construct validity. RESULTS: The test-retest reliability of the total score [intraclass correlation coefficient (ICC), 0.87] and of the subscores with the ICC (sports, leisure, and work 0.73; sensitivity 0.81; physical symptoms 0.82; and behaviour 0.90) was high. The internal consistency of the total scale was also high (Cronbach's alpha 0.89). CONCLUSIONS: The WOSI covers a broad range of symptoms and impaired functioning in patients with shoulder instability. The German translation shows good results regarding understanding, homogeneity, reliability, and validity. Therefore, it is a useful instrument for self-assessment in patients with shoulder instability.

Does classification of persons with fibromyalgia into Multidimensional Pain Inventory subgroups detect differences in outcome after a standard chronic pain management program?

INTRODUCTION: The present study aimed to replicate and validate the empirically derived subgroup classification based on the Multidimensional Pain Inventory (MPI) in a sample of highly disabled fibromyalgia (FM) patients. Second, it examined how the identified subgroups differed in their response to an intensive, interdisciplinary inpatient pain management program. METHODS: Participants were 118 persons with FM who experienced persistent pain and were disabled. Subgroup classification was conducted by cluster analysis using MPI subscale scores at entry to the program. At program entry and discharge, participants completed the MPI, Medical Outcomes Study Short Form-36, Hospital Anxiety and Depression Scale and Coping Strategies Questionnaire. RESULTS: Cluster analysis identified three subgroups in the highly disabled sample that were similar to those described by other studies using less disabled samples of FM. The dysfunctional subgroup (DYS; 36% of the sample) showed the highest level of depression, the interpersonally distressed subgroup (ID; 24%) showed a modest level of depression and the adaptive copers subgroup (AC; 38%) showed the lowest depression scores in the MPI (negative mood), Medical Outcomes Study Short Form-36 (mental health), Hospital Anxiety and Depression Scale (depression) and Coping Strategies Questionnaire (catastrophizing). Significant differences in treatment outcome were observed among the three subgroups in terms of reduction of pain severity (as assessed using the MPI). The effect sizes were 1.42 for DYS, 1.32 for AC and 0.62 for ID (P=0.004 for pairwise comparison of ID-AC and P=0.018 for ID-DYS). DISCUSSION: These findings underscore the importance of assessing individuals' differences in how they adjust to FM.

The patient-rated wrist evaluation (PRWE): cross-cultural adaptation into German and evaluation of its psychometric properties.

OBJECTIVE: To cross-culturally adapt the Patient-Rated Wrist Evaluation form (PRWE) into German (PRWE-G) and to evaluate its reliability and validity. METHODS: A cross-cultural adaptation of the PRWE was carried out, according to established guidelines. 103 patients, who had undergone resection interposition arthroplasty (RIAP) for carpometacarpal osteoarthritis approximately 6.2 years earlier, completed a questionnaire booklet containing the PRWE-G, the Short Form 36 (SF-36), the Disabilities of Arm, Shoulder, and Hand (DASH); they also underwent clinical assessment with the Hand Function Index (HFI, Keitel) and Custom Score including grip and pinch strength tests. The results were used to assess the criterion and construct validity of the PRWE-G. To measure the re-test reliability, 51 patients completed a second PRWE-G within 2 weeks. RESULTS: The test-retest reliability of the PRWE-G was acceptable for the pain and function sub-scales and for the global score, with intraclass correlation coefficients of 0.78-0.87. The PRWE-G showed a high internal consistency (Cronbach's alphas of 0.92-0.97 for the scales and the total score). The typical error of measurement for the global score was 8.1 points, giving a minimal detectable change (MDC95%) of approximately 22.5 points. The PRWE-G scores correlated well with those of the DASH (r=0.82, p<0.001) but less well with those of the physical component summary of the SF-36 (r=0.53, p<0.001) and not at all with the mental component summary scores of the SF-36 (r=0.04, p>0.05). The PRWE-G scores correlated moderately with certain clinical findings of the HFI, Custom Score, and grip/pinch strength tests (r=0.30-0.59, p<0.001). CONCLUSION: The PRWE-G represents a valid and reliable instrument to evaluate self-rated outcome in German-speaking patients with hand and wrist pathology.

Cross-cultural adaptation, reliability and validity of the Patient Rated Elbow Evaluation (PREE) for German-speaking patients.

OBJECTIVE: Patient-orientated questionnaires are important instruments for the assessment of outcome in the clinical environment and in musculoskeletal research. The objective of this study was to cross-culturally adapt the Patient Rated Elbow Evaluation (PREE) into German (PREE-G) and to test its reliability, validity and psychometric properties. METHODS: The PREE was cross-culturally adapted for the German language, according to established guidelines. Fifty-six patients who had undergone elbow arthroplasty for osteoarthritis or chronic polyarthritis, on average 11 years previously, were assessed using the PREE-G, the Short Form 36 (SF-36), the Disabilities of Arm, Shoulder, Hand (DASH) and the modified American Shoulder and Elbow Surgeons (mASES) clinical evaluation. RESULTS: The test-retest reliability (intraclass correlation coefficient) of the PREE-G was 0.80, and the internal consistency 0.96. The PREE-G correlated with the DASH (r = 0.73) and the physical component summary of the SF-36 (r = 0.57) but not with the mental component summary (r = -0.02). The PREE-G correlated moderately with certain clinical findings (mASES) (r = 0.36-0.54; p < 0.01). CONCLUSION: The PREE-G represents a reliable and valid instrument to evaluate subjective outcome in German speaking patients with elbow pathology.

Cross-cultural adaptation, reliability and validity of the German Shoulder Pain and Disability Index (SPADI).

OBJECTIVE: To cross-culturally adapt the Shoulder Pain and Disability Index (SPADI) from English into German, and to test the reliability and validity of the German version. METHODS: Cross-cultural adaptation of the SPADI was performed according to international guidelines. One hundred and eighteen patients who had undergone shoulder arthroplasty, on average 4 yr previously, completed a questionnaire booklet containing the German SPADI, the Short Form 36 (SF-36), the Disability of the Arm, Shoulder and Hand (DASH) questionnaire, and the American Shoulder and Elbow Surgeons (ASES) questionnaire for the shoulder to assess SPADI's construct validity. One week later, they completed the SPADI again to assess test-retest reliability. RESULTS: The six-step cross-cultural adaptation procedure revealed no major problems with the content or language. The intraclass correlation coefficients for the individual items of the SPADI were between 0.68 and 0.89, and that for the SPADI total score was 0.94. The SPADI total score showed a correlation of 0.61-0.69 with the SF-36 physical scales, of 0.88 with the DASH and of 0.92 with the ASES. CONCLUSIONS: The German SPADI is a practicable, reliable and valid instrument, and can be recommended for the self-assessment of shoulder pain and function.

Systematic counselling by general practitioners for promoting physical activity in elderly patients: a feasibility study.

RESEARCH QUESTIONS: To investigate how the daily physical activities of elderly patients can be enhanced by systematic counselling conducted by general practitioners (GPs). METHODS: In this feasibility study with pre-post design, 29 people (14 females, mean age 72.2 years, SD = 6.1) were enrolled during routine visits by two general practitioners. A baseline assessment of current physical activity based on the stages according to the Transtheoretical Model was followed by a counselling session. The target behaviour was defined by performance of 30 minutes of daily moderate-intensity activities that increase the breathing rate, on five days per week. At the 2-month follow-up, subjects were assessed for improvement in stage of physical activity since baseline. After the end of the intervention, participating GPs and patients were asked questions focusing on the feasibility, acceptance and usefulness of counselling. RESULTS: Interview results showed that the two GPs considered the counselling protocol easy to handle and useful for promoting physical activity. Counselling sessions were especially encouraging for the not sufficiently active people. Most of them would like to have additional counselling session. At baseline, 9 of 29 people were sufficiently active. After 2 months, this proportion was 21 of 29. The mean of the number of minutes of physical activity during the previous 4 weeks increased from 247 to 436 minutes (weekly). CONCLUSIONS: The programme was judged positively by the general practitioners and the participating elderly patients. Systematic counselling by general practitioners led to an increase in the physical activity behaviour. Therefore, a more rigorous randomised controlled trial with adequate followup is recommended.

Predictors for response to rehabilitation in patients with hip or knee osteoarthritis: a comparison of logistic regression models with three different definitions of responder.

OBJECTIVE: To identify pre-treatment predictors of who will benefit from a 3-4-week comprehensive rehabilitation intervention in patients with osteoarthritis (OA) of the knee or hip. METHODS: A prospective cohort study with assessments at admission to the clinic and after 6 months was conducted. Two hundred and fifty patients from the rehabilitation clinic Rehaclinic Zurzach, Switzerland, were included. Three different measures of response to a 3-4-week comprehensive rehabilitation intervention were used: one indirect measure (minimal clinically important difference (MCID) in the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) global score=18% improvement), one direct measure (transition question) and a combination of both criteria. Responders were predicted by a sequential logistic regression analysis with nine personal variables, five lifestyle risk factors, seven psychological status variables and the WOMAC global baseline score. RESULTS: The set of statistically significant predictors was dependent on the definition of response. The comparison of predictors that were statistically significant in any of the prediction models showed similar odds ratios (ORs) for the majority of predictors across three regression models with the different response definitions as dependent variable. Female gender, absence of depressive symptoms (dep), history of complementary medicine (cm) and low comorbidity (com) were the most stable predictors and had ORs above 2.0 (female) and above 1.5 (dep, cm, com) across the three regression models with different response definitions. CONCLUSION: A set of predictors for the outcome of rehabilitation in patients with OA was identified. If these predictors could be confirmed in future research, this knowledge might help to adopt and individualize the treatment of patients who are, at present, less likely to respond.

[Comparison of rheumatic and post-traumatic elbow joints after total elbow arthroplasty. Comprehensive and specific evaluation of clinical picture, function, and quality of life]. / Vergleich des rheumatischen und posttraumatischen Ellenbogengelenks nach Totalprothese. Eine umfassende sowie spezifische Beurteilung von Klinik, Funktion und Lebensqualität.

BACKGROUND: Patients with elbow destruction due to rheumatoid arthritis (RA) or trauma (PT) were compared to population-based normative data and to each other after total elbow arthroplasty. PATIENTS AND METHODS: Pain, function, and biopsychosocial health were multidimensionally assessed by the generic Short Form 36 (SF-36), the condition-specific Disabilities of the Arm, Shoulder and Hand questionnaire (DASH), and the Patient Related Elbow Evaluation form (PREE) instrument and analyzed by uni- and multivariate methods. RESULTS: Compared to normative values, the examined 59 RA patients were significantly affected in the function scales of the SF-36 and in all DASH scales. The 20 PT patients were worse than the norm only in the DASH function. Function was lower in RA than in PT in the SF-36 scales and in the DASH (RA: 44.4, PT: 70.3, p<0.001). This difference was less distinct in the PREE. CONCLUSION: Total elbow arthroplasty led to a pain-free outcome and normal quality of life, but failed to restore complete function. Functional deficits were larger in the RA patients and could also be measured by the SF-36, possibly due to polyarticular affection.

Inpatient rehabilitation for hip or knee osteoarthritis: 2 year follow up study.

OBJECTIVE: To examine the course of pain, physical function, and other health dimensions after a comprehensive inpatient rehabilitation intervention in patients with osteoarthritis (OA) of the hip or knee. METHODS: An observational, prospective cohort study with assessments at baseline (entry into clinic), 1 (discharge from inpatient rehabilitation), 3, 6, 9, 12, and 24 months after baseline. Consecutively referred patients to an inpatient rehabilitation centre fulfilling the inclusion criteria were studied. 3-4 week comprehensive rehabilitation intervention, including strengthening exercise, flexibility training, endurance training, relaxation strategies, and consultations for preventive measures, was carried out. Individual home rehabilitation programmes were taught. Generic health status was measured using the SF-36, condition specific health was measured with the WOMAC questionnaire. Effects were analysed with sensitivity statistics (effect size, ES) and non-parametric tests. RESULTS: Data from 128 patients with complete follow up data were analysed. Both pain and physical function improved moderately (WOMAC pain: ES = 0.56, WOMAC function ES = 0.44) until discharge. Although the effect in pain reduction remained significant by month 24 (WOMAC: ES = 0.26), physical function deteriorated close to baseline values after 12 months. CONCLUSIONS: Comprehensive inpatient rehabilitation of patients with OA of the hip or knee may improve pain and physical function in the mid-term, and pain in the long term.

Mortality of patients with mood disorders: follow-up over 34-38 years.

BACKGROUND: All follow-up studies of causes of death in affective disordered patients have found they have markedly elevated suicide rates and a less reproducible increased mortality from other causes. The reported rates by gender, disorder type and treatment are more variable. METHODS: Hospitalised affective disordered patients (n=406) were followed prospectively for 22 years or more. Later, mortality was assessed for 99% of them at which time 76% had died. RESULTS: Standardised Mortality Rates (observed deaths/expected deaths) for patients were elevated especially for suicide and circulatory disorders in both men and women. Women actually had higher suicide rates but that did not take into account the twofold increase in general population rates for men. Unipolar patients had significantly higher rates of suicide than bipolar Is or IIs. In all groups long term medication treatment with antidepressants alone or with a neuroleptic, or with lithium in combination with antidepressants and/or neuroleptics significantly lowered suicide rates even though the treated were more severely ill. Although at the age of onset the suicide rates were most elevated, from ages 30 to 70 the rates were remarkably constant despite the different courses of illness. LIMITATIONS: The patients were identified as inpatients and followed prospectively. The treatments were uncontrolled and are not quantifiable but were documented during the follow-up. CONCLUSIONS: Men and women hospitalised for affective disorders have elevated mortality rates from suicide and circulatory disorders. Unipolars have higher suicide rates than bipolar Is or IIs. Long term medication treatment lowers the suicide rates, despite the fact that it was the more severely ill who were treated.

Smallest detectable and minimal clinically important differences of rehabilitation intervention with their implications for required sample sizes using WOMAC and SF-36 quality of life measurement instruments in patients with osteoarthritis of the lower extremities.

OBJECTIVE: To discuss the concepts of the minimal clinically important difference (MCID) and the smallest detectable difference (SDD) and to examine their relation to required sample sizes for future studies using concrete data of the condition-specific Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and the generic Medical Outcomes Study 36-Item Short Form (SF-36) in patients with osteoarthritis of the lower extremities undergoing a comprehensive inpatient rehabilitation intervention. METHODS: SDD and MCID were determined in a prospective study of 122 patients before a comprehensive inpatient rehabilitation intervention and at the 3-month followup. MCID was assessed by the transition method. Required SDD and sample sizes were determined by applying normal approximation and taking into account the calculation of power. RESULTS: In the WOMAC sections the SDD and MCID ranged from 0.51 to 1.33 points (scale 0 to 10), and in the SF-36 sections the SDD and MCID ranged from 2.0 to 7.8 points (scale 0 to 100). Both questionnaires showed 2 moderately responsive sections that led to required sample sizes of 40 to 325 per treatment arm for a clinical study with unpaired data or total for paired followup data. CONCLUSION: In rehabilitation intervention, effects larger than 12% of baseline score (6% of maximal score) can be attained and detected as MCID by the transition method in both the WOMAC and the SF-36. Effects of this size lead to reasonable sample sizes for future studies lying below n = 300. The same holds true for moderately responsive questionnaire sections with effect sizes higher than 0.25. When designing studies, assumed effects below the MCID may be detectable but are clinically meaningless.

Responsiveness of the WOMAC osteoarthritis index as compared with the SF-36 in patients with osteoarthritis of the legs undergoing a comprehensive rehabilitation intervention.

OBJECTIVE: To compare the responsiveness of the condition-specific Western Ontario and McMaster Universities osteoarthritis (OA) index (WOMAC) and the generic Short Form-36 (SF-36) in patients with OA of the legs undergoing a comprehensive inpatient rehabilitation intervention. METHODS: A prospective follow up study of consecutively referred inpatients of a rehabilitation clinic was made. The patients included fulfilled the American College of Rheumatology criteria for knee or hip OA and underwent both passive and, particularly, active physical therapy for three to four weeks. Responsiveness assessment was performed using the standardised response mean (SRM), effect size, and Guyatt's responsiveness statistic between admission and discharge (end of rehabilitation) and then again between admission and three months later. For pain and function the SRMs were stratified by sex and OA joint. Effects were tested by the t test and SRMs of different scales were compared by the jack knife test. RESULTS: At the three month follow up, complete data were obtained for 223 patients. In general, the three responsiveness statistics showed a similar order of responsiveness. For both instruments, the pain scales were more responsive than the function scales. The responsiveness of the pain scale of both instruments was comparable (SRM=0.723 for WOMAC and SRM=0.528 for SF-36 at the end of rehabilitation; SRM=0.377 for WOMAC and SRM=0.468 for SF-36 at the three month follow up). In the measurement of function, the WOMAC was significantly more responsive than the SF-36 (SRMs, end of rehabilitation: 0.628 v 0.249; three month follow up: 0.235 v -0.001). Responsiveness tended to be higher in women and in knee OA than in men and hip OA. CONCLUSIONS: Both instruments, the WOMAC and the SF-36, capture improvement in pain in patients undergoing comprehensive inpatient rehabilitation intervention. Functional improvement can be detected better by the WOMAC than by the SF-36. All the other scales of both instruments were more weakly responsive.

Suicide risk in patients with major depressive disorder.

Understanding the origins of suicide is the first step in preventing it. Review of the current literature has revealed only limited data from general practice and community samples; most research has been performed on inpatient psychiatric populations, and extended follow-ups are rare. Mood disorders were found to be highly associated with suicide, especially in patients with major depressive disorder. Depression is an important factor in suicides of adolescents and the elderly, but those with late-onset depression are at higher risk. Both comorbidity with other disorders, such as anxiety and agitation, and rapid changes in the depressive state, for instance after release from the hospital, increase the risk for suicide.

Long-term outcome and mortality of treated versus untreated bipolar and depressed patients: A preliminary report.

The mortality of patients with mood disorders is elevated as a consequence not only of suicides and accidents but also of cardiovascular and other diseases - for instance, hypothyroidism and hyperthyroidism. Long-term medication can reduce suicides by two-thirds and can probably reduce non-suicidal mortality also. This long-term study of 406 hospital admissions recruited between 1959 and 1963 and followed up until 1991 suggests that not only lithium (as reported in the literature), but also neuroleptics and antidepressants may have such beneficial effects.

Update on the Epidemiology of Traveler's Diarrhea in East Africa.

Background: Traveler's diarrhea (TD), the most frequent health problem in visitors to subtropical and tropical regions, needs to be reassessed in view of the development of vaccines against its most frequent causative agent, enterotoxigenic Escherichia coli. Methods: Passengers returning from Mombasa to Europe were interviewed by self-applied questionnaires during the flights. Main outcome measures were subjective TD, defined as having had more diarrhea in East Africa than at home, objective TD as traditionally defined, and the cumulative incidence calculated by the method of Kaplan-Meier survival analysis. Results: Subjective TD was reported by 1117 (49.3%) of the 2268 tourists. The cumulative incidence of subjective TD reached 36.7% after a 1-week stay and 47.6% after 2 weeks. Conclusion: Subjective TD attack and incidence rates continue to be high even at frequently visited destinations.