Decline in Mobility and Balance in Persons with Post-COVID-19 Condition.

OBJECTIVES: Post-COVID-19 condition (PCC) may impact mobility and balance and affect physical function. The objectives of the study were to estimate the prevalence of decline in balance and mobility in individuals with PCC; explore the association between comorbidities and sociodemographic characteristics with decline in balance and mobility; and evaluate correlations between decline in mobility and balance with change in performance of usual activities, personal care, and global health perception. METHODS: The design was a cross sectional study of persons with a COVID-19 diagnosis that was confirmed at least 3 months before the study. Those with PCC, defined as those still troubled by symptoms, were evaluated for decline in mobility and balance and with associated clinical and demographic factors using bivariate analysis and multivariable logistic regression. Correlations between decline in mobility and balance were also examined with change in ability to perform usual activities, personal care, and global health perception. RESULTS: In 1031 persons with PCC, mobility deteriorated in 44.9% and balance deteriorated in 37.1%. Older age, hospitalization, comorbidities, and obesity were associated with decline in mobility, while decline in balance was associated with older age and comorbidities. Reduced mobility was associated with changes in ability to carry out usual activities (rp = 0.6), conduct personal care (rp = 0.6), and global health status (rp = 0.5). Correlations between decline in balance and these same outcomes were 0.5, 0.5, and 0.45, respectively. CONCLUSIONS: Almost half the participants with PCC had reduced mobility and over a third reported deterioration in balance, with associated difficulties with daily functioning. Factors associated with greater decline help identify those most at risk. IMPACT: Many people with PCC experience changes in mobility and balance, which can affect functional capacities and lead to physical therapist consultations. Further study should assess specific needs of these patients and determine effective physical therapist interventions to meet these needs.

Many persons with post­COVID-19 condition (PCC) experience symptoms resulting in functional problems, such as difficulties with personal care and performing usual activities. This study focused on difficulty in mobility and problems with balance. Almost half of persons with PCC in the study had declines in getting around and over a third had declines in balance. These problems were associated with older age and having other comorbid health conditions and were linked with decline in ability to perform personal care, carry out usual activities, and perceived global health status.

Long COVID in Persons With Self-Reported Arthritis: Symptoms, Associated Factors, and Functional Limitations.

OBJECTIVE: The aim is to describe both long COVID symptoms and associated factors in a cohort of individuals with a self-reported history of arthritis as well as change in function in persons with arthritis and long COVID compared to pre-COVID status. METHODS: Among 2,764 persons with a confirmed COVID-19 diagnosis who responded to an online survey at least 12 weeks post-infection, 171 reported a history of arthritis and formed our study sample. We calculated the frequency of long COVID defined as troubled by persistent symptoms and evaluated associated factors using bivariate analysis and multivariable logistic regression. Among those with long COVID, we describe limitations in activity and function in comparison to pre-COVID status. RESULTS: In our sample, 53.5% (n = 91) reported being troubled by ongoing symptoms at the time of completing the questionnaire (long COVID), with the most frequent symptoms as the following: fatigue, myalgia, weakness, breathlessness, low mood, anxiety, and sleep disturbance. Factors associated with long COVID were female sex, having been hospitalized for COVID, and having at least 1 other chronic disease. Persons with long COVID had substantial declines in function, notably in global health status, usual activities, mobility, personal care, and employment status. Also, 37% of those with long COVID reported moderate to severe increase in pain. CONCLUSION: Persons with arthritis who have long COVID have substantial limitations in function compared to their pre-COVID status. There is a need to implement effective interventions to improve functional status in persons with arthritis and long COVID.

A decade of progress in juvenile idiopathic athritis treatments and outcomes in Canada: results from ReACCh-Out and the CAPRI registry.

OBJECTIVE: To assess changes in juvenile idiopathic arthritis (JIA) treatments and outcomes in Canada, comparing a 2005-2010 and a 2017-2021 inception cohorts. METHODS: Patients enrolled within three months of diagnosis in the Research in Arthritis in Canadian Children Emphasizing Outcomes (ReACCh-Out) and the Canadian Alliance of Pediatric Rheumatology Investigators Registry (CAPRI) cohorts were included. Cumulative incidences of drug starts and outcome attainment within 70 weeks of diagnosis were compared with Kaplan Meier survival analysis and multivariable Cox regression. RESULTS: The 2005-2010 and 2017-2021 cohorts included 1128 and 721 patients, respectively. JIA category distribution and baseline clinical juvenile idiopathic arthritis disease activity (cJADAS10) scores at enrolment were comparable. By 70 weeks, 6% of patients (95% CI 5, 7) in the 2005-2010 and 26% (23, 30) in the 2017-2021 cohort had started a biologic DMARD (bDMARD), and 43% (40, 47) and 60% (56, 64) had started a conventional DMARD (cDMARD), respectively. Outcome attainment was 64% (61, 67) and 83% (80, 86) for Inactive disease (Wallace criteria), 69% (66, 72) and 84% (81, 87) for minimally active disease (cJADAS10 criteria), 57% (54, 61) and 63% (59, 68) for pain control (<1/10), and 52% (47, 56) and 54% (48, 60) for a good health-related quality of life. CONCLUSION: Although baseline disease characteristics were comparable in the 2005-2010 and 2017-2021 cohorts, cDMARD and bDMARD use increased with a concurrent increase in minimally active and inactive disease. Improvements in parent and patient reported outcomes were smaller than improvements in disease activity.

Gender Issues in Physiotherapy in Quebec, Canada.

Purpose: This study examines gender differences in the physiotherapy (PT) profession in the province of Quebec regarding: (1) areas of practice; (2) roles associated with the advancement of the profession; (3) formal disciplinary complaints; and (4) interests and competency perceptions of PT students. Methods: We collected data from the Canadian Institute of Health Information, the Quebec Professional Order of Physiotherapy, Quebec university public Internet sites, and PT associations. We also surveyed PT students at the Université de Montréal. Results: The PT workforce in Quebec was 76.6% women. The presidents of the four main PT associations were men. In the five university programmes, the percentage of male and female physiotherapists in tenure track positions was 46% and 54%, respectively. There were more sanctioned complaints of sexual misconduct and not maintaining continuing education for male physiotherapists, while more women were sanctioned for problems with documentation and billing. Among students, men were more interested in becoming administrators, but neither men nor women had a strong interest in research. Conclusions: Male physiotherapists make up 23.4% of the PT workforce in Quebec but are more involved in leadership positions in the profession than women.

Objectif : examiner les différences de genre en physiothérapie au Québec à l'égard 1) des secteurs d'exercice, 2) des rôles associés à l'avancement de la profession, 3) des plaintes disciplinaires officielles et 4) des intérêts des étudiants en physiothérapie et de leurs perceptions à l'égard des compétences. Méthodologie : collecte de données auprès de l'Institut canadien d'information sur la santé, de l'Ordre professionnel de la physiothérapie du Québec, des sites Internet publics des universités québécoises et des associations de physiothérapie. Sondage auprès des étudiants en physiothérapie de l'Université de Montréal. Résultats : au Québec, la main-d'œuvre en physiothérapie était composée de 76,6 % de femmes. Ce sont des hommes qui présidaient les quatre principales associations de physiothérapie. Dans les cinq programmes universitaires, le pourcentage de physiothérapeutes de sexe masculin et féminin qui occupaient des postes menant à la permanence s'élevait à 46 % et à 54 %, respectivement. On dénombrait plus de plaintes sanctionnées d'inconduite sexuelle et de non-respect de la formation continue chez les physiothérapeutes de sexe masculin, tandis que plus de femmes étaient sanctionnées pour des problèmes de tenue de dossier et de facturation. Chez les étudiants, les hommes étaient plus intéressés à devenir administrateurs, mais ni les hommes ni les femmes ne témoignaient d'un intérêt marqué envers la recherche. Conclusions : les physiothérapeutes de sexe masculin représentent 23.4% de la main-d'œuvre en physiothérapie au Québec, mais occupent plus de postes de direction dans la profession que les femmes.

Adherence, helpfulness and barriers to treatment in juvenile idiopathic arthritis - data from a German Inception cohort.

OBJECTIVES: To develop and evaluate German versions of the Parent Adherence Report Questionnaire (PARQ) and Child Adherence Report Questionnaire (CARQ) and to evaluate adherence in patients with juvenile idiopathic arthritis (JIA). METHODS: The PARQ and CARQ were translated into German, cross-culturally adapted and administered to patients (age ≥ 8 years) and their parents enrolled in the Inception Cohort Study of newly diagnosed JIA patients (ICON). The psychometric issues were explored by analyzing their test-retest reliability and construct validity. RESULTS: Four hundred eighty-one parents and their children with JIA (n = 465) completed the PARQ and CARQ at the 4-year follow-up. Mean age and disease duration of patients were 10.1 ± 3.7 and 4.7 ± 0.8 years, respectively. The rate of missing values for PARQ/CARQ was generally satisfactory, test-retesting showed sufficient reliability. PARQ/CARQ mean child ability total scores (0-100, 100 = best) for medication were 73.1 ± 23.3/76.5 ± 24.2, for exercise: 85.6 ± 16.5/90.3 ± 15.0, for splints: 72.9 ± 24.2/82.9 ± 16.5. Construct validity was supported by PARQ and CARQ scores for medications, exercise and splints showing a fair to good correlation with the Global Adherence Assessment (GAA) and selected PedsQL scales. Adolescents showed poorer adherence than children. About one third of the parents and children reported medication errors. Perceived helpfulness was highest for medication, and adverse effects were reported the greatest barrier to treatment adherence. CONCLUSIONS: The German versions of the PARQ and CARQ appear to have a good reliability and sufficient construct validity. These questionnaires are valuable tools for measuring treatment adherence, identifying potential barriers and evaluating helpfulness of treatments in patients with JIA.

Functional Limitations in Individuals With Long COVID.

OBJECTIVES: To examine the extent of long-term functional deficits experienced by individuals hospitalized for coronavirus disease 2019 (COVID-19). Specific objectives were to (1) describe changes in perceived global health, mobility, participation in daily activities, and employment status from pre-COVID-19 to ≥2 months after infection and (2) evaluate factors associated with change in function. DESIGN: We conducted a telephone survey (at least 2 months postinfection). SETTING: Population-based study of adults living at home. PARTICIPANTS: Adult residents in Laval, Quebec (n=121), who were discharged home posthospitalization for COVID-19. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Participants responded to a standard questionnaire (COVID-19 Yorkshire Rehabilitation Screen) regarding persistent symptoms and limitations in daily functioning. We calculated the prevalence of changes in perceived global health, mobility, personal care, participation in daily activities, and employment, and evaluated associated factors using bivariate analysis and multivariable logistic regression. RESULTS: Almost all participants (94%) were more fatigued and reported deterioration of their global health status (90%) at least 3 months after infection. The majority were more short of breath and experienced pain and anxiety. The change in outcomes indicates a substantial reduction in those reporting "good" health status, mobility, personal care, and daily activities and less employment. Time since diagnosis was significantly associated with global health, mobility, and participation in daily activities. CONCLUSIONS: This population-based study suggests that individuals hospitalized for COVID-19 infection have symptoms that affect daily functional activities many months after infection. It is imperative that the effect of infection be better understood so that those affected long term can receive the needed services.

Do physical therapists follow evidence-based practices for treatment of inflammatory arthritis? Results from an online survey.

BACKGROUND: Physical therapists (PTs) should know how to best treat patients with inflammatory arthritis. OBJECTIVE: To document interventions chosen by PTs for patients with rheumatoid arthritis (RA) and ankylosing spondylitis (AS) and whether choices follow evidence-based practice. METHODS: Licensed musculoskeletal PTs in Quebec, Canada responded to an online survey. Descriptive statistics illustrated proportions for each treatment choice and inferential statistics explored associations with demographic and practice-related factors. RESULTS: There were 298 PTs who responded to the survey. For both RA and AS respectively, most common interventions were mobility exercises (91.0%; 98.3%) and patient education (90.1%; 92.8%). For both cases, slightly >60% selected strengthening exercises. Passive forms of therapy were chosen by 36% of PTs for RA and 58% for AS. Aerobic exercise was rarely selected. PTs working in the public sector were less likely to use manual therapy for both RA (Odds Ratio (OR) 0.43, 95% confidence interval (CI) 0.22,0.86) and AS (OR 0.46, 95% CI 0.22,0.97). CONCLUSIONS: Most PTs chose mobility exercises and patient education, representing evidence-based approaches. Despite current recommendations, strengthening and especially aerobic exercises were not used as much. There is a need to increase awareness regarding the benefits of strengthening and aerobic exercise for these patients.

Disability Among Persons With Chronic Severe Back Pain: Results From a Nationally Representative Population-based Sample.

We evaluated the association between the chronic severe back pain with disability and participation, in U.S. Adults using data from the US 2019 National Health Interview Survey. In our sample of 2,925 adults (weighted n: 20,468,134) who reported having chronic severe back pain, 60% reported mobility disability, 60% had work limitations, 34% were limited for social participation and 16% had self-care limitations. Older age (65+) was associated with mobility difficulties (OR 1.99, 95% CI 1.28,6.09) and work limitation (OR 2.21, 95% CI 1.61,3.05). Lower socioeconomic status was associated with increasing odds of disability across the 4 categories. Being obese was only associated with mobility difficulties (OR 1.95, 95% CI 1.41,2.71), while not working in the past week was associated with difficulties in mobility (OR 3.55, 95% CI 2.64,4.75), self-care (OR 3.34, 95% CI 2.20,5.08), and social participation (OR 3.20, 95% CI 2.13,4.80). Comorbidities were highly associated with limitations in all 4 categories. Those deeming their ability to manage their pain ineffective were twice as likely to have limitations in self-care, social and work participation but not mobility. Identifying factors associated with disability and limitation may help target appropriate management for persons with chronic pain at high risk for disability. PERSPECTIVE: We evaluated the association between the chronic severe back pain with disability and participation, in a representative sample of Americans. Identifying factors associated with a likelihood of disability may help target appropriate pain management for persons at high risk for disability due to chronic severe back pain.

Long COVID symptoms in a population-based sample of persons discharged home from hospital.

OBJECTIVES: The impact of long COVID among persons hospitalized and discharged home is unknown. We aimed to (1) report the prevalence of long COVID in persons hospitalized for COVID-19 and discharged home; (2) estimate the prevalence of physical, sensory, and psychological/mental health impairments; and (3) explore associated factors. METHODS: We conducted a telephone survey of adult residents in Laval, Quebec, who were discharged home ≥ 2 months post-hospitalization for COVID-19. Participants responded to a standard questionnaire regarding persistent symptoms. We calculated the prevalence of long COVID and of persistent types of symptoms and evaluated associated factors using bivariate analysis and multivariable logistic regression. RESULTS: In our sample (n = 398), 70% reported physical symptoms, 58% psychological problems, and 16% sensory impairments. 31.5% reported being troubled by persistent symptoms (long COVID). Factors associated with long COVID were a greater number of symptoms (odds ratio (OR) = 1.97, 95% confidence interval (CI) = 1.69-2.28) and increased hospital stay (OR = 1.03, 95% CI = 1.01-1.06). Other factors associated with physical and psychological symptoms were female sex (OR = 2.17, 95% CI = 1.27-3.71 and OR = 2.06, 95% CI = 1.25-3.39; respectively), higher education level (OR = 2.10, 95% CI = 1.20-3.68 and OR = 2.43, 95% CI = 1.44-4.14; respectively), and obesity (OR = 1.95, 95% CI = 1.15-3.34 and OR = 1.70, 95% CI = 1.05-2.77; respectively). CONCLUSION: In this population-based study of persons hospitalized for COVID-19 and discharged home, nearly one third were troubled by symptoms for 2 months or more post-discharge. There was a high proportion with persistent physical and psychological/mental health symptoms. Further research will assess the specific needs of these patients to inform health policy makers on service requirements for these persons.

RéSUMé: OBJECTIFS: L'impact de la présence de la COVID longue chez les personnes hospitalisées et lors de leur congé de l'hôpital est inconnu. Dans le cadre de cette étude, nous visions à 1) rapporter la prévalence de la présence de la COVID longue chez les personnes hospitalisées en raison de la COVID-19 et lors de leur congé à la maison; 2) estimer la prévalence des déficiences physiques, sensorielles et psychologiques/cognitives; et 3) explorer les facteurs associés. MéTHODES: Nous avons mené une enquête téléphonique auprès des résidents adultes de Laval, au Québec, qui ont reçu leur congé de l'hôpital plus de deux mois après avoir été hospitalisés en raison de la COVID-19. Les participants ont répondu à un questionnaire standard concernant leurs symptômes résiduels. Nous avons calculé la prévalence de la COVID longue et le type de symptômes résiduels et nous avons évalué les facteurs associés en utilisant une analyse bivariée et une régression logistique multivariable. RéSULTATS: Dans notre échantillon (n=398), 70 % ont déclaré des symptômes physiques, 58 % des problèmes psychologiques et 16 % des déficiences sensorielles. 31,5 % ont déclaré être perturbés par des symptômes résiduels (COVID longue). Les facteurs associés à la COVID longue étaient un plus grand nombre de symptômes (Rapport de cotes (OR)=1,97, intervalle de confiance à 95% (IC)=1,69-2,28) et une durée d'hospitalisation plus longue (OR=1,03, IC 95%=1,01-1,06). Les autres facteurs associés aux symptômes physiques et psychologiques étaient le sexe féminin (OR=2,17, IC 95%=1,27-3,71 et OR=2,06, IC 95%=1,25-3,39; respectivement), un niveau d'éducation plus élevé (OR=2,10, IC 95%=1,20-3,68 et OR=2,43, IC 95%=1,44-4,14; respectivement) et l'obésité (OR=1,95, IC 95%=1,15-3,34 et OR=1,70, IC 95%=1,05-2,77; respectivement). CONCLUSION: Dans cette étude effectuée sur une population de personnes hospitalisées pour la COVID-19 et lors de leur congé de l'hôpital, près d'un tiers ont été perturbées par la présence de symptômes résiduels présents pendant 2 mois ou plus après leur congé. Une forte proportion d'entre elles présentait des symptômes physiques et psychologiques/enjeux de santé mentale persistants. Des recherches futures permettront d'évaluer les besoins spécifiques de ces individus afin d'informer les décideurs politiques en santé de leurs besoins afin d'offrir des services adaptés à leur condition.

"It feels like an endless fight": a qualitative study exploring healthcare utilization of persons with rheumatic conditions waiting for pain clinic admission.

BACKGROUND: Individuals living with a rheumatic pain condition can face delays in accessing pain clinics, which prevents them from receiving timely treatment. Little is known regarding their specific healthcare utilization in order to alleviate pain while waiting to obtain services in pain clinics. Hence, the aim of this study was to explore the perceptions and experiences of persons living with rheumatic conditions regarding healthcare utilization while waiting to access a pain clinic. METHODS: In this qualitative descriptive study, semi-structured interviews were conducted with adults living with a painful rheumatic condition that reported either being waiting for admission in a pain clinic, having been referred but then denied pain clinic services, or having received services during the previous six months, in the province of Quebec, Canada. The interviews were transcribed verbatim, and an inductive thematic analysis was performed. RESULTS: Twenty-six individuals were interviewed (22 women and 4 men; mean age 54 ± 10 years). Three themes were identified: 1) lacking guidance in identifying solutions to their complex and multidimensional needs, 2) struggling to obtain and maintain services due to systemic access barriers, and 3) displaying resilience through a search for accessible and sustainable self-management strategies. CONCLUSIONS: The current approaches and structures of health services fail to adequately answer the service needs of individuals experiencing painful rheumatic conditions. Important shifts are required in pain education, in increasing access to multidisciplinary approaches at the primary care level and in breaking down barriers individuals with chronic pain face to receive appropriate and timely care.

Evaluating a new referral pathway from physical therapists to rheumatologists: A qualitative study.

Early referral to rheumatology of people with suspected inflammatory arthritis is associated with better outcomes. Typically, these individuals are seen by a family physician who would assess the need for rheumatology referral. However, some may first consult a physical therapist where no physician referral is required. New interprofessional referral pathways, such as direct referral from a physical therapist to a rheumatologist, could enhance early access to a rheumatologist. Our objective was to explore perceptions of clinicians and people with inflammatory arthritis regarding physical therapists referring directly to rheumatologists. We used purposive and snowball sampling to recruit participants for five focus groups: rheumatologists, family physicians, physical therapists, people with inflammatory arthritis, and a mixed group of physical therapists and people with inflammatory arthritis. Thematic analysis revealed four core themes: difficulties accessing care, reluctance of family physicians and rheumatologists toward the new pathway, interprofessional relationships (or lack thereof), and opportunities along the referral pathway. The conclusions are that care must be optimized by ensuring swift referral for those who require it; and that there is a need for knowledge translation to all actors on the advantages of this new pathway.

Use of IMMPACT Recommendations to Explore Pain Phenotypes in People with Knee Osteoarthritis.

OBJECTIVE: Knee osteoarthritis (OA) is a disease of multiple phenotypes of which a chronic pain phenotype (PP) is known. Previous PP studies have focused on one domain of pain and included heterogenous variables. We sought to identify multidimensional PPs using the IMMPACT recommendations and their relationship to clinical outcomes. METHODS: Participants >40 years of age with knee OA having a first-time orthopedic consultation at five university affiliated hospitals in Montreal, Quebec, and Hamilton (Canada) were recruited. Latent profile analysis was used to determine PPs (classes) using variables recommended by IMMPACT. This included pain variability, intensity and qualities, somatization, anxiodepressive symptoms, sleep, fatigue, pain catastrophizing, neuropathic pain, and quantitative sensory tests. We used MANOVA and χ2 tests to assess differences in participant characteristics across the classes and linear and Poisson regression to evaluate the association of classes to outcomes of physical performance tests, self-reported function and provincial healthcare data. RESULTS: In total, 343 participants were included (mean age 64 years, 64% female). Three classes were identified with increasing pain burden (class3 > class1), characterized by significant differences across most self-report measures and temporal summation, and differed in terms of female sex, younger age, lower optimism and pain self-efficacy. Participants in class2 and class3 had significantly worse self-reported function, stair climb and 40 m walk tests, and higher rates of healthcare usage compared to those in class1. CONCLUSIONS: Three distinct PPs guided by IMMPACT recommendations were identified, predominated by self-report measures and temporal summation. Using this standardized approach may improve PP study variability and comparison.

Patient engagement partnerships in clinical trials (PEP-CT): protocol for the systematic development and testing of patient partner and investigator decision aids.

INTRODUCTION: Building capacity to improve sex/gender knowledge and strengthen patient engagement in clinical trials requires training and support. The overall goal of this 2-year project is to refine, translate and evaluate two web-based open-access patient and investigator decision aids aimed to improve patient engagement partnerships in clinical trials. METHODS AND ANALYSIS: Two decision aids were designed in Phase 1 of this programme of research and this protocol describes a subsequent sequential phased approach to refine/translate (Phase 2A) and conduct alpha/usability (Phase 2B) and beta/field (Phase 3) testing. Decision aid development is guided by the International Patient Decision Aid Standards, User-Centred Design, Ottawa Decision-Support Framework and the Ottawa Model of Research Use. We have integrated patient-oriented research methods by engaging patient partners across all phases of our programme of research. Decision aids will first be refined and then translated to French (Phase 2A). Eight iterative cycles of semistructured interviews with 40 participants (20 patient partners and 20 investigators) will be conducted to determine usability (Phase 2B). A pragmatic pre/post pilot study design will then be implemented for field/beta testing using another purposive sample of 80 English-speaking and French-speaking participants (40 patients and 40 investigators). The samples are purposive to ensure an equal representation of English-speaking and French-speaking participants and an equal representation of men and women. Since sex and/or gender differences in utilisation and effectiveness of decision aids have not been previously reported, Phase 3 outcomes will be reported for the total sample and separately for men and women. ETHICS AND DISSEMINATION: Ethics approval has been granted from the University of Toronto (41109, 28 September 2021). Informed consent will be obtained from participants. Dissemination will include co-authored publications, conference presentations, educational national public forums, fact sheets/newsletters, social media sharing and videos/webinars.

Strategies to reduce waiting times in outpatient rehabilitation services for adults with physical disabilities: A systematic literature review.

OBJECTIVE: Identifying effective strategies to reduce waiting times is a crucial issue in many areas of health services. Long waiting times for rehabilitation services have been associated with numerous adverse effects in people with disabilities. The main objective of this study was to conduct a systematic literature review to assess the effectiveness of service redesign strategies to reduce waiting times in outpatient rehabilitation services for adults with physical disabilities. METHODS: We conducted a systematic review, searching three databases (MEDLINE, CINAHL and EMBASE) from their inception until May 2021. We identified studies with comparative data evaluating the effect of rehabilitation services redesign strategies on reducing waiting times. The Mixed Methods Appraisal Tool was used to assess the methodological quality of the studies. A narrative synthesis was conducted. RESULTS: Nineteen articles including various settings and populations met the selection criteria. They covered physiotherapy (n = 11), occupational therapy (n = 2), prosthetics (n = 1), exercise physiology (n = 1) and multidisciplinary (n = 4) services. The methodological quality varied (n = 10 high quality, n = 6 medium, n = 3 low); common flaws being missing information on the pre-redesign setting and characteristics of the populations. Seven articles assessed access processes or referral management strategies (e.g. self-referral), four focused on extending/modifying the roles of service providers (e.g. to triage) and eight changed the model of care delivery (e.g. mode of intervention). The different redesign strategies had positive effects on waiting times in outpatient rehabilitation services. CONCLUSIONS: This review highlights the positive effects of many service redesign strategies. These findings suggest that there are several effective strategies to choose from to reduce waiting times and help better respond to the needs of persons experiencing physical disabilities.

Factors Associated with Intermittent, Constant, and Mixed Pain in People with Knee Osteoarthritis.

Purpose: To explore factors associated with intermittent, constant, and mixed pain in people with knee osteoarthritis. Method: We conducted a secondary analysis of a cross-sectional multicentre study with adults ≥ 40 years with knee osteoarthritis. Participants completed questionnaires on personal (e.g., demographics, comorbidities), physical (e.g., physical function), psychological (e.g., depressive symptoms), pain (e.g., qualities), and tests for physical performance and nervous system sensitivity. We qualified patients' pain as intermittent, constant, or mixed using the Modified painDETECT Questionnaire and assessed associations with the variables using multinomial logistic regression. Results: The 279 participants had an average age of 63.8 years (SD 9.6), BMI of 31.5 kg/m2 (SD 8.7), and 58.6% were female. Older age (odds ratio [OR] 0.95; 95% CI: 0.90, 1.00) and higher self-reported physical function (OR 0.94; 95% CI: 0.91, 0.98) were associated with a lower likelihood of mixed pain compared with intermittent pain. Higher pain intensity (OR 1.25; 95% CI: 1.07, 1.47) was related to a 25% higher likelihood of mixed pain compared with intermittent pain. Conclusions: This study provides initial data for associations of personal, pain, and physical function factors with different pain patterns. Awareness of these factors can help clinicians develop targeted strategies for managing patients' pain.

Objectif : explorer les facteurs associés à la douleur intermittente, constante et mixte chez les personnes atteintes d'arthrose du genou. Méthodologie : analyse secondaire d'une étude multicentrique transversale auprès d'adultes atteints d'arthrose du genou de 40 ans et plus. Les participants ont repris des questionnaires sur les aspects personnels (démographie, comorbidité), physiques (fonctionnement physique) et psychologiques (symptômes dépressifs) et sur la douleur (propriétés) et ils ont effectué des tests de performance physique et de sensibilité du système nerveux. Les chercheurs ont qualifié la douleur des patients d'intermittente, de constante ou de mixte, utilisé le questionnaire painDETECT modifié et évalué les associations avec les variables de régression logistique multinomiale. Résultats : les 279 participants avaient un âge moyen de 63,8 ans (ÉT 9,6), un indice de masse corporelle de 31,5 kg/m2 (ÉT 8,7), et 58,6 % étaient des femmes. Un âge plus avancé (rapport de cotes [RC] 0,95; IC à 95 % : 0,90, 1,00) et un fonctionnement physique autodéclaré plus élevé (RC 0,94; IC à 95 % : 0,91, 0,98) étaient liés à une plus faible probabilité de douleur mixte que de douleur intermittente. Une intensité de douleur plus marquée (RC 1,25; IC à 95 % : 1,07, 1,47) était liée à une probabilité 25 % fois plus élevée de douleur mixte que de douleur intermittente. Conclusions : la présente étude fournit des données initiales pour associer les facteurs personnels, les facteurs liés à la douleur et ceux liés au fonctionnement physique à divers profils de douleur. S'ils connaissent ces facteurs, les cliniciens seront mieux en mesure de préparer des stratégies ciblées pour prendre en charge la douleur du patient.

Single session compared with multiple sessions of education and exercise for older adults with spinal pain in an advanced practice physiotherapy model of care: protocol for a randomised controlled trial.

OBJECTIVES: To assess the effectiveness and cost-effectiveness of a single session compared with multiple sessions of education and exercise for older adults with spinal pain treated conservatively in an advanced practice physiotherapy model of care. METHODS AND ANALYSIS: In this pragmatic randomised controlled trial, 152 older adults (≥65 years old) with neck or back pain initially referred for a consultation in neurosurgery, but treated conservatively, will be recruited through the advanced practice physiotherapy neurosurgery CareAxis programme in the Montreal region (Quebec, Canada). In the CareAxis programme, older patients with spinal pain are triaged by an advance practice physiotherapist and are offered conservative care and only potential surgical candidates are referred to a neurosurgeon. Participants will be randomised into one of two arms: 1-a single session or 2-multiple sessions (6 sessions over 12 weeks) of education and exercise with the advance practice physiotherapist (1:1 ratio). The primary outcome measure will be the Brief Pain Inventory (pain severity and interference subscales). Secondary measures will include self-reported disability (the Neck Disability Index or Oswestry Disability Index), the Pain Catastrophizing Scale, satisfaction with care questionnaires (9-item Visit-specific Satisfaction Questionnaire and MedRisk), and the EQ-5D-5L. Participants' healthcare resources use and related costs will be measured. Outcomes will be collected at baseline and at 6, 12 and 26 weeks after enrolment. Intention-to-treat analyses will be performed, and repeated mixed-model analysis of variance will assess differences between treatment arms. Cost-utility analyses will be conducted from the perspective of the healthcare system. ETHICS AND DISSEMINATION: Ethics approval has been obtained from the Comité d'éthique de la recherche du CIUSS de l'Est-de-l'Île-de-Montréal (FWA00001935 and IRB00002087). Results of this study will be presented to different stakeholders, published in peer-reviewed journals and presented at international conferences. PROTOCOL VERSION: V.4 August 2021. TRIAL REGISTRATION NUMBER: NCT04868591; Pre-results.

Scoping Review of Pain and Patient Characteristics and Physical Function Associated with Intermittent and Constant Pain in People with Knee Osteoarthritis.

Purpose: We identified the pain and patient characteristics and physical function associated with intermittent and constant pain in people with knee osteoarthritis (OA). Method: The search strategy was conducted in MEDLINE, CINAHL, Embase, SPORTDiscus, Cochrane, and the Physiotherapy Evidence Database for articles published up to October 2018. We included observational studies, randomized controlled trials, reviews, qualitative studies, and case reports in English and French of adults with knee OA. Articles were screened by two independent reviewers, and disagreements were resolved by a third researcher. Results: Our search yielded 1,232 articles, and 4 articles were included in the review. Constant pain was related to limitations in daily activities, a higher Kellgren and Lawrence grade, a higher prevalence of comorbidities, and symptomatic knee OA and depressive symptoms. Intermittent pain was associated with limitations in high-impact activities, but greater time spent in moderate activities was reported. The evidence is contradictory as to whether intermittent or constant pain has a greater average severity. Conclusions: There was limited evidence available to determine the association of pain and patient characteristics and physical function with constant and intermittent pain in people with knee OA. Future research will help improve our understanding of these two pain patterns by examining their associations across a variety of pain and functional outcomes in people with knee OA.

Objectif : déterminer les caratéristique de la douleur et des patients ainsi que la fonction physique associées à une douleur intermittente et constante chez les personnes atteintes d'arthrose du genou. Méthodologie : les chercheurs ont fouillé les bases de données MEDLINE, CINAHL, Embase, SPORTDiscus, Cochrane et Physiotherapy Evidence Database jusqu'en octobre 2018. Ils ont inclus des études d'observation, des essais aléatoires et contrôlés, des analyses, des études qualitatives et des rapports de cas d'adultes atteints d'arthrose du genou, en anglais et en français. Deux réviseurs indépendants ont parcouru les articles et un troisième chercheur a résolu les désaccords. Résultats : la recherche a permis d'extraire 1 232 articles, dont quatre ont été retenus. La douleur chronique suscitait des limitations aux activités quotidiennes, un score de Kellgren et Lawrence plus élevé, une prévalence de morbidité plus élevée, une arthrose du genou symptomatique et des symptômes de dépression. La douleur intermittente était liée à des limitations lors d'activités à fort impact, mais à plus de temps consacré aux activités modérées. Les données sont contradictoires quant à la gravité moyenne accrue de la douleur constante ou intermittente. Conclusions : les données probantes sont limitées pour déterminer l'association entre, d'une part, les caractéristiques la douleur et des patients et la fonction physique et, d'autre part, les douleurs constantes et intermittentes causées par l'arthrose du genou. Pour mieux comprendre ces deux profils de douleur, de prochaines recherches porteront sur leur association avec divers résultats cliniques sur le plan de la douleur et de la fonction chez les personnes atteintes d'arthrose du genou.

Specialty Differences in Initial Evaluation of Patients With Non-Acute Musculoskeletal Pain.

PURPOSE: To explore medical diagnostic testing of new cases of musculoskeletal (MSK) conditions associated with chronic pain. METHODS: We analyzed nationally representative cross-sectional data of people having visits with a new likely chronic MSK pain condition. We documented depression screening and prescribing of diagnostic imaging and blood tests and explored associations between patient and provider factors for each. RESULTS: Over the 9 years of the survey, there were 11,994 initial visits for chronic MSK pain, an average of 36.8 million weighted visits per year or approximately 11.8% of the population. Proportions for depression screening, prescribed imaging, and blood tests were 1.79%, 36.34%, and 9.70%, respectively. People on any public health insurance had twice the increased relative odds to be screened for depression. Orthopedists had 3 times increased relative odds to prescribe imaging compared with family physicians; oncologists had 4 times increased relative odds to prescribe blood tests. Survey year was significantly associated with depression screening and ordering any type of imaging. CONCLUSIONS: Observed rates of depression screening and nonindicated imaging for patients with chronic MSK pain have fluctuated over time. The impact of these fluctuations on clinical practice is as yet unknown. The type of nonrecommended actions varied by specialty of physician.

The burden of waiting to access pain clinic services: perceptions and experiences of patients with rheumatic conditions.

BACKGROUND: Extensive waiting times before receiving services is a major barrier to adequate pain management. Waiting times may have a detrimental impact on patients' conditions and quality of life. However, there remains a lack of knowledge on the actual experiences of patients waiting to receive services, especially for those with rheumatic conditions. The present study aimed to gain an in-depth understanding of perceptions and experiences of patients with rheumatic conditions regarding access to pain clinic services. The secondary objective was to identify possible solutions to improve this access according to patients' perspectives. METHODS: This qualitative study based on semi-structured interviews was conducted with adults with rheumatic conditions waiting to access pain clinics in the province of Quebec, Canada. Interviews were transcribed verbatim and analyzed using thematic content analysis. RESULTS: Twenty-six participants were interviewed (22 women and 4 men; mean age 54 ± 10 years). Four main themes were identified: 1) the perception that waiting time is unacceptably long; 2) how the lack of information affects patients' experiences of waiting; 3) patients' various expectations towards the pain clinic, from high hopes to disillusionment and 4) carrying an emotional, physical and financial burden resulting from the wait. Participants reported several solutions to improve the experience of waiting, including providing information to patients, increasing resources, improving prioritization processes and care coordination, and providing alternative interventions to patients during the wait. CONCLUSIONS: For patients with rheumatic conditions, access to pain clinic services is challenging due to extensive waiting times. The burden it imposes on them adds to the existing challenge of living with a chronic rheumatic condition. The solutions identified by participants could serve as building blocks to develop and implement measures to improve patients' experience of accessing pain-related services.

National Estimates of Chronic Musculoskeletal Pain and Its Treatment in Children, Adolescents, and Young Adults in the United States: Data From the 2007-2015 National Ambulatory Medical Care Survey.

OBJECTIVES: To portray physician office visits by young Americans with chronic musculoskeletal pain; to describe clinical management in this group; and to explore factors associated with prescribed treatments. STUDY DESIGN: Using nationally representative data of ambulatory physician office visits (2007-2015 United States National Ambulatory Medical Care Survey), we identified and cross-sectionally analyzed visits by persons <25 years of age diagnosed with a chronic musculoskeletal pain condition. RESULTS: There were 28.6 million visits over the 9-year period for chronic musculoskeletal pain for persons <25 years of age, (average 3.2 million visits/year). There were more visits among older age groups, female persons, non-Hispanic White ethnicity/race, and those with more medical visits in the past year. Nonopioid medications were the most frequent treatments in all age groups (range 38.5%-48.8%). Opioids were rarely prescribed for children and adolescents but were prescribed in 23% of visits among young adults (18-24 years of age). Health education and counseling were consistently prescribed at 20% of visits and physical therapy (range 9.5%-23.7%) and other treatments were less frequently prescribed. Age, sex, payment source, and physician specialty were associated with various treatments. CONCLUSION: There were over 3 million annual visits for chronic musculoskeletal pain in young Americans; these increased with age. Pharmacologic treatment is used more than nonpharmacologic approaches, and opioid prescribing in the 18- to 24-year-old age group approaches estimates in adults with musculoskeletal pain.