Consensus-based recommendations on communication and education regarding primary care physical therapy for patients with systemic sclerosis.

OBJECTIVE: This study aimed to develop recommendations for communication and postgraduate education regarding primary care physical therapy for systemic sclerosis (SSc) patients. METHODS: A virtual Nominal Group Technique was used with tasks forces for communication (n = 18) and education (n = 21). Both included rheumatologists, physical therapists (PTs) in primary, secondary or tertiary care, rheumatology nurses, advanced nurse practictioners and patient representatives. Three online meetings were organised for each task force to discuss (1) current bottlenecks; (2) potential solutions; and (3) the resulting draft recommendations. After the final adjustments, participants rated their level of agreement with each recommendation on a scale from 0 (not at all agree) to 100 (totally agree), using an online questionnaire. RESULTS: 19 and 34 recommendations were formulated for communication and education, respectively. For communication the main recommendations concerned the provision of an overview of primary care physical therapists with expertise in rheumatic and musculoskeletal diseases to patients and rheumatologists, the inclusion of the indication by the rheumatologist in the referral to the physical therapist and low-threshold communication with the rheumatologist in case of questions or concerns of the physical therapist. For postgraduate education three types of "on demand" educational offerings were recommended with varying levels of content and duration, to match the competencies and preferences of individual primary care physical therapists. CONCLUSION: Using a systematic qualitative approach, two multi-stakeholder task forces developed practical recommendations for primary care physical therapists' communication with hospital-based care providers and postgraduate education regarding the treatment of SSc patients.

Stratified exercise therapy compared with usual care by physical therapists in patients with knee osteoarthritis: A randomized controlled trial protocol (OCTOPuS study).

OBJECTIVES: Knee osteoarthritis (OA) is characterized by its heterogeneity, with large differences in clinical characteristics between patients. Therefore, a stratified approach to exercise therapy, whereby patients are allocated to homogeneous subgroups and receive a stratified, subgroup-specific intervention, can be expected to optimize current clinical effects. Recently, we developed and pilot tested a model of stratified exercise therapy based on clinically relevant subgroups of knee OA patients that we previously identified. Based on the promising results, it is timely to evaluate the (cost-)effectiveness of stratified exercise therapy compared with usual, "nonstratified" exercise therapy. METHODS: A pragmatic cluster randomized controlled trial including economic and process evaluation, comparing stratified exercise therapy with usual care by physical therapists (PTs) in primary care, in a total of 408 patients with clinically diagnosed knee OA. Eligible physical therapy practices are randomized in a 1:2 ratio to provide the experimental (in 204 patients) or control intervention (in 204 patients), respectively. The experimental intervention is a model of stratified exercise therapy consisting of (a) a stratification algorithm that allocates patients to a "high muscle strength subgroup," "low muscle strength subgroup," or "obesity subgroup" and (b) subgroup-specific, protocolized exercise therapy (with an additional dietary intervention from a dietician for the obesity subgroup only). The control intervention will be usual best practice by PTs (i.e., nonstratified exercise therapy). Our primary outcome measures are knee pain severity (Numeric Rating Scale) and physical functioning (Knee Injury and Osteoarthritis Outcome Score subscale daily living). Measurements will be performed at baseline, 3-month (primary endpoint), 6-month (questionnaires only), and 12-month follow-up, with an additional cost questionnaire at 9 months. Intention-to-treat, multilevel, regression analysis comparing stratified versus usual care will be performed. CONCLUSION: This study will demonstrate whether stratified care provided by primary care PTs is effective and cost-effective compared with usual best practice from PTs.

Proprioception, laxity, muscle strength and activity limitations in early symptomatic knee osteoarthritis: results from the CHECK cohort.

OBJECTIVE: To establish whether proprioception and varus-valgus laxity moderate the association between muscle strength and activity limitations in patients with early symptomatic knee osteoarthritis. DESIGN: A cross-sectional study. SUBJECTS: A sample of 151 participants with early symptomatic knee osteoarthritis from the Cohort Hip and Cohort Knee study. METHODS: Regression analyses were performed to establish the associations between muscle strength, proprioception (knee joint motion detection threshold in the anterior--posterior direction), varus-valgus laxity and activity limitations (self-reported and performance-based). Interaction terms were used to establish whether proprioception and laxity moderated the association between muscle strength and activity limitations. RESULTS: Proprioception moderated the association between muscle strength and activity limitations: the negative association between muscle strength and activity limitations was stronger in participants with poor proprioception than in participants with accurate proprioception (performance-based activity limitations p = 0.02; self-reported activity limitations p = 0.08). The interaction between muscle strength and varus-valgus laxity was not significantly associated with activity limitations. CONCLUSION: The results of the present study support the theory that in the absence of adequate proprioceptive input, lower muscle strength affects a patient's level of activities to a greater degree than in the presence of adequate proprioceptive input.

Avoidance of activities in early symptomatic knee osteoarthritis: results from the CHECK cohort.

BACKGROUND: Pain-related avoidance of activities is hypothesized to lead to lower muscle strength and thereby activity limitations. Negative affect (e.g., low vitality, depression) is thought to strengthen the tendency to avoid activities. PURPOSE: The aim of this study was to assess the validity of this "avoidance model" in patients with early symptomatic knee osteoarthritis (OA). METHODS: Cross-sectional data (n=151) were used. The associations between pain, negative affect, avoidance, muscle strength, and activity limitations were modeled using structural equation modeling. RESULTS: Pain and negative affect were associated with lower muscle strength via avoidance (mediation by avoidance). Avoidance was associated with activity limitations via lower muscle strength (mediation by muscle strength). There were also direct associations between pain, negative affect, avoidance, muscle strength, and activity limitations. CONCLUSIONS: The results support the validity of the avoidance model, which explains the associations between pain, negative affect, avoidance, muscle strength, and activity limitations in patients with early symptomatic knee OA.

Interobserver reliability of the Amsterdam Severity Scale in Stenosing Tenosynovitis (ASSiST).

STUDY DESIGN: Interobserver reliability study. INTRODUCTION: A scale was developed to measure the severity of stenosing tenosynovitis: the Amsterdam Severity Scale in Stenosing Tenosynovitis (ASSiST). PURPOSE OF THE STUDY: To study the interobserver reliability of the ASSiST. METHODS: Patients suffering from various impairments in hand function were referred to our outpatient hand clinic. The grading of stenosing tenosynovitis was assessed independently. The observers were blinded for each other's results. The ASSiST distinguishes between a nodular and a diffuse form. The severity was graded from grades 0 to 3. RESULTS: Kappa coefficient for the distinction between the four grades was 0.72 (95% confidence interval [CI] 0.59-0.85) and for the distinction between the nodular and the diffuse forms 0.16 (95% CI 0.13-0.18). CONCLUSION: The ASSiST can be used to reliably assess the severity of stenosing tenosynovitis in both nodular and diffuse forms, but it does not differentiate between these two forms. LEVEL OF EVIDENCE: Not applicable.

Adherence and satisfaction of rheumatoid arthritis patients with a long-term intensive dynamic exercise program (RAPIT program).

OBJECTIVE: To evaluate adherence and satisfaction of patients with rheumatoid arthritis (RA) in a long-term intensive dynamic exercise program. METHODS: A total of 146 RA patients started an intensive (strength and endurance training for 75 minutes, twice a week, for 2 years) exercise program (Rheumatoid Arthritis Patients In Training) aimed at improving physical fitness. Program attendance and satisfaction were examined. Additional assessments at baseline were done to find possible predictors of attendance. RESULTS: Median (interquartile range) age and disease duration of the patients were 54 (45-61) and 5 (3-10) years, respectively. After 2 years, 118 (81%) patients still participated in an exercise class. The median attendance rate of all patients was 74%. Low attendance was weakly associated with high disease activity, low functional ability, and low quality of life at baseline but not with the severity of joint damage at baseline. At the end, 78% of all participants would (strongly) recommend the program to other RA patients. CONCLUSION: Adherence and satisfaction of RA patients with an intensive dynamic exercise program over a prolonged time can be high. Disease severity parameters do not strongly predict the compliance of participants in an intensive exercise program.