Evidence-based development of a post-surgical lumbar discectomy leaflet intervention: a Delphi consensus study.

OBJECTIVE: To produce free, expert-informed postoperative information for lumbar discectomy patients, satisfying UK National Health Service Information Standards. DESIGN: A mixed methods approach utilising the Delphi technique and focus groups. SETTING: Five spinal centres across the UK. PARTICIPANTS: Panel members included 23 physiotherapists, 11 patients and 17 spinal surgeons. INTERVENTION: Three rounds of questionnaires including open and closed questions and attendance at a clinician/patient focus group. RESULTS: Response rates of 85%, 26% and 35% were achieved for the Delphi rounds. Ten clinicians and six patients participated in the focus groups. Consensus for leaflet sections was achieved in round 1 and content in round 3. The focus groups informed further revisions. CONCLUSIONS: A consensually agreed, Information Standard compliant, patient lumbar discectomy leaflet was produced containing: (1) normal spine anatomy; (2) anatomy disc herniation and surgery; (3) back protection strategies and (4) frequently asked questions. Illustrations of exercises enable tailoring to the individual patient.

Attentional focus of feedback for improving performance of reach-to-grasp after stroke: a randomised crossover study.

OBJECTIVE: To investigate whether feedback inducing an external focus (EF) of attention (about movement effects) was more effective for retraining reach-to-grasp after stroke compared with feedback inducing an internal focus (IF) of attention (about body movement). It was predicted that inducing an EF of attention would be more beneficial to motor performance. DESIGN: Crossover trial where participants were assigned at random to two feedback order groups: IF followed by EF or EF followed by IF. SETTING: Research laboratory. PARTICIPANTS: Forty-two people with upper limb impairment after stroke. INTERVENTION: Participants performed three reaching tasks: (A) reaching to grasp a jar; (B) placing a jar forwards on to a table; and (C) placing a jar on to a shelf. Ninety-six reaches were performed in total over one training session. MAIN OUTCOME MEASURES: Kinematic measures were collected using motion analysis. Primary outcome measures were movement duration, peak velocity of the wrist, size of peak aperture and peak elbow extension. RESULTS: Feedback inducing an EF of attention produced shorter movement durations {first feedback order group: IF mean 2.53 seconds [standard deviation (SD) 1.85]; EF mean 2.12 seconds (SD 1.63), mean difference 0.41 seconds; 95% confidence interval -0.68 to 1.5; P=0.008}, an increased percentage time to peak deceleration (P=0.01) when performing Task B, and an increased percentage time to peak velocity (P=0.039) when performing Task A compared with feedback inducing an IF of attention. However, an order effect was present whereby performance was improved if an EF of attention was preceded by an IF of attention. CONCLUSIONS: Feedback inducing an EF of attention may be of some benefit for improving motor performance of reaching in people with stroke in the short term; however, these results should be interpreted with caution. Further research using a randomised design is recommended to enable effects on motor learning to be assessed.

Selecting outcome measures in sports medicine: a guide for practitioners using the example of anterior cruciate ligament rehabilitation.

Using examples from the field of anterior cruciate ligament rehabilitation, this review provides sports and health practitioners with a comprehensive, user-friendly, guide to selecting outcome measures for use with active populations. A series of questions are presented for consideration when selecting a measure: is the measure appropriate for the intended use? (appropriateness); is the measure acceptable to patients? (acceptability); is it feasible to use the measure? (feasibility); does the measure provide meaningful results? (interpretability); does the measure provide reproducible values? (reliability); does the measure assess what it is supposed to assess? (validity); can the measure detect change? (responsiveness); do substantial proportions of patients achieve the worst or best scores? (floor and ceiling effects); is the measure structured and scored correctly? (dimensionality and internal consistency); has the measure been tested with the types of patients with whom it will be used? (sample characteristics). Evaluation of the measure using these questions will assist practitioners in making their judgements.

A 12-month follow-up study of self-management training for people with chronic disease: are changes maintained over time?

OBJECTIVE: A previous study reported some improved outcomes at 4-month follow-up after attendance on a lay-led, chronic disease self-management course (CDSMC). The purpose of this study was to determine whether changes were maintained over time (i.e. at 12 months) and to describe participants' current use of self-management techniques. DESIGN: The study was a 12-month follow-up of a sample of 171 participants who attended a CDSMC in the UK. METHOD: Data were collected by self-administered questionnaires mailed to participants 12 months after they commenced a CDSMC and via telephone interviews with a sub-sample. RESULTS: The sample had a mean age of 54 years, mean disease duration of 16 years, 73% were women, and chronic diseases included endometriosis, depression, diabetes, myalgic encephalomyelitis, osteoporosis and polio. The significant improvements in outcomes identified at 4 months (i.e. cognitive symptom management, self-efficacy, communication with physician, fatigue, anxious and depressed moods and health distress) were sustained at 12 months. No significant changes between 4- and 12-month assessments were found on any study variables. Interview data confirmed that participants continued to use some of the self-management techniques learned on the course. CONCLUSION: Attendance on the CDSMC may lead to longer-term changes in key outcomes such as self-efficacy, use of some self-management behaviours and some aspects of health status (e.g. fatigue, depressed mood).

Being a parent or grandparent with back pain, ankylosing spondylitis or rheumatoid arthritis: a descriptive postal survey.

Research that explores being a parent or grandparent with musculoskeletal problems has been fairly limited to date. The aim of this study was to describe the experience of parenting in the context of back pain (BP), ankylosing spondylitis (AS) and rheumatoid arthritis (RA), with a particular focus on the extent and nature of childcare experiences and to compare these experiences across the three groups. In addition, the possible reasons for these reported experiences, the availability of advice and support and the development of strategies for coping were explored using a cross-sectional descriptive survey. A total of 448 participants was recruited from relevant charitable organizations and the National Health Service (280 with BP, 106 with AS and 62 with RA). A combination of opportunistic and random sampling was used. Quantitative data were analysed with appropriate descriptive and inferential statistics using Statistical Package for the Social Sciences (SPSS version 10). Qualitative data were analysed using content analysis. Results indicate that a high proportion of all groups experienced a wide range of difficulties with parenting (81% BP, 77% AS, 97% RA). The most prevalent problems were similar for all three groups: lifting baby/child from the floor or cot, encouraging children/grandchildren to help with domestic chores and keeping up (in terms of energy) with children/grandchildren. However, the RA group reported having greater difficulties than the other two groups. Very little advice was offered to participants with parenting difficulties which may indicate a gap in service provision. However, a wide range of strategies for coping were described by respondents. The study highlighted a need for healthcare professionals to develop a greater awareness of parenting issues and to provide opportunities for these issues to be addressed.

Self-management training for people with chronic disease: an exploratory study.

OBJECTIVE: To determine the effectiveness of a community-based Chronic Disease Self-management Course (CDC) for UK participants with a range of chronic diseases. DESIGN: The study was a multiple baseline, pre-test post test design with a sample of 185 participants who attended a CDC delivered in community settings by lay tutors, in the UK. METHOD: Data were collected by self-completed questionnaires before attendance and at four-month follow-up. RESULTS: The sample comprised 72% women (mean age = 53 years, mean disease duration = 16 years). The main chronic diseases included endometriosis, depression, diabetes, myalgic encephalomyelitis, osteoporosis and polio. Adjusting for baseline values and gender, small to moderate increases were found on cognitive symptom management, self-efficacy (disease and symptoms) and communication with physician. A similar sized decrease was found on fatigue, and small decreases were evident on anxious and depressed moods, and health distress. There were no changes in the use of health care resources, or on self-reported exercise behaviour. CONCLUSION: The results of this exploratory study suggest that self-management training for people with chronic diseases can offer benefits in terms of enhanced self-efficacy, greater use of cognitive behavioural techniques, and improvement in some aspects of physical and psychological well-being.

Development of job-seeking ability in people with arthritis: evaluation of a pilot program.

Working Horizons is an intervention designed to prevent work disability by addressing the internal and external barriers faced by people with arthritis in their attempts to enter or maintain their positions in the employment arena. The aim of the pilot study was to determine whether Working Horizons influenced participants' self-efficacy and psychological well-being and to describe the experience of Working Horizons from the perspectives of participants and employment advisors (EAs). The study was a pre-test post-test design with an Intervention Group (n = 22) and Comparison Control Group (n = 22). Quantitative data were collected by self-completed questionnaires at baseline and at six-months follow-up. Qualitative data were collected via open questions on the questionnaires, interviews with a sub-sample of 10 participants, and a focus group with EAs at the end of the programme. Pilot data suggested that Working Horizons was effective in terms of increasing participants' job-seeking self-efficacy. In addition, the Intervention Group showed significant improvements on self-esteem and satisfaction with life. Qualitative findings confirmed that participants felt more 'confident' in relation to seeking employment, were more accepting of their condition, felt more positive and had greater awareness of the social model of disability. Participants valued the emotional and instrumental support provided by the EAs, who acted as successful 'work' role models. Interventions, such as Working Horizons, may be an effective means of addressing work disability, acting as a gateway to statutory services. The value of suitable role models in mentoring capacities was highlighted.

Reproducibility and repeatability: errors of three groups of physiotherapists in locating spinal levels by palpation.

Location of spinal levels by palpation is an essential part of physiotherapy assessment and treatment of spinal musculoskeletal conditions. This study aimed to (i) investigate the reproducibility and repeatability of three groups of physiotherapists in locating three randomly selected spinal levels by palpation, (ii) explore whether these groups were palpating similar points at each level, and (iii) investigate whether there were differences in palpation across the spinal levels tested. Reproducibility was estimated using a convenience sample of 30 physiotherapists: 13 undergraduate students, 10 clinicians, and seven manual therapists (MTs). Repeatability was investigated using six physiotherapists (two students, two clinicians and two MTs). Each therapist palpated the spinous processes (C5, T6, L5) once for reproducibility, and 10 times for repeatability, on each asymptomatic model. The skin overlying the spinal levels was marked with an invisible pen. Using an ultra-violet light, marks were transcribed onto transparent plastic strips for analysis, and the distances were measured with an electronic caliper. Repeated measures analyses of variance (ANOVA) indicated poor reproducibility across therapists at all spinal levels (F=18.43, P=0.001), but good repeatability within therapists (F=2.09, P=0.161). Students produced different mean locations of their palpatory marks from the other two groups in two spinal levels. Clinicians and MTs were more reproducible than students, and located similar levels. Palpation of L5 spinous process presented the most difficulty, for all groups. Further research is needed to compare different methods of palpation and explore whether reproducibility can be improved.

Intention-to-treat approach to data from randomized controlled trials: a sensitivity analysis.

The intention-to-treat (ITT) approach to randomized controlled trials analyzes data on the basis of treatment assignment, not treatment receipt. Alternative approaches make comparisons according to the treatment received at the end of the trial (as-treated analysis) or using only subjects who did not deviate from the assigned treatment (adherers-only analysis). Using a sensitivity analysis on data for a hypothetical trial, we compare these different analytical approaches in the context of two common protocol deviations: loss to follow-up and switching across treatments. In each case, two rates of deviation are considered: 10% and 30%. The analysis shows that biased estimates of effect may occur when deviation is nonrandom, when a large percentage of participants switch treatments or are lost to follow-up, and when the method of estimating missing values accounts inadequately for the process causing loss to follow-up. In general, ITT analysis attenuates between-group effects. Trialists should use sensitivity analyses on their data and should compare the characteristics of participants who do and those who do not deviate from the trial protocol. The ITT approach is not a remedy for unsound design, and imputation of missing values is not a substitute for complete, good quality data.

Associations between water-treatment methods and diarrhoea in HIV-positive individuals.

This manuscript extends our previously published work (based on data from one clinic) on the association between three drinking water-treatment modalities (boiling, filtering, and bottling) and diarrhoeal disease in HIV-positive persons by incorporating data from two additional clinics collected in the following year. We conducted a cross-sectional survey of drinking water patterns, medication usage, and episodes of diarrhoea among HIV-positive persons attending clinics associated with the San Francisco Community Consortium. We present combined results from our previously published work in one clinic (n = 226) with data from these two additional clinics (n = 458). In this combined analysis we employed logistic regression and marginal structural modelling of the data. The relative risk of diarrhoea for 'always' vs. 'never' drinking boiled water was 0.68 (95% CI 0.45-1.04) and for 'always' vs. 'never' drinking bottled water was 1.22 (95 % CI 0.82-1.82). Drinking filtered water was unrelated to diarrhoea (1.03 (95% CI 0.78, 1.35) for 'always' vs. 'never' drinking filtered water]. Adjustment for confounding did not have any notable effect on the point estimates (0.61, 1.35 and 0.98 for boiled, bottled, and filtered water respectively, as defined above). The risk of diarrhoea was lower among those consuming boiled water but this finding was not statistically significant. Because of these findings, the importance of diarrhoea in immunocompromised individuals, and the limitations of cross-sectional data further prospective investigations of water consumption and diarrhoea among HIV-positive individuals are needed.

Risk factors in HIV-associated diarrhoeal disease: the role of drinking water, medication and immune status.

In a cross-sectional survey of 226 HIV-infected men, we examined the occurrence of diarrhoea and its relationship to drinking water consumption patterns, risk behaviours, immune status and medication use. Diarrhoea was reported by 47% of the respondents. Neither drinking boiled nor filtered water was significantly associated with diarrhoea (OR = 0.5 [0.2, 1.6], 1.2 [0.6, 2.5] respectively), whereas those that drank bottled water were at risk for diarrhoea (OR = 3.0 [1.1, 7.8]). Overall, 47% always or often used at least one water treatment. Of the 37% who were very concerned about drinking water, 62% had diarrhoea, 70% always or often used at least one water treatment. An increase in CD4 count was protective only for those with a low risk of diarrhoea associated with medication (OR = 0.6 [0.5, 0.9]). A 30% attributable risk to diarrhoea was estimated for those with high medication risk compared to those with low medication risk. The significant association between concern with drinking water and diarrhoea as well as between concern with drinking water and water treatment suggests awareness that drinking water is a potential transmission pathway for diarrhoeal disease. At the same time we found that a significant portion of diarrhoea was associated with other sources not related to drinking water such as medication usage.

Work disability among people with ankylosing spondylitis.

OBJECTIVE: To investigate work disability among people with ankylosing spondylitis (AS) in terms of correlates and coping mechanisms. METHODS: The sample group (n = 133) was recruited through 2 sources: 1) consecutive patients attending outpatient clinics over a 6-month period, and 2) a random sample of members of the National Ankylosing Spondylitis Society. We used a cross-sectional survey with data collected by self-administered questionnaires and telephone interviews with a randomly selected subsample (n = 6). RESULTS: The majority of participants were men. The mean age was 49 years; the mean disease duration was 28 years. Thirty-one percent were unable to work because of AS, with an additional 15% reporting changes to their working lives attributable to AS (e.g., reduction in hours worked, change of job). Compared with being in full-time work, work disability was associated with being older, longer disease duration, lower educational standard, comorbidity, greater physical impairment, pain, fatigue, stiffness, anxious and depressed mood, and lower self-esteem. Descriptive data added further insight into the experience of work disability and coping with AS in a work environment. CONCLUSION: Work disability is worthy of further investigation to determine exact prevalence rates and psychosocial implications. Work disability could be addressed with simple interventions or adaptations in the workplace.

Evaluating the health significance of hazardous air pollutants using monitoring data.

OBJECTIVE: Though many contaminants are released into the atmosphere, in the US only six air pollutants-ozone, particulate matter, sulfur dioxide, carbon monoxide, nitrogen dioxide, and lead-are closely monitored and carefully assessed for health significance. Other pollutants, even if highly toxic, are neither widely monitored nor routinely assessed at the national level. The goal of this study was to analyze the availability of information needed to characterize the health significance of hazardous air pollutants, focusing on urban areas in California. METHODS: The authors compared different approaches to identifying which contaminants should be considered hazardous air pollutants of potential health concern; reviewed the availability of toxicity values for these pollutants; and analyzed the usefulness of air monitoring data from California agencies for determining populations risks, by comparing method detection limits with health benchmarks. RESULTS: Approaches to identifying air contaminants of possible health concern differ. Toxicity values are not available for many hazardous air pollutants, including those identified in the Clean Air Act. In California, monitoring data are available for many, though not all, pollutants of concern. Monitoring methods for several pollutants do not have adequate sensitivity to detect all relevant concentrations. CONCLUSION: The information necessary to fully assess the health significance of hazardous air pollutants is not currently available.

Patient education for people with arthritis in rural communities: the UK experience.

Research literature, based largely on studies conducted in the USA and Australia, suggests that rural and urban residents differ on health status variables. This assumption was examined in an exploratory study conducted in the UK. The experience of arthritis in rural communities was explored through interviews and comparisons were made between rural and urban participants attending an educational intervention designed to improve self-management ability. Results showed that rural residents valued their independence and the sense of community spirit. Contrary to expectations, urban rather than rural residents showed greater psychological distress. However, the effectiveness of the educational intervention was found to be independent of location; both urban and rural dwellers appeared to derive similar benefits.

Development and preliminary validation of a children's arthritis self-efficacy scale.

OBJECTIVE: To develop a valid and reliable measure of arthritis self-efficacy for use with school-age children with juvenile idiopathic arthritis (JIA). METHODS: Construction of the 11-item Children's Arthritis Self-Efficacy Scale (CASE) was based on an existing body of knowledge and the results of focus groups with children, their parents, and health professionals. Data for validation of the CASE were collected by self-administered questionnaires completed by 89 children and 151 caregivers. RESULTS: Analyses revealed a 3-factor structure relating to self-efficacy for managing symptoms, emotional consequences, and activities, explaining 76.5% of the total variance. The CASE demonstrated high internal consistency, concurrent validity, and construct validity. CONCLUSION: Preliminary findings suggest that the CASE is worthy of further psychometric testing and may have the potential to help delineate variations in adjustment among children with JIA.

Psychometric properties of the Rosenberg Self-esteem Scale among people with arthritis.

After 30 years of use the factor structure of the Rosenberg Self-esteem Scale remains the subject of debate. Most studies have focused on school-aged or undergraduate students. There are few psychometric data for older people or for those with disabilities. This study compared the factor structures of the Rosenberg Self-esteem Scale among 117 adults with arthritis and 185 undergraduate students. A two-factor solution provided the best fit for both samples, although the item content of the factors differed slightly. Further investigation is required to assess whether the difference is due to age or the presence of physical disability. Nonetheless, the scale discriminated well between students and adults with arthritis.

A randomized controlled study of the Arthritis Self-Management Programme in the UK.

The objective of this study was to determine whether the Arthritis Self-Management Programme (ASMP) improves perceptions of control, health behaviours and health status, and changes use of health care resources. The design was a pragmatic randomized controlled study; participants were allocated to ASMP (Intervention Group) or a 4-month waiting-list Control Group. The Intervention Group completed a 12-month follow-up. In total, 544 people with arthritis were recruited from the community--311 in the Intervention Group and 233 in the Control Group. Main outcome measures included: arthritis self-efficacy, health behaviours (exercise, cognitive symptom management, diet and relaxation) and health status (pain, fatigue, anxiety, depression and positive affect). At 4 months follow-up, the ASMP had a significant effect on arthritis self-efficacy for other symptoms and pain subscales. Performance of a range of health behaviours (cognitive symptom management, communication with physicians, dietary habit, exercise and relaxation) was significantly greater among the Intervention Group. The Intervention Group were significantly less depressed and had greater positive mood. In addition, trends towards decreases on fatigue and anxiety were noted. Physical functioning, pain and GP visits remained stable at 4 months. A similar pattern of findings was found at 12 months follow-up for the Intervention Group. Furthermore, a significant improvement was found on pain and visits to GPs had decreased. Apart from a small improvement on physical functioning among the Intervention Group participants with osteoarthritis 12 months, all effects were independent of the type of arthritis. The findings suggest that the ASMP is effective in promoting improvements in perception of control, health behaviours and health status, when delivered in UK settings.

Development and preliminary validation of a self-efficacy measure for use among parents of children with juvenile idiopathic arthritis.

OBJECTIVE: To develop a valid and reliable measure to assess parents' perceived ability to control, or manage, aspects of their children's juvenile idiopathic arthritis (JIA). METHODS: Construction of the Parent's Arthritis Self-Efficacy Scale (PASE) was based on existing knowledge and the results of focus groups with parents of children with JIA, children with JIA, and health professionals. Data for validation of the PASE were collected by self-administered questionnaires completed by 178 parents and 89 children with JIA. RESULTS: Analyses revealed a 2-factor structure for both mothers and fathers. These factors related to parents' self-efficacy for managing children's arthritis-related symptoms and psychosocial health. Taken together, the two factors explained 75.5% and 65.8% of the total variance (mothers' and fathers,' respectively). The PASE demonstrated high internal consistency, concurrent validity, and construct validity, particularly among mothers. CONCLUSION: Preliminary findings suggest that the PASE is worthy of further psychometric testing and may have the potential to help delineate variations in adjustment among parents of children with JIA.

'Instilling the strength to fight the pain and get on with life': learning to become an arthritis self-manager through an adult education programme.

The aim of this study was to determine whether the Arthritis Self-Management Programme (ASMP) is effective in promoting perceived control and self-management ability when delivered in an adult education setting. The study was a pre-test-post-test design based on a sample of 89 people attending an ASMP. Data were collected by self-administered questionnaires prior to the intervention and after the intervention, 4 months from baseline. The sample comprised 80% women, with a mean age of 57 years and a mean disease duration of 13 years. Most participants had either osteoarthritis or rheumatoid arthritis. After 4 months, participants demonstrated significant increases in arthritis self-efficacy (P < 0.0005), cognitive symptom management (P < 0.0005), communication with doctors (P = 0.018), exercise (P = 0.003) and relaxation (P < 0.00005). In addition, significant decreases were found in terms of pain (P = 0.034) and visits to other health professionals (P = 0.004). The first evaluation of the ASMP, delivered within the context of adult education, suggests that this form of community health education programme can offer substantial benefits for participants, particularly in terms of perceived ability to control various aspects of arthritis and in greater utilization of cognitive-behavioral techniques.