Quality indicators for physiotherapy care in hip and knee osteoarthritis: development and clinimetric properties.

OBJECTIVE: The aim of the present study was to develop process quality indicators for physiotherapy care based on key recommendations of the Dutch physiotherapy guideline on hip and knee osteoarthritis (OA). METHODS: Guideline recommendations were rated for their relevance by an expert panel, transformed into potential indicators and incorporated into a questionnaire, the Quality Indicators for Physiotherapy in Hip and Knee Osteoarthritis (QIP-HKOA). Adherence with each indicator was rated on a Likert scale (0 = never to 4 = always). The QIP-HKOA was administered to groups of expert (n = 51) and general (n = 134) physiotherapists (PTs) to test its discriminative power. Reliability was tested in a subgroup of 118 PTs by computing the intraclass correlation coefficient (ICC). QIP-HKOA items were included if they were considered to be related to the cornerstones of physiotherapy in hip and knee OA (exercises and education), had discriminative power and/or if they were followed by <75% of PTs in both groups. RESULTS: Nineteen indicators were derived from 41 recommendations. Twelve indicators were considered to be the cornerstones of physiotherapy care; six indicators had discriminative power and/or were followed by <75% PTs in both groups, resulting in an 18-item QIP- HKOA. The QIP-HKOA score was significantly higher with expert [60.73; standard deviation (SD) 5.67] than with general PTs (54.65; SD 6.17) (p < 0.001). The ICC of the QIP-HKOA among 46/118 PTs was 0.89. CONCLUSION: The QIP-HKOA, based on 18 process indicators derived from a physiotherapy guideline on hip and knee OA was found to be reliable and discriminated between expert and general PTs. Its ability to measure improvement in the quality of the process of physiotherapy care needs to be further examined.

Randomized comparison of a multidisciplinary team care program with usual care in patients with systemic sclerosis.

OBJECTIVE: To compare the effectiveness of a multidisciplinary team care program with usual outpatient care in patients with systemic sclerosis (SSc; scleroderma). METHODS: We performed a randomized controlled trial comparing a 12-week multidisciplinary team care program (1 day per week; individual treatments, group exercises, and group education) with outpatient clinic care. Outcome measures included the Hand Mobility in Scleroderma (HAMIS) test, grip strength, maximal mouth opening (MMO), 6-minute walk distance (6MWD), maximum aerobic capacity (VO(2max) ), Checklist Individual Strength 20 (CIS-20), SSc Health Assessment Questionnaire (HAQ), and Short Form 36 (SF-36), assessed at 0, 12, and 24 weeks. Statistical comparisons of change scores were done by analysis of covariance. RESULTS: Twenty-eight patients were assigned to the intervention group (mean age 53.9 years, 15 of 28 with diffuse SSc) and 25 were assigned to the control group (mean age 51.7 years, 15 of 25 with diffuse SSc). Twenty-five patients (89%) in the intervention group completed the treatment program. At 12 weeks, there was a significantly greater improvement in grip strength (2.2 versus -1.8 kg; P = 0.001), MMO (1.4 versus -0.9 mm; P = 0.011), 6MWD (42.8 versus 3.9 meters; P = 0.021), and HAQ score (-0.18 versus 0.13; P = 0.025) in the intervention group, whereas differences for the other outcome measures did not reach significance. At 24 weeks, the effect on grip strength persisted. CONCLUSION: In patients with SSc, a 12-week multidisciplinary day patient treatment program was more effective than regular outpatient care with respect to 6MWD, grip strength, MMO, and HAQ score, but not for VO(2max) , HAMIS test, CIS-20, SF-36, and visual analog scale for pain. This study provides a first step in quantifying the effect of a multidisciplinary team care program and warrants the conduct of further intervention studies.

Exploring the public health impact of an intensive exercise program for patients with rheumatoid arthritis: a dissemination and implementation study.

OBJECTIVE: To evaluate the implementation of an intensive group exercise program in patients with rheumatoid arthritis (RA). METHODS: In 4 regions in The Netherlands, the Rheumatoid Arthritis Patients In Training exercise program was implemented on a limited scale. Evaluation using the RE-AIM model included: Reach, the proportion of the target population participating; Efficacy, effects on muscle strength, aerobic capacity, functional ability, and psychological functioning; Adoption, program adoption by stakeholders; Implementation, intervention quality (quality audits); and Maintenance, stakeholders' willingness to continue the program in the future. RESULTS: Twenty-five physical therapists from 14 practices were trained to provide the program. In total, 150 RA patients were recruited (by estimation, 2% of the target population). Of the 81 patients who had finished the 12-month intervention and were available for followup directly after the intervention, 62 patients provided clinical data. Muscle strength improved significantly, whereas aerobic capacity, functional ability, psychological functioning, and disease activity did not change. All 9 informed local patient organizations facilitated patient recruitment, and 35 of 51 rheumatologists involved referred one or more patients. All 10 approached health insurance companies funded the program for 12 months. The quality audits showed sufficient quality in 9 of 12 practices. All of the providers of the program were willing to provide the program in the future, whereas future reimbursement by health insurance companies remained unclear. CONCLUSION: The implementation of an intensive exercise program for RA patients on a limited scale can be considered successful regarding its reach, adoption, and implementation. The limited effectiveness and the limited data regarding maintenance warrant additional research.

Value of serum cartilage oligomeric matrix protein as a prognostic marker of large-joint damage in rheumatoid arthritis--data from the RAPIT study.

OBJECTIVE: To investigate the utility of serum COMP level measurements as a predictor of future damage of the weight-bearing (large) joints in RA patients participating in intensive exercise. METHODS: Data of the 281 completers of a 2-yr randomized controlled trial (Rheumatoid Arthritis Patients In Training; RAPIT) comparing the effects of usual care physical therapy with high-intensity weight-bearing exercises were analysed. The primary outcome variable was defined as the change in radiological joint damage (Larsen score) of the large joints. Potential predictors of outcome were defined: baseline and change in serum level of COMP after 3 months, baseline radiological damage of the large and small joints, number of months on glucocorticoids, change in disease activity and in physical capacity (aerobic fitness and muscle strength) after 2 yrs, and participation in the exercise group. RESULTS: In cross-sectional evaluation of baseline data, we found strong association between the high serum COMP level and current damage of the large joints. Serum COMP level at baseline, however, was not associated with an increased rate of radiological joint damage after 2 yrs of follow-up. Furthermore, neither interaction between baseline COMP level and participation in exercises, nor change in COMP level after 3 months of exercising were associated with future damage of the large joints. CONCLUSION: Neither baseline serum COMP level nor its individual change after 3 months from start of intensive exercise predict longitudinal progression of damage of the large joints in this population.

A multidisciplinary hand clinic for patients with rheumatic diseases: a pilot study.

To describe the characteristics, management strategies and outcomes of patients with rheumatic diseases and complex hand function problems referred to a multidisciplinary hand clinic. Assessments (baseline and after three months of follow-up) included sociodemographic and disease characteristics and various hand function measures. The most frequently mentioned impairments and limitations of the 69 patients enrolled in the study pertained to grip, pain, grip strength, and shaking hands. Fifty-six patients received treatment advice, conservative therapy (n=39), surgery (n=12), or a combination of both (n=5). In 38 of 56 patients (68%) the recommended treatment was performed, and 33 completed the follow-up assessment. On average, patients improved, with an increase in grip strength and the Michigan Hand Outcomes Questionnaire scores reached statistical significance. Two-thirds of patients with rheumatic conditions visiting a multidisciplinary hand clinic reportedly followed the treatment advice (recommendations), with an overall trend toward a beneficial effect on hand function. To further determine the added value of a structured, multidisciplinary approach a controlled comparison with other treatment strategies is needed.

Bone mineral density in patients with rheumatoid arthritis: relation between disease severity and low bone mineral density.

OBJECTIVE: To examine variables associated with bone mineral density (BMD) in patients with rheumatoid arthritis (RA). METHODS: We investigated 373 patients with low to moderately active RA. Patients with low disease activity were recruited from a cohort of patients in clinical remission. Patients with moderately active disease were included in a trial comparing the effects of long term high intensity exercise programme and conventional physical therapy. Demographic and clinical data were collected. Bone mineral density (BMD) was measured by means of dual x ray absorptiometry (DXA). Associations between demographic and clinical measurements on the one hand and BMD on the other were investigated in regression analyses. RESULTS: The patient group consisted of middle aged, mainly female, patients. The median (interquartile range) disease duration was 7 (4 to 13) years, the mean disease activity score (standard deviation) was 3.2 (1.4). Of the group, 66% was rheumatoid factor positive, and 83% (n = 304) had never used corticosteroids. The median Larsen score of hands and feet was 27 (5 to 61). Greater age and low body mass index were related to low BMD at the hip and spine. High Larsen score for hands and feet was significantly associated with low BMD at the hip. The use of corticosteroids was not independently associated with BMD. The results of the multiple regression analyses also applied to the subgroup of corticosteroid naive patients. CONCLUSION: BMD data of patients with low to moderately active RA demonstrated an association between high radiological RA damage and low BMD at the hip, which suggests an association between the severity of RA and the risk of generalised bone loss, which also occurred in corticosteroid naive patients.

Long term high intensity exercise and damage of small joints in rheumatoid arthritis.

OBJECTIVE: To investigate the effect of long term high intensity weightbearing exercises on radiological damage of the joints of the hands and feet in patients with rheumatoid arthritis (RA). METHODS: Data of the 281 completers of a 2 year randomised controlled trial comparing the effects of usual care physical therapy (UC) with high intensity weightbearing exercises were analysed for the rate of radiological joint damage (Larsen score) of the hands and feet. Potential determinants of outcome were defined: disease activity, use of drugs, change in physical capacity and in bone mineral density, and attendance rate at exercise sessions. RESULTS: After 2 years, the 136 participants in high intensity weightbearing exercises developed significantly less radiological damage than the 145 participants in UC. The mean (SD) increase in damage was 3.5 (7.9) in the exercise group and 5.7 (10.2) in the UC group, p = 0.045. Separate analysis of the damage to the hands and feet suggests that this difference in rate of increase of damage is more pronounced in the joints of the feet than in the hands. The rate of damage was independently associated with less disease activity, less frequent use of glucocorticoids, and with an improvement in aerobic fitness. CONCLUSION: The progression of radiological joint damage of the hands and feet in patients with RA is not increased by long term high intensity weightbearing exercises. These exercises may have a protective effect on the joints of the feet.

Differences between participants and nonparticipants in an exercise trial for adults with rheumatoid arthritis.

OBJECTIVE: To investigate the generalizability of the results of a randomized controlled trial on the effectiveness of long-term, high-intensity exercises in the rheumatoid arthritis patients in training (RAPIT) trial by comparing the characteristics of the participants with the nonparticipants. METHODS: Participants and nonparticipants were mailed questionnaires on sociodemographic characteristics, health status, reasons not to participate, and attitudes toward intensive exercise. RESULTS: The questionnaires from 892 (75%) nonparticipants and 299 (97%) participants were collected. The nonparticipants were slightly older, more often male, and had longer disease duration than the participants. The nonparticipants perceived their disease as more serious, used fewer disease-modifying antirheumatic drugs, had a lower level of education, and a more negative attitude toward intensive exercise. CONCLUSION: The results of the RAPIT trial might not be generalizable to the entire target population. To promote participation in long-term, high-intensity exercises, health professionals should more actively discuss the potential benefits of exercise with their RA patients while taking into consideration specific factors related to participation.

High intensity exercise or conventional exercise for patients with rheumatoid arthritis? Outcome expectations of patients, rheumatologists, and physiotherapists.

OBJECTIVE: To examine the outcome expectations of RA patients, rheumatologists, and physiotherapists regarding high intensity exercise programmes compared with conventional exercise programmes. METHODS: An exercise outcome expectations questionnaire was administered to 807 RA patients, 153 rheumatologists, and 624 physiotherapists. The questionnaire consisted of four statements regarding positive and negative outcomes of high intensity exercise programmes and four similar statements for conventional exercise programmes. A total expectation score for both conventional and high intensity exercise was calculated, ranging from -2 (very negative expectation) to 2 (very positive expectation). RESULTS: The questionnaire was returned by 662 RA patients (82%), 132 rheumatologists (86%), and 467 physiotherapists (75%). The mean (95% confidence interval) scores for high intensity exercise programmes were 0.30 (0.25 to 0.34), 0.68 (0.62 to 0.74), and -0.06 (-0.15 to 0.02), and for conventional exercise programmes were 0.99 (0.96 to 1.02), 1.13 (1.09 to 1.17), and 1.27 (1.21 to 1.34) for RA patients, rheumatologists, and physiotherapists, respectively. In all three respondent groups, the outcome expectations of high intensity exercise were significantly less positive than those of conventional exercise programme. CONCLUSIONS: Despite the existing evidence regarding the effectiveness and safety of high intensity exercise programmes, RA patients, rheumatologists, and physiotherapists have more positive expectations of conventional exercise programmes than of high intensity exercise programmes. Physiotherapists were the least positive about outcomes of high intensity exercise programmes while rheumatologists were the most positive. To help the implementation of new insights in the effectiveness of physical therapy modalities in rheumatology, the need for continuous education of patients, rheumatologists and physiotherapists is emphasised.

The validity of the Rheumatoid Arthritis Quality of Life (RAQoL) questionnaire.

OBJECTIVE: To examine further the usefulness of a 30-item disease-specific quality of life (QoL) questionnaire in patients with rheumatoid arthritis (RA). METHODS: The Rheumatoid Arthritis Quality of Life (RAQoL) questionnaire was applied to two groups consisting of 210 and 300 patients with RA, one group with increasing difficulty in performing activities of daily living and one group with stable disease. The associations between the RAQoL and measures of utility, QoL, functional status and disease activity were evaluated. Factor analysis was carried out to investigate if one or more QoL dimensions could be distinguished within this questionnaire. RESULTS: Similar results regarding the association between the RAQoL and different sets of outcome measures were found in the two groups of patients. Regression analysis showed that about 75% of the variance of the RAQoL could be explained with variables of QoL, functional status and disease activity. Physical contact could be distinguished as a separate dimension within the RAQoL, in addition to the dimensions mobility/energy, self-care and mood/emotion. CONCLUSION: The RAQoL is a valid instrument for measuring QoL in different populations of patients with RA. Physical contact, a dimension that is not covered by other common instruments in RA, could be distinguished as a separate dimension within the questionnaire.

The value of a continuous ambulatory activity monitor to quantify the amount and intensity of daily activity in patients with rheumatoid arthritis.

OBJECTIVE: To examine the reliability, validity, and responsiveness of a continuous ambulatory activity monitor in patients with rheumatoid arthritis (RA). METHODS: Forty-one patients with RA, participating in a randomized controlled trial examining the effect of an intensive exercise program, were assessed by means of the Dynaport ADL (activities of daily living) monitor (AM). The time spent on activities (locomotion, standing, and active sitting) during 24 hours and the intensity of trunk movement during these activities were recorded. To determine test-retest reliability 20 patients were reassessed with the AM one week after the first assessment. Construct validity of the AM was determined by comparing the AM results with physical fitness measures (muscle strength, endurance, joint mobility), disease activity, and functional status. As well, 37 patients were assessed 18 months after the first assessment to determine responsiveness. RESULTS: All AM measurements showed satisfactory test-retest reliability (ICC 0.63-0.76). AM measures were significantly associated with physical fitness, functional status, and disease activity, indicating construct validity of the AM. The AM could discriminate between patients with improvement and deterioration in physical fitness, indicating sufficient responsiveness of AM variables. CONCLUSION: This study shows the value of an ambulatory activity monitor to quantify both the amount and intensity of physical activity of patients with RA during a day in their own environment. The ambulatory activity monitor seems to be a promising instrument for research into rehabilitation of patients with RA.

The reliability and construct validity of the RAQoL: a rheumatoid arthritis-specific quality of life instrument.

The present study was designed to test the psychometric properties of the RAQoL, a rheumatoid arthritis (RA)-specific quality of life (QoL) instrument. All stages of the development were conducted simultaneously in The Netherlands and the UK. The content of the draft measure was derived from qualitative interviews with RA patients in both countries. The final version of the RAQoL has 30 items with a 'yes'/'no' response format and takes approximately 6 min to complete. Both language versions have high internal consistency and test-retest reliability (> 0.9), and good sensitivity to discriminate between groups with various disease activity and severity. Given the excellent psychometric properties of the new instrument, it will prove to be a valuable tool for assessing quality of life in clinical trials and for monitoring patients in routine clinical practice.

Quality of life in rheumatoid arthritis.

Patient-completed health status instruments currently available for use with rheumatoid arthritis (RA) patients lack adequate reliability and responsiveness, making them unsuitable for use as outcome measures in clinical trials. A search of the literature failed to identify a quality of life (QoL) instrument specific to RA. The present study was designed to be the first stage in the development of such a measure. Qualitative interviews were held with 50 RA patients, 25 in the UK and 25 in The Netherlands. The interviews indicated that RA has a detrimental effect on many areas of life, including moods and emotions, social life, hobbies, everyday tasks, personal and social relationships, and physical contact. Transcripts of the interviews formed the source of items for the RAQoL, the first RA-specific QoL instrument.

[Percutaneous endopyelotomies. Preliminary results (a series of 16 patients)]. / Endopyélotomies percutanées. Résultats préliminaires (à propos d'une série de 16 malades).

Percutaneous endopyelotomy was performed in 16 patients with ureteropelvic junction obstruction. The procedure was always completed with no intra-operative complication. After a mean follow-up of 18 months (6-30 mos), we report 12 good results (75%), 2 patients with no clinical symptoms but remaining partial radiological obstruction, and 2 failures (12.5%) which required early open surgery. Much care must be given to the ureteral stenting: one of our failures was due to extra-pelvic migration of the stent. Endopyelotomy may be considered as an efficient procedure, but long-term evaluation is still required.

[Evolution and treatment of 8 patients with Fournier's perineal-scrotal gangrene]. / Evolution et traitement de huit malades atteints d'une gangrène périnéo-scrotale de Fournier.

The authors present eight cases of Fournier's gangrene treated from 1987 to 1989 (3 years). There was no discernable cause for 5 patients (62.5%). Immediate aggressive surgical debridement of all necrotic tissue was performed. Intravenous antibiotics and resuscitation fluid and hyperbaric oxygenation were also administered to all patients. Skin grafting was performed for 4 patients (40%), 3 weeks after surgical debridement. One patient died (12.5%) and 2 subsequently developed an urethral stricture. Etiology, treatment and outcome of Fournier's gangrene are discussed and the results of the study are compared to other studies. This disease is still serious, its pathogenesis is not completely elucidated, but when immediate adequate treatment is performed, the outcome is generally favourable.

[Nosocomial infections in an urological department. Incidence and etiological factors]. / Infections nosocomiales dans un service d'urologie. Incidence et facteurs étiologiques.

The authors report a prospective study with active request of data for nosocomial infections (NI) in an urological department during six months. From 453 patients, 43 developed an NI (incidence = 9.5%): urinary tract infections (53.5%), bloodstream infections (16.3%), lower respiratory tract infections (7%), surgical wound infections (2.3%) and sepsis syndrome (20.9%). For microorganisms, most often Pseudomonas aeruginosa (22.5%) and E. coli (20%) were encountered. Other microorganisms were the next-ones: Staphylococcus aureus (15%), Staphylococcus epidermidis (7.5%), Acinetobacter baumanii (7.5%), Streptococcus group D (7.5%), Klebsiella pneumoniae (7.5%), Candida albicans (2.5%) and others (10%). Urological interventions with a high risk of NI were cystectomy with intestinal urinary diversion (68.7%), pyeloplasty for ureteropelvic junction obstruction (40%) and percutaneous nephrolitothomy (30%). Even if the last two interventions classically do not have a high risk of NI, we think that their antibioprophylaxis is recommended.

Single-dose fosfomycin trometamol (Monuril) versus multiple-dose norfloxacin: results of a multicenter study in females with uncomplicated lower urinary tract infections.

The results of an open, randomized study comparing the efficacy and safety of Fosfomycin trometamol (Monuril), 3-gram single dose, and Norfloxacin (Noroxine 400), 400 mg twice daily for 5 days, are reported. Clinical and bacteriological assessments were performed before and 3-4 (short-term) and 25-30 days (long-term) after treatment. Only female patients with uncomplicated lower urinary tract infection were eligible for inclusion in the study: 33 cases were given Fosfomycin trometamol and 30 cases Norfloxacin. In the overall etiology, Escherichia coli (74% of the strains found), Proteus mirabilis (6%) and Klebsiella pneumoniae (6%) are highly predominant. With regard to bacteriological efficacy, the percentages of eradication in the two groups were similar: after the short-term test, 93.9% (31 of 33 patients) in the Fosfomycin trometamol group and 86.6% (26 of 30) in the Norfloxacin group, and after the long-term tests, 73.3% (22 of 30) in the Fosfomycin trometamol group and 77.89% (21 of 27) in the Norfloxacin group. There are no statistically significant differences. The duration of the reported side effects was significantly lower in the Fosfomycin trometamol group. The simplified dosage regimen (single dose) and its favorable benefit/risk ratio justifies the use of Fosfomycin trometamol as a treatment for uncomplicated urinary tract infections in female patients.

[Functional outcome of a U-shaped ileocystoplasty (the Camey I procedure) in cancer of the bladder. Apropos of 14 cases]. / Devenir fonctionnel des iléocystoplasties en u (intervention de Camey I) dans le cancer de la vessie. A propos de quatorze cas.

The authors studied postoperatively fourteen men who underwent urinary diversion with a Camey ileal bladder for bladder cancer in association with radical cystoprostatectomy, from March 1986 to June 1988. Mean follow-up was 19.5 +/- 9 months. Three patients died (21.4%), two other patients are alive with metastases. Ureteral reflux and upper tract dilatation occurred in 14.3 and 28.6% of the renal units, respectively. Daytime continence was achieved in 92.9% of the patients (13 patients), frequently 6 months after the operation. Nocturnal incontinence was almost universal (1 patient circumvented this problem by getting up to void every three hours during the night). Thirteen patients had urodynamic testing after the operation. Mean capacity of the ileal bladder was 344 ml with mean intraluminal pressure of 24 cm water. Mean urethral closing pressure was 49 cm water. Voiding was accomplished by abdominal straining concomitant with external sphincter relaxation. Post-void residual was less than 50 ml, except in one patient. The authors discuss these results and compare them to those of other studies.

[Is venous cavernous insufficiency the only cause of organic impotence?]. / L'insuffisance veino-caverneuse n'est-elle pas la seule cause de dysérection organique?

Organic causes for impotence are rarely detected because of the inadequate investigation of the patients. The assessment of impotence must include clinical examination (principally interview) and complementary investigations. The clinical history is strongly suggestive of an organic cause. Organic investigation must be proposed to these patients when they are motivated and occasionally in obviously "psychological" patients in order to reassure him that all of the organic factors "function correctly". The complementary investigations are as follows: hormonal survey (testosterone, prolactin), nocturnal penile plethysmography, penile arterial Doppler, EMG of the bulbocavernosus muscles and the papaverine test (30 mg or 60 mg). When the papaverine test is abnormal, cavernometry should be proposed. In conclusion, supportive sex therapy is often essential and a penile prosthesis should only be proposed as a last resort, when treatments adapted to the cause have failed.

Conservative management of renal stab wound by double-J ureteral stent and specific percutaneous arterial embolization.

We report on the conservative management of a renal stab wound by double-J stenting and specific percutaneous arterial embolization in a 34-year-old man. Surgical exploration was avoided because there was a little doubt about the associated intra-abdominal injuries. Recovery was excellent and the patient left the hospital 2 weeks later.