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BACKGROUND: Optimizing self-management is a key element in multidisciplinary pulmonary rehabilitation in patients with asthma or COPD. This observational study aimed to investigate the changes in self-management following pulmonary rehabilitation in subjects with chronic lung disease. METHODS: Data were prospectively and routinely gathered at initial assessment and discharge in subjects taking part in a 12-week multidisciplinary out-patient pulmonary rehabilitation program. Measures of self-management included the Patient Activation Measure (PAM), the Health Education Impact Questionnaire (HEIQ) (8 subscales), a Self-Efficacy Questionnaire (2 subscales), the Lung Information Needs Questionnaire (LINQ), and the Health Literacy Questionnaire (HLQ) (9 subscales). Mean differences with 95% CI and effect sizes were computed. RESULTS: A total of 70 subjects (62.9% women) were included, with a median age of 63.5 y; most of the subjects had been diagnosed with COPD (77%). Between admission and discharge, all measures of self-management increased significantly except for the HEIQ subscales of constructive attitudes and approaches, social integration and support, and health services navigation; and the HLQ subscale of social support for health. The largest improvements (effect size > 0.55) were seen for the PAM (0.57); the HEIQ subscales of health-directed behavior (0.71), self-monitoring and insight (0.62), and skill and technique acquisition (1.00); the HLQ subscales of having sufficient information to manage my health (1.21) and actively managing my health (0.66); and the LINQ (1.85). CONLCUSIONS: Self-management, including activation, improved significantly in subjects with asthma or COPD who took part in a multidisciplinary pulmonary rehabilitation program. (C) 2021 Daedalus Enterprises.

Background Implementation of an eRehabilitation intervention named Fit After Stroke @Home (Fast@home) - including cognitive/physical exercise applications, activity-tracking, psycho-education - after stroke resulted in health-related improvements. This study investigated what worked and why in the implementation. Methods Implementation activities (information provision, integration of Fast@home, instruction and motivation) were performed for 14 months and evaluated, using the Medical Research Council framework for process evaluations which consists of three evaluation domains (implementation, mechanisms of impact and contextual factors). Implementation activities were evaluated by field notes/surveys/user data, it's mechanisms of impact by surveys and contextual factors by field notes/interviews among 11 professionals. Surveys were conducted among 51 professionals and 73 patients. User data (n = 165 patients) were extracted from the eRehabilitation applications. Results Implementation activities were executed as planned. Of the professionals trained to deliver the intervention (33 of 51), 25 (75.8%) delivered it. Of the 165 patients, 82 (49.7%) were registered for Fast@home, with 54 patient (65.8%) using it. Mechanisms of impact showed that professionals and patients were equally satisfied with implementation activities (median score 7.0 [IQR 6.0-7.75] versus 7.0 [6.0-7.5]), but patients were more satisfied with the intervention (8.0 [IQR 7.0-8.0] versus 5.5 [4.0-7.0]). Guidance by professionals was seen as most impactful for implementation by patients and support of clinical champions and time given for training by professionals. Professionals rated the integration of Fast@home as insufficient. Contextual factors (financial cutbacks and technical setbacks) hampered the implementation. Conclusion Main improvements of the implementation of eRehabilitation are related to professionals' perceptions of the intervention, integration of eRehabilitation and contextual factors.Implication for rehabilitation To increase the use of eRehabilitation by patients, patients should be supported by their healthcare professional in their first time use and during the rehabilitation process. To increase the use of eRehabilitation by healthcare professionals, healthcare professionals should be (1) supported by a clinical champion and (2) provided with sufficient time for learning to work and getting familiar with the eRehabilitation program. Integration of eRehabilitation in conventional stroke rehabilitation (optimal blended care) is an important challenge and a prerequisite for the implementation of eRehabilitation in the clinical setting.

Purpose: Both the International Consortium for Health Outcomes Measurement and the National Institutes of Health recommend the use of Patient-Reported Outcomes Measurement Information System (PROMIS®) measures in clinical care and research for stroke patients. This study aimed to systematically review the literature on the measurement properties and interpretability of PROMIS measures in stroke patients. Methods: Nine databases were searched from January 1st, 2007 till April 12th, 2021 for studies concerning the measurement properties and interpretability of PROMIS measures in stroke patients. The findings of these studies were analyzed according to the COnsensus‐based Standards for the selection of health Measurement INstruments (COSMIN) guideline for systematic reviews of Patient‐Reported Outcome Measures (PROMs). Results: Ten studies were included. The PROMIS Global Health was studied the most: its two subscales had sufficient structural validity in one study of very good quality, sufficient construct validity with > 75% of hypotheses tested confirmed (high GRADE rating), sufficient internal consistency, i.e. α ≥ 0.70 in two studies (high GRADE rating), sufficient reliability, i.e. ICC ≥ 0.70 in one study of doubtful quality, and indeterminate responsiveness in one study of inadequate quality. For other PROMIS measures, the measurement properties and interpretability were limitedly studied. Conclusion: The PROMIS Global Health showed sufficient structural and construct validity and internal consistency in stroke patients. There is a need for further research on content validity, structural validity, and measurement invariance of PROMIS measures in stroke patients. Trial Registration Information: CRD42020203044 (PROSPERO).

Supervised group exercise (SGE) is recommended for people with axial spondyloarthritis (axSpA). Recent literature suggests that its contents and dosage must probably be revised. As a first step towards renewal, this study examined the current SGE organisation and content for people with axSpA in The Netherlands. A pen-and-paper survey was sent to the boards of the 82 local patient associations affiliated with the Dutch Arthritis Society in 2016. One member of each board was asked to complete questions on the nature and organisation of SGE and one of the supervising therapists to complete questions on the SGE supervision and contents. The questionnaire was returned by representatives of 67/82 (82%) local patient associations, of which 17 (25%) provided axSpA-specific SGE (16/17 SGE programmes with both land-based exercise and hydrotherapy and 1/17 with only hydrotherapy). These involved in total 56 groups with 684 participants and 59 supervisors, of whom 54 were physical therapists and 21 had had postgraduate education on rheumatic and musculoskeletal diseases (RMDs). Besides mobility and strengthening exercises and sports (17/17), most programmes included aerobic exercise (10/17), but rarely with heart rate monitoring (1/17), patient education (8/17), periodic assessments (2/17), or exercise personalisation (1/17). In the Netherlands, a quarter of local patient associations organised axSpA-specific SGE, mostly containing land-based exercises combined with sports and hydrotherapy. Most supervisors lacked postgraduate education on RMDs and most programmes lacked intensity monitoring, patient education, periodic assessments, and personalisation, which are needed for optimising exercise programmes according to current scientific insights.

Purpose Pituitary diseases severely affect patients’ health-related quality of life (HRQoL). The most frequently used generic HRQoL questionnaire is the Short Form-36 (SF-36). The shorter 12-item version (SF-12) can improve efficiency of patient monitoring. This study aimed to determine whether SF-12 can replace SF-36 in pituitary care. Methods In a longitudinal cohort study (August 2016 to December 2018) among 103 endoscopically operated adult pituitary tumor patients, physical and mental component scores (PCS and MCS) of SF-36 and SF-12 were measured preoperatively, and 6 weeks and 6 months postoperatively. Chronic care was assessed with a cross-sectional study (N = 431). Mean differences and agreement between SF-36 and SF-12 change in scores (preoperative vs. 6 months) were assessed with intraclass correlation coefficients (ICC) and limits of agreement, depicting 95% of individual patients. Results In the longitudinal study, mean differences between change in SF-36 and SF-12 scores were 1.4 (PCS) and 0.4 (MCS) with fair agreement for PCS (ICC = 0.546) and substantial agreement for MCS (ICC = 0.931). For 95% of individual patients, the difference between change in SF-36 and SF-12 scores varied between −14.0 and 16.9 for PCS and between −7.8 and 8.7 for MCS. Cross-sectional results showed fair agreement for PCS (ICC = 0.597) and substantial agreement for MCS (ICC = 0.943). Conclusions On a group level, SF-12 can reliably reproduce MCS in pituitary patients, although PCS is less well correlated. However, individual differences between SF-36 and SF-12 can be large. For pituitary diseases, alternative strategies are needed for concise, but comprehensive patient-reported outcome measurement.

Background To evaluate the effect of a stand-alone mobile and web-based educational intervention (eHealth tool) compared to usual preparation of a first orthopedic consultation of patients with hip or knee osteoarthritis (OA) on patients’ satisfaction. Methods A two-armed randomized controlled trial involving 286 patients with (suspicion of) hip or knee OA, randomly allocated to either receiving an educational eHealth tool to prepare their upcoming consultation (n = 144) or usual care (n = 142). Satisfaction with the consultation on three subscales (range 1–4) of the Consumer Quality Index (CQI - primary outcome) and knowledge (assessed using 22 statements on OA, range 0–22), treatment beliefs (assessed by the Treatment beliefs in OsteoArthritis questionnaire, range 1–5), assessment of patient’s involvement in consultation by the surgeon (assessed on a 5-point Likert scale) and patient satisfaction with the outcome of the consultation (numeric rating scale), were assessed. Results No differences between groups were observed on the 3 subscales of the CQI (group difference (95% CI): communication 0.009 (− 0.10, 0.12), conduct − 0.02 (− 0.12, 0.07) and information provision 0.02 (− 0.18, 0.21)). Between group differences (95% CI) were in favor of the intervention group for knowledge (1.4 (0.6, 2.2)), negative beliefs regarding physical activities (− 0.19 (− 0.37, − 0.002) and pain medication (− 0.30 (− 0.49, − 0.01)). We found no differences on other secondary outcomes. Conclusions An educational eHealth tool to prepare a first orthopedic consultation for hip or knee OA does not result in higher patient satisfaction with the consultation, but it does influence cognitions about osteoarthritis. Trial registration Dutch Trial Register (trial number NTR6262). Registered 30 January 2017.

BACKGROUND: Physical activity is an important intervention for improving disease-related symptoms and systemic manifestations in rheumatic and musculoskeletal disease (RMDs). However, studies suggest that RMD patients report that the lack of individualized and consistent information about physical activity from managing doctors and healthcare professionals, acts as a barrier for engagement. On the other hand, managing doctors and healthcare professionals report lack of knowledge in this area and thus lack of confidence to educate and advise RMD patients about the beneficial effects of physical activity. The aim of the present study therefore, is to develop two e-Learning courses for RMD doctors and health professionals: a) the first one to provide consistent information about the collective benefits of physical activity in RMDs and b) the second on how to implement physical activity advice in routine clinical practice. METHODS: An international collaboration of seven countries, consisting of one academic institution and one patient organization from each country, will co-develop the two e-Learning courses. The final e-Learning courses will primarily target to improve - through physical activity advice - RMD symptoms which are important for patients. DISCUSSION: The main result of this study will be to co-develop two e-Learning courses that can be used by managing RMD doctors and healthcare professionals to be made aware of the overall benefits of physical activity in RMDs as well as how to implement physical activity advise within their practice. ispartof: The Mediterranean Journal of Rheumatology vol:30 issue:4 pages:231-236 ispartof: location:Greece status: published

Background One of the main aims of rehabilitation is to improve participation. Patient-Reported Outcomes Measurement Information System (PROMIS®) item banks ‘Ability to Participate in Social roles and Activities, (PROMIS-APS) and ‘Satisfaction with Social Roles and Activities’ (PROMIS-SPS) are promising options to measure participation, but the literature on PROMIS measures of (satisfaction with) participation across diagnoses in rehabilitation is limited. Therefore, the objective of this study was to describe levels of and changes in participation, as assessed with the PROMIS-APS and the PROMIS-SPS short forms, of patients in outpatient rehabilitation. Methods This study had quantitative, observational design with assessments at admission and discharge. Consecutive patients treated between April and August 2018 receiving outpatient multidisciplinary rehabilitation were the population of this study. The following diagnosis categories were included: brain injury (e.g. stroke), spinal cord and nerve injury, neuromuscular disorder (e.g. lateral sclerosis), amputation, musculoskeletal condition (e.g. osteoarthritis) or heart or lung disease (e.g. myocardial infarction, chronic obstructive pulmonary disease). The main patient-reported outcomes (PRO) of this study were the short form of the PROMIS-APS (8 items, Dutch general population reference score 50.6 [SD 9.5]), and PROMIS-SPS (8 items, Dutch general population reference score 47.5 [SD 8.3]. Results Of the 1279 patients invited, 777 (61%) completed the online forms at admission. Of those, 329 patients were invited at discharge, with 209 (64%) completing the forms. The mean (SD) T-scores of the PROMIS-APS and PROMIS-SPS were lower at admission (42.7 [SD 7.4]; (41.4 [SD 7.7]) and discharge (43.6 [SD 7.2]; (43.7 [SD 7.8]) than the Dutch general population. The change scores of the PROMIS-APS and PROMIS-SPS were 1.2 (95% CI 0.4–1.9; p = 0.004; effect size 0.16), and 2.4 (95% CI 1.6–3.2; p 30 paired measurements statistically significant improvements of PROMIS-APS, PROMIS-SPS or both were seen. Conclusions Patients undergoing outpatient rehabilitation had, both at admission and discharge, considerably lower PROMIS-APS and PROMIS-SPS T-scores short forms than the general Dutch population, and showed small T-score improvements at discharge.

Background Physiotherapy is a proven effective treatment strategy after total knee and hip arthroplasty (TKA/THA), however there is considerable practice variation regarding its timing, content and duration. This study aims to compare the (cost-) effectiveness of a standardized, treat-to-target postoperative physiotherapy strategy with usual postoperative care. Methods Using a cluster randomized study design, consecutive patients scheduled for a primary TKA/THA in 18 hospitals in the Netherlands will be assigned to the treat-to-target physio therapy strategy or usual postoperative care. With the treat-to-target strategy a standardized, individually tailored, exercise program is aimed at the attainment of specific functional milestones. Assessments are done at baseline, 6 weeks and 3, 6, 9 and 12 months follow up. The primary outcome will be the Knee injury / Hip disability and Osteoarthritis Outcome Score - Physical Function Short Form (KOOS-PS / HOOS-PS) at 3 months follow up. Secondary outcomes are the numeric rating scale for pain, the Oxford Knee and Hip Scores, performance-based test and the EuroQol 5D-5L for quality of life. Healthcare use, productivity and satisfaction with postoperative care are measured by means of questionnaires. In total, 624 patients will be needed of which 312 TKA and 312 THA patients. Discussion The study will provide evidence concerning the (cost-) effectiveness of the treat-to-target postoperative physiotherapy treatment compared to usual postoperative care. The results of this study will address an important evidence gap and will have a significant impact in daily practice of the physio therapist. Trial registration Registered in the Dutch Trial Registry on April 15, 2018. Registration number: NTR7129.

Background: Compliance rates with patient-reported outcome measures (PROMs) collected alongside arthroplasty registries vary in the literature. We described the feasibility of a routinely collected set PROMs alongside the Dutch Arthroplasty Register. Methods: The longitudinal Leiden Orthopaedics Outcomes of OsteoArthritis Study is a multicenter (7 hospitals), observational study including patients undergoing total hip or total knee arthroplasty (THA or TKA). A set of PROMs: Short Form-12, EuroQol 5 Dimensions, Hip/Knee injury and Osteoarthritis Outcome Score, Oxford Hip/Knee Score was collected preoperatively and at 6, 12, 24 months, and every 2 years thereafter. Participation rates and response rates were recorded. Results: Between June 2012 and December 2014, 1796 THA and 1636 TKA patients were invited, of whom 1043 THA (58%; mean age 68 years [standard deviation, SD: 10]) and 970 TKA patients (59%; mean age 71 years [SD 9.5]) participated in the study. At 6 months, 35 THA/38 TKA patients were lost to follow-up. Response rates were 90% for THA (898/1000) and 89% for TKA (827/932) participants. At 1 and 2 years, 8 and 18 THA and 17 and 11 TKA patients were lost to follow-up, respectively. The response rates among those eligible were 87% (866/992) and 84% (812/972) for THA and 84% (771/917) and 83% (756/906) for TKA patients, respectively. The 2-year questionnaire was completed by 78.5% of the included THA patients and by 77.9% of the included TKA patients. Conclusions: About 60% of patients undergoing THA or TKA complete PROMs preoperatively, with more than 80% returning follow-up PROMs. To increase the participation rates, more efforts concerning the initial recruitment of patients are needed.

The Evaluation of Daily Activity Questionnaire (EDAQ) is a detailed patient-reported outcome measure of activity ability. The objective of this research was to assess the linguistic and cross-cultural validity and psychometric properties of the EDAQ in rheumatoid arthritis for Dutch and German speakers. The EDAQ was translated into Dutch and German using standard methods. A total of 415 participants (Dutch n = 252; German n = 163) completed two questionnaires about four weeks apart. The first included the EDAQ, Health Assessment Questionnaire (HAQ) and 36-item Short-Form v2 (SF-36v2) and the second, the EDAQ only. We examined construct validity using Rasch analysis for the two components (Self-Care and Mobility) of the Dutch and German EDAQ. Language invariance was also tested from the English version. We examined internal consistency, concurrent and discriminant validity and test–retest reliability in the 14 EDAQ domains. The Self-Care and Mobility components satisfied Rasch model requirements for fit, unidimensionality and invariance by language. Internal consistency for all 14 domains was mostly good to excellent (Cronbach’s alpha ≥ 0.80). Concurrent validity was mostly strong: HAQ rs = 0.65–0.87; SF36v2 rs = − 0.61 to − 0.87. Test–retest reliability was excellent [ICC (2,1) = 0.77–0.97]. The EDAQ has good reliability and validity in both languages. The Dutch and German versions of the EDAQ can be used as a measure of daily activity in practice and research in the Netherlands and German- speaking countries.

Objective The purpose of this paper is to revise the 2010 Dutch guideline for physical therapy (PT) in patients with hip or knee osteoarthritis (OA), issued by the Royal Dutch Society for Physical Therapy (KNGF). Method This revised guideline was developed according to the Appraisal of Guidelines for Research and Evaluation (AGREE) and Guidelines International Network (G-I-N) standards. A multidisciplinary guideline panel formulated clinical questions based on perceived barriers to current care. A narrative or systematic literature review was undertaken in response to each clinical question. The panel formulated recommendations based on evidence and additional considerations, as described in the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) Evidence-to-Decision framework. Results A comprehensive assessment should be based on the International Classification of Functioning Disability and Health (ICF) core set for OA, including the identification of OA-related red flags. Based on the assessment, four treatment profiles were distinguished: (1) education and instructions for unsupervised exercises, (2) education and short-term supervised exercise therapy, (3) education and longer term supervised exercise therapy, and (4) education and exercise therapy before and/or after total hip or knee surgery. Education included individualized information, advice, instructions, and self-management support. Exercise programs were tailored to individual OA-related issues, were adequately dosed, and were in line with public health recommendations for physical activity. Recommended measurement instruments included the Patient-Specific Complaints Instrument, the Numeric Pain Rating Scale, the Hip Disability and Osteoarthritis Outcome Score/the Knee Injury Osteoarthritis Outcome Score, and the Six Minute Walk Test. Conclusion An evidence-based PT guideline for the management of patients with hip or knee OA was developed. To improve quality of care for these patients, an extensive implementation strategy is necessary.

Introduction This study aimed to compare the engagement in moderate- and vigorous-intensity PA in axSpA patients with and without current physical therapy (PT). Methods In this cross-sectional study, a survey, including current PT treatment (yes/no) and PA, using the ‘Short QUestionnaire to ASsess Health-enhancing PA’ (SQUASH), was sent to 458 axSpA patients from three Dutch hospitals. From the SQUASH, the proportions meeting aerobic PA recommendations (≥ 150 min/week moderate-, ≥ 75 min/week vigorous-intensity PA or equivalent combination; yes/no) were calculated. To investigate the association between PT treatment and meeting the PA recommendations, odds ratios (OR) with 95% confidence intervals (95% CI) were estimated using logistic regression models, adjusting for sex, age, health status and hospital. Results The questionnaire was completed by 200 patients, of whom 68%, 50% and 82% met the moderate-, vigorous- or combined-intensity PA recommendations, respectively. Ninety-nine patients (50%) had PT treatment, and those patients were more likely to meet the moderate- (OR 2.09 [95% CI 1.09–3.99]) or combined-intensity (OR 3.35 [95% CI 1.38–8.13]) PA recommendations, but not the vigorous-intensity PA recommendation (OR 1.53 [95% CI 0.80–2.93]). Aerobic exercise was executed in 19% of individual PT programs. Conclusion AxSpA patients with PT were more likely to meet the moderate- and combined-intensity PA recommendations, whereas there was no difference in meeting the vigorous-intensity PA recommendation. Irrespective of having PT treatment, recommendations for vigorous-intensity PA are met by only half of the patients. Implementation should thus focus on aerobic PA in patients without PT and on vigorous-intensity PA in PT programs.

Objective. Supervised group exercise (SGE) has been proven effective in patients with axial spondyloarthritis (SpA), but its contents and dosage do not always comply with current scientific insight. This aim of this study was to describe axial SpA patients’ satisfaction with current SGE and perspective on potential evidence-based SGE enhancements. Methods. Patients with axial SpA who participated in SGE in 4 regions in The Netherlands (n = 118) completed a cross-sectional survey on their satisfaction with features of their current SGE (8 questions scored on a 3-point Likert scale; 1 overall grade, scored according to an 11-point scale) and their perspective on the introduction of appropriately dosed cardiorespiratory and strengthening exercise, monitoring of exercise intensity, periodic reassessments, patient education, and supervision by physical therapists with specific expertise (4 dichotomous questions and one 5-point Likert scale). Results. Most patients were satisfied with the current total intensity (84 of 112 patients [75%]), duration (93 of 111 patients [84%]), and load (89 of 117 patients [76%]) of the program and the proportion of mobility (102 of 114 patients [90%]), strengthening (90 of 115 patients [78%]), and cardiorespiratory exercise (82 of 114 patients [72%]). The median overall grade of the program was a 7 (interquartile range 7–8). Most patients agreed with the implementation of more frequent (home) exercise (73 of 117 patients [62%]), heart-rate monitoring (97 of 117 patients [83%]), and annual reassessments (97 of 118 patients [82%]), whereas 50% agreed with the introduction of patient education (37 of 74 patients). The majority found supervision by therapists specializing in axial SpA to be of high importance (105 of 118 patients [89%]). Conclusion. The majority of SGE participants with axial SpA were satisfied with current SGE but also agreed with enhancements in line with scientific evidence. Current satisfaction levels indicate that a planned implementation strategy, including education and addressing potential barriers and facilitators for the uptake of enhancements, is warranted.

OBJECTIVE: The objectives of the present study were to: (1) evaluate the effect of an educational course on competence (knowledge and clinical reasoning) of primary care physical therapists (PTs) in treating patients with knee osteoarthritis (KOA) and comorbidity according to the developed strategy; and (2) identify facilitators and barriers for usage.METHOD: The present research was an observational study with a pretest-posttest design using mixed methods. PTs were offered a postgraduate course consisting of e-learning and two workshops (blended education) on the application of a strategy for exercise prescription in patients with KOA and comorbidity. Competences were measured by questionnaire on knowledge (administered before and 2 weeks after the course), and a patient vignette to measure clinical reasoning (administered before the course and after a 6 month period of treating patients). Facilitators and barriers for using the strategy were assessed by a questionnaire and semi-structured interviews.RESULTS: Thirty-four PTs were included. Competence (knowledge and clinical reasoning) improved significantly (p < 0.01). Fourteen out of 34 PTs had actually treated patients with KOA and comorbidity, during a 6-month period. The strategy was found to be feasible in daily practice. The main barriers included the limited number of (self-) referrals of patients, limited number of reimbursed treatment sessions by insurance companies and a suboptimal collaboration with (referring) physicians.CONCLUSION: A blended course on exercise therapy for patients with KOA and comorbidity seems to improve PTs' competence through increasing knowledge and clinical reasoning skills. Identified barriers should be solved before large-scale implementation of exercise therapy can take place in these complex patients.

Objective Discharge policies concerning hospitalization after endoscopic pituitary tumor surgery are highly variable. A few studies support fast-track discharge; however, this is not commonplace. Our goal was to report the transition to and evaluate the feasibility, safety, clinical- and patient-reported outcomes and costs of fast-track care in pituitary surgery. Methods This observational study included 155 patients undergoing pituitary surgery between December 2016 and December 2018. Fast-track care consisted of planned discharge 2–3 days after surgery, followed by daily surveillance by a case manager. All outcomes were compared with patients not eligible for fast-track discharge. The total group (fast-track and non-fast-track) was compared with historic controls (N = 307). Results A total of 79/155 patients (51%) were considered eligible for fast-track discharge, of whom 69 (87%) were discharged within 3 days. The total group was discharged more often within 3 days compared with historic controls (49 vs. 20%, p p = 0.363). Although the total group had more readmissions compared with historic controls (17 vs. 10%, p = 0.002), no life-threatening complications occurred after discharge. On average, clinical- and patient-reported outcomes improved over time, both in the fast-track and non-fast-track groups. The mean overall costs within 30 days after surgery did not differ between the total group € 9992 (SD € 4562) and historic controls € 9818 (SD € 3488) (p = 0.649). Conclusion A stratified fast-track care trajectory with enhanced postoperative outpatient surveillance after pituitary tumor surgery is safe and feasible. As expected, costs of the fast-track were lower than the non-fast-track group, however we could not prove overall cost-effectiveness compared with the historic controls.

ObjectiveMany individuals with axial spondyloarthritis (axSpA) do not engage in adequate exercise, despite its proven health benefits. This study aimed to identify the intervention components needed to optimize exercise behavior in people with axSpA.MethodsThe first three steps of the Intervention Mapping protocol were used: 1) needs assessment; 2) identification of axSpA-specific exercise barriers and facilitators (´determinants’); 3) selection of effective intervention components addressing potentially modifiable determinants. All three steps included scoping reviews and semi-structured interviews with patients (n = 2) and physical therapists (n = 2).ResultsThe scoping reviews included 28, 23 and 15 papers, respectively. Step 1 showed that only one third of axSpA patients exercise regularly, demonstrating especially a lack of strengthening and cardiorespiratory exercises. Based on eight determinants identified in Step 2, 10 intervention components were selected in Step 3: education, motivational interviewing, goal setting, action planning, monitoring, feedback, tailoring, guided practice, therapists’ training and group exercise encouragement.ConclusionUsing the Intervention Mapping method, 10 intervention components for optimizing exercise behavior in people with axSpA were identified and an intervention with behavior change guidance and a training for health professionals is proposed.Practice ImplicationsThis study provides a foundation for the development of an axSpA-specific exercise intervention.

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.

About 33% patients with osteoarthritis undergoing total hip/knee arthroplasty are not satisfied with the outcome, warranting the need to improve patient selection. Handgrip strength (HGS) has been suggested as a proxy for overall muscle strength and may be associated with post-arthroplasty function. This study aims to assess the association of pre-operative HGS with change in hip/knee function and quality of life in patients with arthroplasty. 226 hip (THA) and 246 knee (TKA) arthroplasty patients were included in this prospective cohort study. Pre-operative HGS was assessed by means of a dynamometer and the HOOS/KOOS and SF-36 questionnaires were collected before arthroplasty and 1 year thereafter. The association of HGS with score change on each sub-domain of the included questionnaires was assessed by linear regression models, adjusting for sex, body mass index and baseline score. Mean pre-operative HGS was 26 kg for patients undergoing THA and 24 kg for those undergoing TKA. HGS was positively associated with an increased improvement score on “function in sport and recreation”-domain in hip (β = 0.68, P = 0.005) and knee (β = 0.52, P = 0.049) and “symptoms”-domain in hip (β = 0.56, P = 0.001). For patients with THA, HGS was associated with the “quality of life” domain (β = 0.33, P = 0.033). In patients with TKA, HGS was associated with the physical component score (β = 0.31, P = 0.001). All statistically significant effects were positive, indicating that with greater pre-operative HGS, an increased gain in 1-year post-surgery score was observed. HGS can be used as a tool to inform patients with OA who are future candidates for a prosthesis about the possible improvements of certain aspects of life after arthroplasty.

Background To address the well-documented gap between hip and knee osteoarthritis (OA) treatment recommendations and current clinical practice, a structured model for integrated OA care was developed and evaluated in a stepped-wedge cluster-randomised controlled trial. The current study used secondary outcomes to evaluate clinically important response to treatment through the Outcome Measures in Rheumatology Clinical Trials clinical responder criteria (OMERACT-OARSI responder criteria) after 3 and 6 months between patients receiving the structured OA care model vs. usual care. Secondly, the study aimed to investigate if the proportion of responders in the intervention group was influenced by adherence to the exercise program inherent in the model. Methods The study was conducted in primary healthcare in six Norwegian municipalities. General practitioners and physiotherapists received training in OA treatment recommendations and use of the structured model. The intervention group attended a physiotherapist-led OA education program and performed individually tailored exercises for 8–12 weeks. The control group received usual care. Patient-reported pain, function and global assessment of disease activity during the last week were evaluated using 11-point numeric rating scales (NRS 0–10). These scores were used to calculate the proportion of OMERACT-OARSI responders. Two-level mixed logistic regression models were fitted to investigate differences in responders between the intervention and control group. Results Two hundred eighty-four intervention and 109 control group participants with hip and knee OA recruited from primary care in six Norwegian municipalities. In total 47% of the intervention and 35% of the control group participants were responders at 3 or 6 months combined; showing an uncertain between-group difference (ORadjusted 1.38 (95% CI 0.41, 4.67). In the intervention group, 184 participants completed the exercise programme (exercised ≥2 times/week for ≥8 weeks) and 55% of these were classified as responders. In contrast, 28% of the 86 non-completers were classified as responders. Conclusions The difference in proportion of OMERACT-OARSI responders at 3 and 6 months between the intervention and control group was uncertain. In the intervention group, a larger proportion of responders were seen among the exercise completers compared to the non-completers. Clinical trial registration Clinicaltrials.gov identifier: NCT02333656. Registered 7. January 2015.

Information on the association of self-reported knee instability with clinical outcomes after Total Knee Arthroplasty (TKA) and 1 year follow-up is scarce. The aims were to determine (i) the course and prevalence of self-reported knee instability before and 1 year after TKA and (ii) the associations of preoperative, postoperative, and retained self-reported knee instability with pain, activity limitations, and quality of life (QoL) in patients with knee osteoarthritis. Patients undergoing primary TKA, selected from the Longitudinal Leiden Orthopaedics and Outcomes of OsteoArthritis Study, had their knee instability measured using a questionnaire. The Knee injury and Osteoarthritis Outcome Score pain, activity limitations, and QoL subscales were administered before and 1 year after surgery. Multivariable regression analyses were performed to examine associations between knee instability, pain, activity limitations, and QoL, adjusted for covariates (age, gender, comorbidities, and radiographic severity). Of the 908 included patients, 649 (71%) and 187 (21%) reported knee instability before and following TKA, respectively. Of the patients with preoperative knee instability, this perception was retained in 165 (25%) cases. Knee instability was preoperatively associated with pain (B -9.6; 95%CI: -12.4 to -6.7), activity limitations (B -7.5; 95%CI: -10.2 to -4.8), and QoL (B -4.7; 95%CI: -7.0 to -2.4) and postoperatively with pain (B -15.0; 95%CI: -18.5 to -11.6), activity limitations (B -15.1; 95%CI: -18.4 to -11.8), and QoL (B -18.7; 95%CI: -22.3 to -15.3). Retained knee instability was associated with postoperative pain (B -15.1; 95%CI: -18.9 to -11.2), activity limitations (B -14.1; 95%CI: -17.8 to -10.4), and QoL (B -18.0; 95%CI: -21.7 to -14.3). In conclusion, in clinical care, self-reported knee instability is retained postoperatively in 25% of the patients. Retained knee instability is associated with more pain, activity limitations, and poorer QoL postoperatively. © 2018 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 36:2671-2678, 2018.

Objective Although widely advocated, applying Value Based Health Care (VBHC) in clinical practice is challenging. This study describes VBHC-based perioperative outcomes for patients with pituitary tumors up to 6 months postoperatively. Methods A total of 103 adult patients undergoing surgery were prospectively followed. Outcomes categorized according to the framework of VHBC included survival, degree of resection, endocrine remission, visual outcome (including self-perceived functioning), recovery of pituitary function, disease burden and health-related quality of life (HRQoL) at 6 months (Tier 1); time to recovery of disease burden, HRQoL, visual function (Tier 2); permanent hypopituitarism and accompanying hormone replacement (Tier 3). Generalized estimating equations (GEEs) analysis was performed to describe outcomes over time. Results Regarding Tier 1, there was no mortality, 72 patients (70%) had a complete resection, 31 of 45 patients (69%) with functioning tumors were in remission, 7 (12%, with preoperative deficits) had recovery of pituitary function and 45 of 47 (96%) had visual improvement. Disease burden and HRQoL improved in 36–45% at 6 months; however, there were significant differences between tumor types. Regarding Tier 2: disease burden, HRQoL and visual functioning improved within 6 weeks after surgery; however, recovery varied widely among tumor types (fastest in prolactinoma and non-functioning adenoma patients). Regarding Tier 3, 52 patients (50%) had persisting (tumor and treatment-induced) hypopituitarism. Conclusions Though challenging, outcomes of a surgical intervention for patients with pituitary tumors can be reflected through a VBHC-based comprehensive outcome set that can distinguish outcomes among different patient groups with respect to tumor type.

Background To improve quality of care for patients with hip and knee osteoarthritis (OA), a structured model for integrated OA care was developed based on international recommendations. The objective of this study was to assess the effectiveness of this model in primary care. Methods and findings We conducted a cluster-randomised controlled trial with stepped-wedge cohort design in 6 Norwegian municipalities (clusters) between January 2015 and October 2017. The randomised order was concealed to the clusters until the time of crossover from the control to the intervention phase. The intervention was implementation of the SAMBA model, facilitated by interactive workshops for general practitioners and physiotherapists with an update on OA treatment recommendations. Patients in the intervention group attended a physiotherapist-led OA education and individually tailored exercise programme for 8–12 weeks. The primary outcome was patient-reported quality of care (OsteoArthritis Quality Indicator questionnaire; 0–100, 100 = optimal quality) at 6 months. Secondary outcomes included patient-reported referrals to physiotherapy, magnetic resonance imaging (MRI), and orthopaedic surgeon consultation; patients’ satisfaction with care; physical activity level; and proportion of patients who were overweight or obese (body mass index ≥ 25 kg/m2). In all, 40 of 80 general practitioners (mean age [SD] 50 [12] years, 42% females) and 37 of 64 physiotherapists (mean age [SD] 42 [8] years, 65% females) participated. They identified 531 patients, of which 393 patients (mean age [SD] 64 [10] years, 71% females) with symptomatic hip or knee OA were included. Among these, 109 patients were recruited during the control periods (control group), and 284 patients were recruited during interventions periods (intervention group). The patients in the intervention group reported significantly higher quality of care (score of 60 versus 41, mean difference 18.9; 95% CI 12.7, 25.1; p < 0.001) and higher satisfaction with OA care (odds ratio [OR] 12.1; 95% CI 6.44, 22.72; p < 0.001) compared to patients in the control group. The increase in quality of care was close to, but below, the pre-specified minimal important change. In the intervention group, a higher proportion was referred to physiotherapy (OR 2.5; 95% CI 1.08, 5.73; p = 0.03), a higher proportion fulfilled physical activity recommendations (OR 9.3; 95% CI 2.87, 30.37; p < 0.001), and a lower proportion was referred to an orthopaedic surgeon (OR 0.3; 95% CI 0.08, 0.80; p = 0.02), as compared to the control group. There were no significant group differences regarding referral to MRI (OR 0.6; 95% CI 0.13, 2.38; p = 0.42) and proportion of patients who were overweight or obese (OR 1.3; 95% CI 0.70, 2.51; p = 0.34). Study limitations include the imbalance in patient group size, which may have been due to an increased attention to OA patients among the health professionals during the intervention phase, and a potential recruitment bias as the patient participants were identified by their health professionals. Conclusions In this study, a structured model in primary care resulted in higher quality of OA care as compared to usual care. Future studies should explore ways to implement the structured model for integrated OA care on a larger scale. Trial registration ClinicalTrials.gov NCT02333656., Author summary Why was this study done? Hip and knee osteoarthritis is a common chronic joint disease in the adult population causing significant pain and disability. Non-surgical treatment modalities including patient osteoarthritis education, exercise therapy, and weight management represent core treatments recommended in professional guidelines. However, they are currently underutilised in people with hip and knee osteoarthritis. It is not established to what extent a structured osteoarthritis care model can change this and improve the quality of care. What did the researchers do and find? A cluster-randomised trial was conducted to compare a structured osteoarthritis care model with usual care with respect to appropriate care delivery in people with hip and knee osteoarthritis. Forty general practitioners and 37 physiotherapists working in primary care attended workshops to get an update on recommendations for osteoarthritis care and were trained in the core elements of the structured care model: osteoarthritis education in groups, an individually tailored 8- to 12-week exercise programme, and a dietary intervention, if needed. Of the 393 patient participants, 284 were allocated to the intervention group and 109 to the usual care group. At 6 months, patient-reported quality of care and satisfaction with care were greater, more patients were referred to physiotherapy and fewer to orthopaedic surgeons, and more patients fulfilled physical activity criteria in the intervention group as compared to the usual care group. What do these findings mean? A structured osteoarthritis care model provided by trained primary care general practitioners and physiotherapists resulted in the provision of osteoarthritis care that was more in line with current care recommendations and in higher patient-reported quality of care and satisfaction as compared to usual care. A structured and well-planned approach, in line with evidence-based treatment recommendations for hip and knee osteoarthritis and executed in primary care, has the potential to improve patients’ health and reduce disability. In doing so, it may also reduce the risk of sick leave and may thereby reduce the direct and indirect costs of osteoarthritis for the individual and the society. Although a stepped-wedge cluster-randomised controlled trial design is appropriate to conduct an effectiveness study in a clinical practice setting, strategies to prevent selection bias and differences in recruitment rates in the control and intervention periods are needed.

Background Foot orthoses (FOs) are prescribed as an important conservative treatment option in patients with foot problems related to rheumatoid arthritis. However, a broad variation in FOs is used, both in clinical practice and in research. To date, there is no overview on the outcomes of the treatment with different kinds of FOs in patients with rheumatoid arthritis and a specific foot problem. The objectives of the present study were to summarize the comparative effectiveness of FOs in the treatment of various foot problems in patients with rheumatoid arthritis, on the primary outcomes foot function and foot pain, and the secondary outcomes physical functioning, health related quality of life, compliance, adverse events, the costs of FOs and patient satisfaction. Methods Studies comparing different kinds of FOs, with a presumed therapeutic effect, in the treatment of foot problems related to rheumatoid arthritis were included. A literature search was conducted in The Cochrane Central Registry for Controlled Trials (CENTRAL), PubMed, EMBASE and PEDro up to May 18th, 2018. Data was meta-analyzed, when this was not possible qualitative data analysis was performed. Results Ten studies were identified, with a total number of 235 patients. These studies made a comparison between different materials used (soft versus semi-rigid), types of FOs (custom-made versus ready-made; total-contact versus non-total contact), or modifications applied (metatarsal bars versus domes). Also, different techniques to construct custom-made FOs were compared (standard custom-molding techniques versus more sophisticated techniques). A medium effect for (immediate) reduction of forefoot plantar pressure was found in favor of treatment with soft FOs compared to semi-rigid FOs (SMD 0.60, 95% CI 0.07–1.14; P = 0.03; 28 participants). Other comparisons between FOs resulted in non-significant effects or inconclusive evidence for one kind of FOs over the other. Conclusions Foot orthoses made of soft materials may lead to more (immediate) forefoot plantar pressure reduction compared to foot orthoses constructed of semi-rigid materials. Definitive high quality RCTs, with adequate sample sizes and long-term follow-up, are needed to investigate the comparative (cost-) effectiveness of different kinds of foot orthoses for the treatment of foot problems related to rheumatoid arthritis. Electronic supplementary material The online version of this article (10.1186/s13047-019-0338-x) contains supplementary material, which is available to authorized users.

Introduction: Up to 33% and 25% of patients with end-stage hip and knee osteoarthritis (OA) are considered frail by the Groningen Frailty Indicator (GFI). This study aims to assess whether frail patients have lower functional gains after arthroplasty and to assess GFI as a tool to discriminate between good and adverse change score. Materials and Methods: Patients with end-stage hip/knee OA scheduled for arthroplasty were recruited from the Longitudinal Leiden Orthopaedics Outcomes of Osteo-Arthritis Study. Functional outcome was measured as change score on the Hip Osteoarthritis Outcome Score/Knee Osteoarthritis Outcome Score (HOOS/KOOS), by subtracting preoperative score from 1-year postsurgery score and then dichotomized based on a cutoff of 20 points. For each HOOS/KOOS subscale, 3 models were estimated: GFI univariate (model 1), GFI and baseline score (model 2), and baseline score univariate (model 3). A receiver operating characteristic analysis was performed to assess the discriminative ability of each model. Results: Eight hundred five patients with end-stage hip OA (31.4% frail) and 640 patients with end-stage knee OA (25.4% frail) were included. Frail patients were older, had a higher body mass index, had more comorbidities, and lived more often alone. Persons considered frail by GFI had significant lower baseline score; however, except for “function in sports and recreation” and “quality of life,” change scores were similar in frail and nonfrail persons. The discriminatory value of GFI was negligible for all HOOS/KOOS subscales. Baseline score, however, was adequate to discriminate between total knee arthroplasty patients with more or less than twice the minimally clinically important difference on KOOS symptoms subscale (area under the curve = 0.802). Discussion/Conclusion: Although frail patients with OA have lower functioning scores at baseline, the change scores on HOOS/KOOS subscales are similar for both frail and nonfrail patients. Exploring other heath assessements may improve patient-specific outcome prediction.

Background and purpose — There is no consensus on the impact of radiographic severity of hip and knee osteoarthritis (OA) on the clinical outcome of total hip arthroplasty (THA) and total knee arthroplasty (TKA). We assessed whether preoperative radiographic severity of OA is related to improvements in functioning, pain, and health-related quality of life (HRQoL) 1 year after THA or TKA. Patients and methods — This prospective cohort study included 302 THA patients and 271 TKA patients with hip or knee OA. In the THA patients, preoperatively 26% had mild OA and 74% had severe OA; in the TKA patients, preoperatively 27% had mild OA and 73% had severe OA. Radiographic severity was determined according to the Kellgren and Lawrence (KL) classification. Clinical assessments preoperatively and 1 year postoperatively included: sociodemographic characteristics and patient-reported outcomes (PROMs): Oxford hip/knee score, hip/knee injury and osteoarthritis outcome score (HOOS/KOOS), SF36, and EQ5D. Change scores of PROMs were compared with mild OA (KL 0–2) and severe OA (KL 3–4) using a multivariate linear regression model. Results — Adjusted for sex, age, preoperative scores, BMI, and Charnley score, radiographic severity of OA in THA was associated with improvement in HOOS “Activities of daily living”, “Pain”, and “Symptoms”, and SF36 physical component summary (“PCS”) scale. In TKA, we found no such associations. Interpretation — The decrease in pain and improvement in function in THA patients, but not in TKA patients, was positively associated with the preoperative radiographic severity of OA.

Introduction Pituitary tumors may have a considerable impact on patients’ functional status, including paid employment, yet research in this area is sparse. Objective To describe work disability and its determinants in patients treated for a pituitary tumor. Methods Cross-sectional study including patients treated for a pituitary tumor in the working age (18–65 years), who completed five validated questionnaires assessing work disability [Short Form-Health and Labour Questionnaire, Work Role Functioning Questionnaire 2.0 (WRFQ)], health-related quality of life (HRQoL) and utility (Short Form-36, EuroQoL) and disease burden (Leiden Bother and Needs Questionnaire-Pituitary). Additional data were extracted from the medical records (age, gender, tumor type, treatment, date of diagnosis) and self-reports (marital status, education, endocrine status). Associations of disease-specific and sociodemographic characteristics, HRQoL, and disease burden with (not) having a paid job were examined through multivariate logistic regression. Results We included 241 patients (61% female, median age 53 years, median time since diagnosis 11 years), of whom 68 (28%) were without a paid job. Patients who had acromegaly, Cushing’s disease, (pan)hypopituitarism, radiotherapy, were single, less educated, lower HRQoL, and increased disease burden were more often without a paid job (p

Background and aims Previous studies have suggested there is an association between preoperative expectations about the outcome and outcomes of total knee and total hip arthroplasty (TKA/THA). However, expectations have been rarely examined on their clinical relevance relative to other well-known predictive factors. Furthermore expectations can be measured on a more generic level (e.g. does one expect their symptoms to improve after surgery) or on a more specific level (e.g. does one expect to be able to squat again after surgery). Aim of this study was to examine whether patients’ general and specific preoperative outcome expectations predict function and pain 12-months after TKA/THA, when assessed as one of the candidate predictive variables alongside other relevant clinical and sociodemographic variables. Moreover, we explored whether a more generic or a more specific assessment of expectations would better predict outcome. Methods A prospective cohort study on consecutive TKA/THA patients, with assessments done preoperatively and 12-months postoperative. Primary outcomes were the knee injury and osteoarthritis outcome score (KOOS) and hip injury and osteoarthritis outcome score (HOOS) activities of daily living (ADL) and pain subscale scores at 12-months. The pain subscales consist of nine-(KOOS) and 10-(HOOS) items and the ADL of 17 items. Patients’ preoperative outcome expectations were measured with the credibility expectancy questionnaire (CEQ), which contains three items scored on a 0–9 scale and sum score 0–27 and the Hospital for Special Surgery expectations surveys (HSS expectation surveys) for 17(TKA) or 18(THA) outcomes on 0–4 scale. Other candidate predictors: preoperative pain and function as measured with HOOS/KOOS, sex, age, education level, body mass index, Kellgren/Lawrence score, preoperative mental health and treatment credibility as measured with CEQ. Eight prediction models were constructed using multivariate linear regression analysis with a backward selection procedure. Results The 146 TKA patients included in this study had a mean age of 66.9 years (SD 9.2) and 69% was female. The 148 THA patients had a mean age 67.2 (SD 9.5) and 57% was female. Mean outcomes: postoperative HOOS-ADL 84.3 (SD 16.6), pain 88.2 (SD 15.4), KOOS-ADL 83.9 (SD 15.8) and pain 83.6 (SD 17.1). CEQ-expectancy median was in THA 23 (IQR 21;24) and TKA 23 (IQR 20;24). HSS-expectation surveys function was for THA 21.0 (18.0;24.0) and 19.0 (14.0;22.0) in TKA. Patients’ outcome expectations were consistently part of the combination of variables that best predicted outcomes for both TKA/THA 1-year post-operatively. Expectations alone explained between 17.0 and 30.3% of the variance in outcomes. The CEQ expectancy subscale explained more variance of postoperative function in TKA and of function and pain in THA as compared to the HSS expectation surveys. Conclusions In planning of surgical treatment, orthopedic surgeons should take a range of variables into account of which the patient’s expectations about outcome of surgery is one. The CEQ expectancy subscale predicted outcomes slightly better as the HSS expectation surveys, but differences in predictive value of the two measurements were too small to prefer between the two. Future studies are advised to replicate these findings and externally validate the models presented.

The study summarizes the evidence on the effectiveness of therapeutic shoes on foot function, foot pain, physical functioning, health-related quality of life, adherence, adverse events and patient satisfaction in patients with rheumatoid arthritis (RA). Studies investigating the effect of (ready- or custom-made) therapeutic shoes were included. For between-group designs, studies comparing therapeutic shoes versus non-therapeutic shoes were included. A literature search was conducted in The Cochrane Central Registry for Controlled Trials (CENTRAL), PubMed, EMBASE and PEDro up to January 19, 2017. Quantitative data analysis was conducted; when this was not possible qualitative data analysis was performed. Eleven studies were identified. For custom-made shoes, no studies reporting between-group differences were available. Qualitative data-syntheses of the within-group differences resulted in weak evidence for the reduction of foot pain and improvement of physical functioning. For ready-made shoes, one study reported between-group differences, resulting in inconclusive evidence for improvement of foot function. Quantitative data-analyses of within-group differences resulted in a medium to large effect for the reduction of foot pain (SMD 0.60, 95% CI 0.28-0.92; P ≤ 0.001; 184 participants) and a small to medium effect for the improvement of physical functioning (SMD 0.30, 95% CI 0.04-0.56; P = 0.02; 150 participants). Qualitative data-synthesis of within-group differences resulted in weak evidence for improvement of foot function. Within-group results indicate that therapeutic shoes are likely to be effective in patients with RA. Definitive high-quality RCTs are necessary to investigate the between-group effectiveness of therapeutic shoes in patients with RA.

Background The aim of this randomized controlled trial was to evaluate the effect of a ‘supply on demand’-distribution strategy, compared to an ‘unsolicited supply’-distribution strategy, on the use of a care booklet and clinical outcomes among patients with rheumatoid arthritis (RA). In addition, differences in socio-demographic and clinical characteristics between users and non-users were explored. Methods As part of regular care the care booklet was distributed among RA-patients of two hospitals in the Netherlands. 1000 patients received the care booklet by mail, whereas another 1000 received an information letter with the option to order the care booklet. Four months after distribution, a random sample of 810 patients (stratified by hospital and distribution method) received a questionnaire on the use of the booklet, social-demographic and clinical characteristics. To compare effects between the two distribution strategies and differences between users and non-users univariate and multilevel regression analyses were performed. Secondary analysis included a per-protocol analysis (excluding participants who did not order the care booklet). Results One hundred ninety four patients in the ‘unsolicited supply’ and 176 patients in the ‘supply on demand’ group (46%) returned the questionnaire. In the ‘supply on demand’ group 106 (60.2%) participants ordered the care booklet. In total, no difference was found in use between the ‘unsolicited supply’-group (23.2%) and the ‘supply on demand’-group (21.6%) (OR 0.9 CI:0.6–1.5). However, the proportion of users among patients in the ‘supply on demand’-group who ordered the booklet (35%) was significantly higher than in the ‘unsolicited supply’-group (OR 1.9 CI:1.1–3.2). Regardless of distribution method, use of the care booklet was associated with being married (OR 2.4 CI:1.2–4.6), higher disease activity (mean difference 0.5 CI: 0.0–1.1), more activity limitations (mean difference 0.2 CI: 0.1–0.4), use of corticosteroids (OR 1.9 CI:1.0–3.5), perception of disease course as fluctuating (mean difference 1.4 CI:0.5–2.3) and higher educational needs (mean difference 9.7 CI: 2.9–16.6). Conclusions From an economic and environmental perspective a ‘supply on demand’-distribution strategy could be recommended. Results of this study provide starting points to optimize further implementation strategies of a care-booklet in routine care. Trial registration ISRCTN registry (ISRCTN22703067). Retrospectively registered 27 March 2017. Electronic supplementary material The online version of this article (10.1186/s12913-018-3039-4) contains supplementary material, which is available to authorized users.

Background The ability to preoperatively predict postoperative complication risks is valuable for individual counseling and (post)operative planning, e.g. to select low-risk patients eligible for short stay surgery or those with higher risks requiring special attention. These risks however, are not well established in pituitary surgery. Methods We conducted a systematic review of associations between preoperative characteristics and postoperative complications of endoscopic transsphenoidal surgery according to the PRISMA guidelines. Risk of bias was assessed through the QUIPS tool. Results In total 23 articles were included, containing 5491 patients (96% pituitary adenoma). There was a wide variety regarding the nature and number of risk factors, definitions, measurement and statistics employed, and overall quality of mainly retrospective studies was low. Consistent significant associations were older age for complications in general, and intraventricular extension for cerebrospinal fluid (CSF) leaks. Associations identified in some but not all studies were younger age, increased BMI, female gender, and learning curve for CSF leaks; increased tumor size for complications in general; and Rathke’s cleft cysts for diabetes insipidus. Mortality (incidence rate 1%) was not addressed as a risk factor. Conclusion Based on current literature, of low to medium quality, it is not possible to comprehensively quantify risk factors for complications. Nevertheless, older age and intraventricular extension were associated with increased postoperative complications. Future research should aim at prospective data collection, reporting of outcomes, and uniformity of definitions. Only then a proper risk analysis can be performed for endoscopic pituitary surgery. Electronic supplementary material The online version of this article (doi:10.1007/s11102-017-0839-1) contains supplementary material, which is available to authorized users.

Background Unmet needs are common after stroke. We aimed to translate the 22-item Longer-term Unmet Needs after Stroke (LUNS) Questionnaire and validate it in a Dutch stroke population. Methods The LUNS was translated and cross-culturally adapted according to international guidelines. After field testing, the Dutch version was administered twice to a hospital-based cohort 5-8 years after stroke. Participants were also asked to complete the Frenchay Activity Index (FAI) and Short Form (SF)-12. To explore acceptability, the response and completion rates as well as number of missing items were computed. For concurrent validity, the differences in health status (FAI, SF-12) between groups who did and did not report an unmet need were calculated per item. To determine the 14-day test-retest reliability, the percentage of agreement between the first and the second administration was calculated for each item. Results Seventy-eight of 145 patients (53.8%) returned the initial Dutch LUNS (average age 68.3 [standard deviation 14.0] years, 59.0% male); 66 of these patients (84.6%) fully completed it. Of all items, 3.3% were missing. Among completers, the median number of unmet needs was 3.5 (2.0-5.0; 1.0-14.0). For 15 of 22 items, there was a significant association with the FAI or SF-12 Mental or Physical Component Summary scales. The percentage of agreement ranged from 69.8% to 98.1% per item. Conclusions Among the 53.8% who completed the survey, the LUNS was concluded to be feasible, reliable, and valid; two-thirds of its items were related to activities and quality of life. Its usefulness and acceptability when administered in routine practice require further study.

Musculoskeletal ultrasound has evolved into an important clinical decision-making tool by assisting in the diagnosis of inflammatory arthritis, monitoring disease activity and therapeutic response, and guiding interventions.1–7 The role of the non-medical health professional has advanced, with many undertaking training and using musculoskeletal ultrasound to improve patient care and in doing so, increasing their scope of practice. Health professionals with clinical expertise and experience using ultrasound are also providing training for colleagues and medical clinicians. As previously described among rheumatologists,8 ,9 the use of musculoskeletal ultrasound and training undertaken varies significantly between different professional groups and across Europe. Guidelines to support training for rheumatologists have been formulated10 but currently there are no recommendations to support the education and training needs of non-medical health professionals using musculoskeletal ultrasound. A European League Against Rheumatism (EULAR) task force was established to reach a consensus on the role of, and education and training needs of health professionals undertaking musculoskeletal ultrasound for the management of people with …

Background Physical activity (PA) in patients with traumatic brain injury (TBI) may be impaired leading to secondary health issues and limitations in participation. Aim This study aims to determine the level of PA and its determinants in adolescents and young adults with TBI. Design Cross-sectional survey study. Setting Outpatient clinic of a rehabilitation center. Population Discharged patients aged 12-39 years with a diagnosis of TBI >6 months treated in the rehabilitation center between 2009-2012. Methods The Activity Questionnaire for Adults and Adolescents (AQuAA) measuring PA, with results dichotomized for meeting or not meeting Dutch recommendations for health-enhancing physical activity (D-HEPA) and the Checklist Individual Strength questionnaire (CIS; range 20-140, higher scores represent higher levels of fatigue), measuring fatigue, were administered. Results Fifty (47%) of the 107 invited patients completed the questionnaire. Mean age was 25.0±7.2 years and 22 (44%) were male. Eighteen (36%) had a mild injury, 13 (26%) a moderate injury and 19 (38%) a severe injury. Median time spent on moderate-vigorous physical activity was 518 minutes/week (IQR 236-1725) (males performing significantly more minutes on moderate-vigorous activity than women) and on sedentary activity 2728 minutes/week (IQR 1637-3994). Thirty-two (64%) participants met the D-HEPA. According to the CIS, 19 participants (38%) were severely fatigued. Both the CIS total score and the subscales motivation and physical activity were associated with meeting the D-HEPA. Conclusions The proportion of individuals with TBI meeting D-HEPA was similar to the general population, with the PA level being associated with self-reported fatigue. Clinical rehabilitation impact Physical activity programs are continuously being developed to increase the percentage of individuals meeting public health recommendations for PA; when developing programs for individuals with TBI extra consideration should be taken for the presence of fatigue. As in the general population, females with TBI are less active, PA programs should probably consider gender differences in their development.

BACKGROUND: To describe the prevalence of self-reported knee joint instability in patients with pre-surgery knee osteoarthritis (OA) and to explore the associations between self-reported knee joint instability and radiological features.METHODS: A cross-sectional study including patients scheduled for primary Total Knee Arthroplasty (TKA). Self-reported knee instability was examined by questionnaire. Radiological features consisted of osteophyte formation and joint space narrowing (JSN), both scored on a 0 to three scale. Scores >1 are defined as substantial JSN or osteophyte formation. Regression analyses were provided to identify associations of radiological features with self-reported knee joint instability.RESULTS: Two hundred and sixty-five patients (mean age 69years and 170 females) were included. Knee instability was reported by 192 patients (72%). Substantial osteophyte formation was present in 78 patients (41%) reporting and 33 patients (46%) not reporting knee joint instability. Substantial JSN was present in 137 (71%) and 53 patients (73%), respectively. Self-reported knee instability was not associated with JSN (relative to score 0, odds ratios (95% CI) of score 1, 2 and 3 were 0.87 (0.30-2.54), 0.98 (0.38-2.52), 0.68 (0.25-1.86), respectively) or osteophyte formation (relative to score 0, odds ratios (95% CI) of score 1, 2 and 3 were 0.77 (0.36-1.64), 0.69 (0.23-1.45), 0.89 (0.16-4.93), respectively). Stratified analysis for pain, age and BMI showed no associations between self-reported knee joint instability and radiological features.CONCLUSION: Self-reported knee joint instability is not associated with JSN or osteophyte formation.

Background Perioperative autologous blood salvage and preoperative erythropoietin are not (cost) effective to reduce allogeneic transfusion in primary hip and knee arthroplasty, but are still used. This study aimed to evaluate the effectiveness of a theoretically informed multifaceted strategy to de-implement these low-value blood management techniques. Methods Twenty-one Dutch hospitals participated in this pragmatic cluster-randomized trial. At baseline, data were gathered for 924 patients from 10 intervention and 1040 patients from 11 control hospitals undergoing hip or knee arthroplasty. The intervention included a multifaceted de-implementation strategy which consisted of interactive education, feedback on blood management performance, and a comparison with benchmark hospitals, aimed at orthopedic surgeons and anesthesiologists. After the intervention, data were gathered for 997 patients from the intervention and 1096 patients from the control hospitals. The randomization outcome was revealed after the baseline measurement. Primary outcomes were use of blood salvage and erythropoietin. Secondary outcomes included postoperative hemoglobin, length of stay, allogeneic transfusions, and use of local infiltration analgesia (LIA) and tranexamic acid (TXA). Results The use of blood salvage (OR 0.08, 95% CI 0.02 to 0.30) and erythropoietin (OR 0.30, 95% CI 0.09 to 0.97) reduced significantly over time, but did not differ between intervention and control hospitals (blood salvage OR 1.74 95% CI 0.27 to 11.39, erythropoietin OR 1.33, 95% CI 0.26 to 6.84). Postoperative hemoglobin levels were significantly higher (β 0.21, 95% CI 0.08 to 0.34) and length of stay shorter (β −0.36, 95% CI −0.64 to −0.09) in hospitals receiving the multifaceted strategy, compared with control hospitals and after adjustment for baseline. Transfusions did not differ between the intervention and control hospitals (OR 1.06, 95% CI 0.63 to 1.78). Both LIA (OR 0.0, 95% CI 0.0 to 0.0) and TXA (OR 0.3, 95% CI 0.2 to 0.5) were significantly associated with the reduction in blood salvage over time. Conclusions Blood salvage and erythropoietin use reduced over time, but not differently between intervention and control hospitals. The reduction in blood salvage was associated with increased use of local infiltration analgesia and tranexamic acid, suggesting that de-implementation is assisted by the substitution of techniques. The reduction in blood salvage and erythropoietin did not lead to a deterioration in patient-related secondary outcomes. Trial registration www.trialregister.nl, NTR4044 Electronic supplementary material The online version of this article (doi:10.1186/s13012-017-0601-0) contains supplementary material, which is available to authorized users.

Purpose. The aim of this study was to translate and culturally adapt the Toronto Extremity Salvage Score (TESS) to Dutch and to validate the translated version. Methods. The TESS lower and upper extremity versions (LE and UE) were translated to Dutch according to international guidelines. The translated version was validated in 98 patients with surgically treated bone or soft tissue tumors of the LE or UE. To assess test-retest reliability, participants were asked to fill in a second questionnaire after one week. Construct validity was determined by computing Spearman rank correlations with the Short Form- (SF-) 36. Results. The internal consistency (0.957 and 0.938 for LE and UE, resp.) and test-retest reliability (intraclass correlation coefficients 0.963 and 0.969 for LE and UE, resp.) were good for both questionnaires. The Dutch LE and UE TESS versions correlated most strongly with the SF-36 physical function dimension (r=0.737 for LE, 0.726 for UE) and the physical component summary score (r=0.811 and 0.797 for LE and UE). Interpretation. The Dutch TESS questionnaire for lower and upper extremities is a consistent, reliable, and valid instrument to measure patient-reported physical function in surgically treated patients with a soft tissue or bone tumor.

Background This systematic review gives an overview of guidelines and original publications as well as the evidence on which the currently proposed indication criteria are based. Until now such a state-of-the-science overview was lacking. Methods Websites of orthopaedic and arthritis organizations (English/Dutch language) were independently searched by two authors for THA/TKA guidelines for OA. Furthermore, a systematic search strategy in several databases through August 2014 was performed. Quality of the guidelines was assessed with the AGREE II instrument, which consists of 6 domains (maximum summed score of 6 indicating high quality). Also, the level of evidence of all included studies was assessed. Results We found 6 guidelines and 18 papers, out of 3065 references. The quality of the guidelines summed across 6 domains ranged from 0.46 to 4.78. In total, 12 THA, 10 TKA and 2 THA/TKA indication sets were found. Four studies stated that no evidence-based indication criteria are available. Indication criteria concerning THA/TKA consisted of the following domains: pain (in respectively 11 and 10 sets), function (12 and 7 sets), radiological changes (10 and 9 sets), failed conservative therapy (8 and 4 sets) and other indications (6 and 7 sets). Specific cut-off values or ranges were often not stated and the level of evidence was low. Conclusion The indication criteria for THA/TKA are based on limited evidence. Empirical research is needed, especially regarding domain specific cut-off values or ranges at which the best postoperative outcomes are achieved for patients, taking into account the limited lifespan of a prosthesis. Electronic supplementary material The online version of this article (doi:10.1186/s12891-016-1325-z) contains supplementary material, which is available to authorized users.

Background The aims of this study were to assess patients' preoperative expectations of the outcome of total hip or knee arthroplasty (THA/TKA) regarding specific aspects of functioning and to determine to what extent each expectation was fulfilled after 1 year. Methods This was a prospective cohort study. Preoperative expectations and their fulfillment after 1 year were measured with the Hospital for Special Surgery Hip/Knee arthroplasty Expectations Surveys. Preoperative and postoperative scores were subtracted to calculate whether expectations were unfulfilled, fulfilled, or exceeded. Results A total of 343 THA and 322 TKA patients with complete follow-up were included. Preoperatively, >60% of patients (both THA/TKA) expected to get back to normal or have much improvement in 19 of 20 (THA) and 12 of 19 (TKA) items. Expectations were fulfilled or exceeded in >60% of patients in all 20 items for THA and 17 of 19 items for TKA. In THA, items with the largest proportions patients with unfulfilled expectations (>30%) were “improvement in walking ability: long distances” (31%), “walking stairs” (33%), and “improve ability to cut toenails” (38%). In TKA, expectations for 12 of 19 items were unfulfilled in >30% of patients, with the largest proportions seen for “being able to kneel down” (44%) and “being able to squat” (47%). Conclusion Although for most items, >60% of THA and TKA patients indicated that their expectations were met or exceeded, there was a substantial number of patients, particularly TKA patients, having unfulfilled expectations. These need more attention in preoperative patient information and education.

BackgroundLittle is known about the extent to which improvements in various problem areas are attained after multidisciplinary rehabilitation program in patients with chronic musculoskeletal pain (CMP).AimTo describe the pre- and postcontents of problems in functioning from the Canadian Occupational Performance Measure (COPM) in terms of the International Classification of Functioning, Disability and Health (ICF) in CMP patients following a 15-week rehabilitation program.MethodsIn all patients admitted to a rehabilitation program, the COPM was administered at admission and discharge. The problems identified at admission were linked to ICF chapters using an established linking procedure. Changes of COPM Performance/Satisfaction scores (1-10; low-high) with 95% confidence intervals (CIs) were calculated, and effect sizes (ESs) were computed.ResultsIn total, 165 patients were included with a mean age of 44.1 (SD 12.9)years; among them, 143 (87%) were women. At admission, totally 801 problems were identified and linked to 706 unique ICF categories: 83 (12%) were related to the ICF component Body Functions and 621 (88%) to Activities and Participation. ICF chapters d4 Mobility (124, 18%) and d9 Community social and civic life (143, 20%) were most frequently identified. The median changes of the COPM total scores for Performance and Satisfaction were 2.1 (95% CI 1.9 to 2.3, ES: 1.75) and 3.2 (95% CI 2.9 to 3.4, ES: 2.38).ConclusionA 15-week multidisciplinary treatment program showed that most problems were seen within chapters Mobility and Community life of the ICF. The program led to significant improvements of patient reported problems, the magnitude of which was similar for all different problem areas.