Delivery of a quality improvement program in team-based rehabilitation for patients with rheumatic and musculoskeletal diseases: a mixed methods study

To investigate how a quality improvement program (BRIDGE), designed to promote coordination and continuity in rehabilitation services, was delivered and perceived by providers in routine practice for patients with rheumatic and musculoskeletal diseases. A convergent mixed methods approach was nested within a stepped-wedge, randomized controlled trial. The intervention program was developed to bridge gaps between secondary and primary healthcare, comprising the following elements: motivational interviewing; patient-specific goal setting; written rehabilitation-plans; personalized feedback on progress; and tailored follow-up. Data from health professionals who delivered the program were collected and analyzed separately, using two questionnaires and three focus groups. Results were integrated during the overall interpretation and discussion. The program delivery depended on the providers’ skills and competence, as well as on contextual factors in their teams and institutions. Suggested possibilities for improvements included follow-up with sufficient support from next of kin and external services, and the practicing of action and coping plans, standardized outcome measures, and feedback on progress. Leaders and clinicians should discuss efforts to ensure confident and qualified rehabilitation delivery at the levels of individual providers, teams, and institutions, and pay equal attention to each component in the process from admission to follow-up.IMPLICATIONS FOR REHABILITATIONQuality in rehabilitation should be characterized by a continuous and coordinated process from goal setting to follow-up.To improve the quality, sufficient involvement of next of kin and external services is needed.Clinicians may need training to build confidence in motivational interviewing, action- and coping planning, feedback on progress, and follow-up.Leaders should organize education sessions, optimize schedules, insert standardized outcome measures, and facilitate collaboration across levels of care and services. Quality in rehabilitation should be characterized by a continuous and coordinated process from goal setting to follow-up. To improve the quality, sufficient involvement of next of kin and external services is needed. Clinicians may need training to build confidence in motivational interviewing, action- and coping planning, feedback on progress, and follow-up. Leaders should organize education sessions, optimize schedules, insert standardized outcome measures, and facilitate collaboration across levels of care and services.</p

Effects of high intensity exercise on disease activity, inflammatory markers and cytokines.

<p>Differences between the groups in post intervention (3 months) values, analyzed with ANCOVA with baseline values as covariates.</p><p>All BAS-instruments 0–10, 10 =  worst.</p><p>ASDAS, Ankylosing Spondylitis Disease Activity Score; BASDAI, Bath Ankylosing Spondylitis Disease Activity Index; BASFI, Bath Ankylosing Spondylitis Functional Index; BASMI, Bath Ankylosing Spondylitis Metrology Index; CRP, C-reactive protein; ESR, erythrocyte sedimentation rate; IL, interleukin; sTNFR, soluble tumor necrosis factor receptor.</p>a<p>Estimated regression coefficients,</p>b<p>Hodges-Lehman median estimator,</p>c<p>Mann-Whitney U-test.</p><p>Effects of high intensity exercise on disease activity, inflammatory markers and cytokines.</p

Efficacy of High Intensity Exercise on Disease Activity and Cardiovascular Risk in Active Axial Spondyloarthritis: A Randomized Controlled Pilot Study

<div><p>Background</p><p>Physical therapy is recommended for the management of axial spondyloarthritis (axSpA) and flexibility exercises have traditionally been the main focus. Cardiovascular (CV) diseases are considered as a major health concern in axSpA and there is strong evidence that endurance and strength exercise protects against CV diseases. Therefore, the aim of this study was to investigate the efficacy of high intensity endurance and strength exercise on disease activity and CV health in patients with active axSpA.</p><p>Methods</p><p>In a single blinded randomized controlled pilot study the exercise group (EG) performed 12 weeks of endurance and strength exercise while the control group (CG) received treatment as usual. The primary outcome was the Ankylosing Spondylitis (AS) Disease Activity Score (ASDAS). Secondary outcomes included patient reported disease activity (Bath AS Disease Activity Index [BASDAI]), physical function (Bath AS Functional Index [BASFI]), and CV risk factors measured by arterial stiffness (Augmentation Index [Alx]) and Pulse Wave Velocity [PWV]), cardiorespiratory fitness (VO₂ peak) and body composition. ANCOVA on the post intervention values with baseline values as covariates was used to assess group differences, and Mann Whitney U-test was used for outcomes with skewed residuals.</p><p>Results</p><p>Twenty-eight patients were included and 24 (EG, n = 10, CG, n = 14) completed the study. A mean treatment effect of −0.7 (95%CI: −1.4, 0.1) was seen in ASDAS score. Treatment effects were also observed in secondary outcomes (mean group difference [95%CI]): BASDAI: −2.0 (−3.6, −0.4), BASFI: −1.4 (−2.6, −0.3), arterial stiffness (estimated median group differences [95% CI]): AIx (%): −5.3 (−11.0, −0.5), and for PVW (m/s): −0.3 (−0.7, 0.0), VO₂ peak (ml/kg/min) (mean group difference [95%CI]: 3.7 (2.1, 5.2) and trunk fat (%): −1.8 (−3.0, −0.6). No adverse events occurred.</p><p>Conclusion</p><p>High intensity exercise improved disease activity and reduced CV risk factors in patients with active axSpA. These effects will be further explored in a larger trial.</p><p>Trial Registration</p><p>ClinicalTrials.gov <a href="https://clinicaltrials.gov/ct2/show/NCT01436942" target="_blank">NCT01436942 </a></p></div

Median change in arterial stiffness after 3 months intervention of high intensity exercise, compairsons between control group and exercise group using Mann-Whitney U-test.

<p>Median change in arterial stiffness after 3 months intervention of high intensity exercise, compairsons between control group and exercise group using Mann-Whitney U-test.</p

Baseline descriptive of all patients, exercise group and control group.

<p>ASDAS, Ankylosing Spondylitis Disease Activity Score; BASDAI, Bath Ankylosing Spondylitis Disease Activity Index (0–10, 10 =  worst); CRP, C-reactiv protein; ESR, erythrocyte sedimentation rate NSAIDs, non-steroidal anti-inflammatory drugs; TNF, tumor necrosis factor, SD; standard deviation.</p>a<p>Statistically significant differences between groups. Analysed with bivariate test as appropriate.</p><p>Baseline descriptive of all patients, exercise group and control group.</p

Flow of participants through the randomized controlled pilot study.

<p>EG: exercise group. CG: control group.</p