The MAP-HAND : psychometric properties and differences in activity performance between patients with carpometacarpal osteoarthritis and rheumatoid arthritis

Objective: To assess construct validity (Rasch analyses) of the Measure of Activity Performance of the Hand (MAP-Hand) in people with carpometacarpal osteoarthritis (CMC1 OA), and to explore differences in activity performance between people with CMC1 OA and those with rheumatoid arthritis. Design: Cross-sectional study. Subjects: A total of 180 people with CMC1 OA referred for surgical consultation were recruited from rheumatology clinics in Norway, and 340 people with rheumatoid arthritis were recruited from outpatient rheumatology clinics in the UK. Methods: The MAP-Hand consists of 18 predefined items scored on a 4-point scale from 1 (no difficulty) to 4 (unable to do), from which a mean score is calculated. Construct validity was assessed using Rasch analyses. Differences between the 2 groups were assessed using an independent sample t-test at the group level and differential item functioning (condition as grouping variable) at the item level. Results: Some mis-targeting of data and clusters of dependency were found, but the MAP-Hand scores showed an overall fit to the model. No between group difference in total mean MAP-Hand score was found, but there were significant differences between the 2 groups on item levels. Conclusion: The MAP-Hand showed satisfactory construct validity and could differentiate between people with CMC1 OA and those with rheumatoid arthritis on item levels

Examining the Building Blocks of Health Behavior Change in Rheumatology Rehabilitation: A Theory-Driven Qualitative Study

Gunnhild Berdal,1 Ingvild Kjeken,1 Anita Dyb Linge,2 Ann Margret Aasvold,3 Kjetil Tennebø,4 Siv Grødal Eppeland,5 Anne Sirnes Hagland,6 Guro Ohldieck-Fredheim,7 Helene Lindtvedt Valaas,1,7 Ingvild Bø,8 Åse Klokkeide,9 Maryam Azimi,10 Turid N Dager,1 Anne-Lene Sand-Svartrud1 1Health Services Research and Innovation Unit, Center for Treatment of Rheumatic and Musculoskeletal Diseases (REMEDY), Diakonhjemmet Hospital, Oslo, Norway; 2Muritunet Rehabilitation Centre, Valldal, Ålesund, Norway; 3Meråker Rehabilitation Centre, Meråker, Norway; 4Valnesfjord Health Sports Centre, Valnesfjord, Norway; 5Department of Physiotherapy, Sørlandet Hospital, Arendal, Norway; 6Haugesund Hospital for Rheumatic Diseases, Haugesund, Norway; 7Vikersund Rehabilitation Centre, Vikersund, Norway; 8Department of Rehabilitation, Hospital for Rheumatic Diseases, Lillehammer, Norway; 9Rehabilitering Vest Rehabilitation Centre, Haugesund, Norway; 10REMEDY Patient Advisory Board, Diakonhjemmet Hospital, Oslo, NorwayCorrespondence: Gunnhild Berdal, Health Services Research and Innovation Unit, Center for Treatment of Rheumatic and Musculoskeletal Diseases (REMEDY), Diakonhjemmet Hospital, P.O. Box 23 Vinderen, Oslo, N-0319, Norway, Tel +47 91 88 71 63, Email [email protected]: To identify and describe behavior change techniques (BCTs) used in rehabilitation for patients with rheumatic and musculoskeletal diseases (RMDs), according to their own perceptions. Further, to examine patients’ descriptions of their capability, opportunity, motivation, and readiness for health behavior change.Patients and Methods: Patients were adults in need of specialized, multidisciplinary rehabilitation services due to inflammatory rheumatic disease, systemic connective tissue disease, or fibromyalgia / chronic widespread pain. Semi-structured interviews of 21 patients were analyzed with deductive qualitative content analysis applying three theoretical frameworks: the Behavior Change Technique Taxonomy, the transtheoretical model and stages of change, and the capability, opportunity, and motivation model of behavior.Results: Forty-six BCTs aggregated within 14 BCT groups were identified used by either patients, healthcare professionals (HPs), or both. Goals and planning, feedback and monitoring, social support, shaping knowledge, repetition and substitution were most frequently used to facilitate behavior change. Twenty patients had reached the action stage and made specific lifestyle changes concerning more than half of their goals. Concerning other goals, 6 of these patients reported to be contemplating behavior change and 15 to be preparing for it. The rehabilitation process appeared to strengthen capability, opportunity, motivation, and the desired behaviors. Patient-reported barriers to behavior change were connected with restrictions in physical capability resulting from an unpredictable and fluctuating disease course, weakened motivation, and contextual factors, such as lack of access to healthcare support and training facilities, and high domestic care burden.Conclusion: The rehabilitation process seemed to strengthen individual and contextual prerequisites for behavior change and facilitate the use of required techniques and engagement in the desired behaviors. However, patients with RMDs may need prolonged support from HPs to integrate healthy lifestyle changes into everyday life. The findings can be used to optimize rehabilitation interventions and patients’ persistent engagement in healthy behaviors.Keywords: rheumatic diseases, musculoskeletal diseases, rehabilitation, behavior therapy, qualitative research, patient engagemen

Pre- and post-treatment: Do depression, physical activity and symptom intensity of the eating disorder predict quality of life in women with bulimia nervosa or binge eating disorder?

Background: Eating disorders (EDs) are among the top ten of the gender and age adjusted global burden of diseases in terms of poor quality of life, affecting young women in particular. Treatment of EDs generally focus on alleviating ED-symptomology and quality of life (QoL) is usually not considered an outcome measure, although women with EDs claim that well-being and learning to cope with the disease may be just as important as remission from the symptoms of disease. Therefore, an increased understanding of the relationship between EDs and QoL could be beneficial for improving treatment outcomes in this population. Objective: This study explored the influence of depression, level of physical activity and symptom intensity of eating disorders on quality of life in women with bulimia nervosa (BN) and binge eating disorder (BED) receiving either physical exercise and dietary therapy (PED-t) or cognitive behavioral therapy (CBT). Method: This study utilized data material obtained at the “PED-t trial”. Of the 149 who met at pre-therapy measures, 148 were included in the current thesis and 111 completed measures at post-therapy. Multiple regression analysis was conducted to estimate the influence of the explanatory power of the regression model and the unique contribution from depression, level of physical activity and symptom intensity of eating disorders on variance in QoL both on the complete sample and the two treatment groups. Pearson correlations was used to identify and describe changes in association between depression and symptom intensity of EDs from pre- to post therapy. Results: The regression model consisted of depression, physical activity and symptom intensity of eating disorders, explaining 38 % - 60 % of the variance in QoL. Depression and level of physical activity made a significant unique contribution to variance of QoL, accounting for respectively 38 % - 42 % and 4.7 % of the unique variance in QoL in various analysis. The association between symptom intensity of eating disorder and depression changed from weak to moderate from pre- to post-therapy. Conclusion: Depression may be a more important explanatory variable for QoL than level of physical activity and symptom intensity of eating disorders. It can be beneficial to assess and address depression when treating EDs

Regeneration of Shorea robusta and Schima wallichii under Community Forest Management in Ludikhola watershed, Gorkha district, Nepal

Resource and forest management in Nepal: Resource management is of current global interest because of its role in sustaining natural resources and livelihood for future generations. Hardin's paper, the Tragedy of the Commons", served as a starting point to the wider discussion on challenges for sustainable resource management. Hardin's theory is widely cited in the context of forest management, especially to explain forest degradation, e.g. in the Himalaya where forest degradation has a long history. During the 1950s-1970s it became increasingly difficult to ignore the warnings of severe on-going deforestation in Nepal. Forests were nationalized and owned by the state and they were poorly, if at all, managed. In practice they were therefore commons' in the way that Hardin used the concept; an area of open access resources for anybody to use. The precarious situation pushed forth the formation of institutions and policies that aimed to secure forest sustainability by regulating forest-product outtake. Community Forestry (CF) management was introduced in the late 1970s. Rights to use forests were decentralized from top-down governmental management to bottom-up management by means of locally-run Community Forests (CFs). Theories, aims and hypotheses: Deforestation and forest degradation have shifted towards a stable or a growing forest cover in several areas. Contrary to Hardin's argument that commons' will be depleted if not managed by a public government system or private land tenure, Ostrom argues that communities are capable of managing resources in sustainable ways by self-regulating practices and social check-ups. I hypothesise that her argument is valid with changes in underlying human-ecological factors such as forest user-density and market proximity, i.e. I assume that forests can regenerate sustainably independently of the number of users per forest area, distance to the urban centre and the main district road. I test this by analysing the regeneration of Shorea robusta and Schima wallichii in six CFs located in Ludikhola watershed, Gorkha district, Nepal. The close located forests were heavily degraded when CF management was established c 30 years ago. Methods: I combined results from systematic forest sampling and interviews to determine if forest regeneration is sustainable under the current management regime. Physical and biological features were analysed in a total of 90 plots (10m10m) in a balanced design. Recruits were counted, and DBH of trees measured. I used univariate and multivariate statistics to analyse the quantitative data, whereas qualitative data were used to contextualize numerical results. Major results and conclusions: The CFs are regenerating in a sustainable manner. This is shown by reversed J-shaped size-class distributions and sufficient number of recruits. The environmental variables with the greatest impact on recruits indicate that both species are prone to disturbances related to land-use. Shorea robusta recruits decrease with denser canopy closure and more leaf litter on the ground. The intensity of lopping does not influence the number of recruits, but decreases seedling abundance; and number of recruits decreases in areas where many stems were cut. Environmental variables with an impact on Schima wallichii recruits are fewer, and the environmental variable that explains most of the variability within Schima wallichii recruits is degree..

Evakuering av Bergen Lufthavn

Denne oppgaven tar for seg sikkerhet ved evakuering av et stort bygg. Meningen med oppgaven er at den skal kunne fungere som et verktøy for luftfartsverket i deres sikkerhetsarbeid. Det er derfor tatt for seg en del problem som de kanskje ikke hadde sett for seg. Sikkerheten er blitt vurdert med bakgrunn i både organisasjonsmessige og tekniske forhold. For å vurdere sikkerheten er det benyttet flere verktøy. Det er blant annet gjennomført et brannsyn, en spørreundersøkelse blant de ansatte samt at det er foretatt beregninger som omhandler evakuering og røykkontroll. Det har gjennom utarbeidelsen av denne oppgaven blitt avdekket en hel del forhold ved terminalbygget, både positive og negative. Med bakgrunn i det arbeidet som er gjort er det kommet frem til følgende sluttvurdering av bygget og dets eier: - De ansatte mangler grunnleggende opplæring innen bruk og plassering av slokkeutstyr. - Det mangler mye jobbing med den organisatoriske delen. - Rutiner er dårlige eller finnes ikke. - Enkelte bedrifter er mer opptatt av å øke kunnskapen hos de ansatte enn andre. - Altfor mange har ikke vært med på evakueringsøvelse i løpet av det siste året. - De ansatte er stort sett veldig positive til å øke fokuseringen på sikkerhetsarbeidet, og savner noen som viser initiativ og tar ansvar for dette arbeidet. - Bygget er oversiktlig og lett og ta seg frem i. Dette har en positiv innvirkning på den menneskelige oppførselen ved en evakueringssituasjon - Røykkontrollsystemet er tilfredsstillende så lenge alle dører til tilluft blir satt i åpen stilling. - Den tekniske delen av bygget er god. Alarmanlegget er veldig bra, det er mye slokkeutstyr og rømningsveier og seksjoneringen for å gi trygge rømningsveier er tilfredstillende. - Sett under ett er terminalbygget et sikkert bygg, men har en del større og mindre feil som bør tas tak i for å gjøre bygget enda sikrere

Is multimodal occupational therapy in addition to usual care cost-effective in people with thumb carpometacarpal osteoarthritis? A cost-utility analysis of a randomised controlled trial

Objective The aim was to evaluate the cost-utility of a 3-month multimodal occupational therapy intervention in addition to usual care in patients with thumb carpometacarpal osteoarthritis (CMC1 OA).Methods A cost-utility analysis was performed alongside a multicentre randomised controlled trial including three rheumatology departments in Norway. A total of 180 patients referred to surgical consultation due to CMC1 OA were randomised to either multimodal occupational therapy including patient education, hand exercises, assistive devices and orthoses (n=90), or usual care receiving only information on OA (n=90). The outcome measure was quality-adjusted life-years (QALYs) derived from the generic questionnaire EQ-5D-5L over a 2-year period. Resource use and health-related quality of life of the patients were prospectively collected at baseline, 4, 18 and 24 months. Costs were estimated by taking a healthcare and societal perspective. The results were expressed as incremental cost-effectiveness ratios, and a probabilistic sensitivity analysis with 1000 replications following intention-to-treat principle was done to account for uncertainty in the analysis.Results During the 2-year follow-up period, patients receiving multimodal occupational therapy gained 0.06 more QALYs than patients receiving usual care. The mean (SD) direct costs were €3227 (3546) in the intervention group and €4378 (5487) in the usual care group, mean difference €−1151 (95% CI −2564, 262). The intervention was the dominant treatment with a probability of 94.5% being cost-effective given the willingness-to-pay threshold of €27 500.Conclusions The within-trial analysis demonstrated that the multimodal occupational therapy in addition to usual care was cost-effective at 2 years in patients with CMC1 OA.Trial registration number NCT01794754

Non-pharmacological treatment gap preceding surgical consultation in thumb carpometacarpal osteoarthritis- A cross-sectional study

Background: Osteoarthritis (OA) in the thumb carpometacarpal joint (CMCJ) is a prevalent disease which may lead to structural damage, severe pain and functional limitations. Evidence-based treatment recommendations state that all patients with hand OA should be offered non-pharmacological treatment. Surgery should be considered only when other treatment has proven insufficient in relieving pain. The purpose of this study was to investigate prior treatment and characteristics of patients referred to specialist health care surgical consultation due to CMCJ OA. The study includes exploring differences in pain and function between referred and non-referred hand, between men and women, and between patients with and without OA affection of other finger joints than CMCJ. Methods: Patients in this cross-sectional study reported prior non-pharmacological treatment for CMCJ OA. Patient demographics, disease and functional variables were assessed based on hand radiographs, patient-reported and observer-based outcome measures. Differences in pain and function between referred and non-referred hand, men and women, and between patients with and without additional affection of finger joints other than CMCJ, were analysed using Paired-samples T-tests, Wilcoxon Signed Rank, or Chi-Square tests. Results: One hundred and eighty patients were included. The mean age was 63 years and 79% were women. Only 21% reported having received non-pharmacological treatment before referral to surgical consultation. The results show a statistically significant worse function for referred hands, women and involvement of additional interphalangeal joints. Most patients reported no pain or mild pain in their referred hand. Conclusions: The results of this study show a non-pharmacological treatment gap in OA care. Most patients report no pain or mild pain, and that they had not received non-pharmacological treatment prior to being referred to CMCJ OA surgical consultation. The results furthermore show that CMCJ OA negatively affects all aspects of function. Strategies need to be developed to improve OA care, including educating general practitioners in evidence-based treatment recommendations and in the assessment of hand pain, and encourage the routine referral of patients with symptomatic hand OA to occupational therapy before considering surgery

Patient Goals and Motivation for Thumb Carpometacarpal Osteoarthritis Surgery

Background: Knowledge is lacking on patient goals and motivation for carpometacarpal joint osteoarthritis (CMCJ OA) surgery. The objective of this study was to explore patient goals and motivation for surgery, whether patient goals were reflected in self-reports of pain and function, and factors characterizing patients highly motivated for surgery. Methods: This cross-sectional study included 180 patients referred from their general practitioner for CMCJ surgical consultation. Goals for surgery were collected with an open-ended question, categorized with the International Classification of Functioning, Disability and Health coding system, and compared to self-reports of pain and function. Motivation for surgery was rated with a Numeric Rating Scale (NRS, 0-10, 0 = not motivated). Factors characterizing patients highly motivated for surgery (NRS ≥ 8) were explored with multivariate regression analyses. Results: The mean age of the participants was 63 years (SD = 7.6), and 142 (79%) were women. The most common goals for surgery were to reduce pain and improve arm and hand use, but these were not reflected in self-reports of pain and function. Fifty-six (31%) of the patients were characterized as highly motivated for surgery. High motivation for surgery was strongly associated with reporting more activity limitations (odds ratio [OR] = 4.00, P = .008), living alone (OR = 3.18, P = .007), and a young age (OR = 0.94, P = .002). Conclusions: Decisions on CMCJ OA surgery should be based on assessment and discussion of patients’ life situation, hand pain, activity limitations for, and goals and motivation for surgery. According to the european league against rheumatism (EULAR) recommendations, previously received conservative and pharmacological treatment should also be evaluated