EXPLORATION OF FACTORS ASSOCIATED WITH PATIENT ADHERENCE IN UPPER EXTREMITY REHABILITATION: A MIXED-METHODS EMBEDDED DESIGN

Adherence is considered a prerequisite for the success of exercise programs for musculoskeletal disorders. The negative effects of non-adherence to exercise recommendations impact the cost of care, and also treatment effectiveness, treatment duration, the therapeutic relationship, waiting times, the efficiency of personnel and use of equipment. Adherence to therapeutic exercise intervention is a multifaceted problem.The World Health Organization (WHO) established the multidimensional adherence model (MAM). The MAM describes five interactive dimensions (socioeconomic. healthcare team and system, condition-related, therapy-related, and patient-related factors) that have an effect on patient adherence.The first purpose of this dissertation was to explore the MAM dimension of condition-related factors to determine the Quick Disabilities of the Arm Shoulder and Hand (QDASH) minimal clinical important difference (MCID) for three distal upper extremity conditions. The second purpose was to explore the MAM dimension of personal factors to learn from individuals who expressed incongruence between their QDASH and GROC scores; how they described their perceived change in therapy. The third purpose was to explore the MAM dimension of therapy-related factors to examine the effect of patient-therapist collaborative goal setting on patient adherence to treatment and QDASH outcomes.Results demonstrated in the first study that diagnosis specific MCID’s differed from the global MCID using multiple diagnoses. In the second study results demonstrated that patients expect to have a dedicated therapist who they can trust to work collaboratively with them to establish goals and spend time with them to achieve these goals. In the third study, our first hypothesis was not supported for all three measures of adherence. The median for home exercise program diary adherence was found to trend towards significance by 8.7 percent favoring the experimental group Mann-Whitney U (p\u3c .100). Our second hypothesis was not supported. The experimental group receiving collaborative goal setting intervention had similar QDASH mean change scores 45.9±27.6 compared to the control group 46.1±23.8, Mann-Whitney U (p\u3c .859)

EXPLORATION OF FACTORS ASSOCIATED WITH PATIENT ADHERENCE IN UPPER EXTREMITY REHABILITATION: A MIXED-METHODS EMBEDDED DESIGN

Adherence is considered a prerequisite for the success of exercise programs for musculoskeletal disorders. The negative effects of non-adherence to exercise recommendations impact the cost of care, and also treatment effectiveness, treatment duration, the therapeutic relationship, waiting times, the efficiency of personnel and use of equipment. Adherence to therapeutic exercise intervention is a multifaceted problem. The World Health Organization (WHO) established the multidimensional adherence model (MAM). The MAM describes five interactive dimensions (socioeconomic, healthcare team and system, condition-related, therapy-related, and patient-related factors) that have an effect on patient adherence. The first purpose of this dissertation was to explore the MAM dimension of condition-related factors to determine the Quick Disabilities of the Arm Shoulder and Hand (QDASH) minimal clinical important difference (MCID) for three distal upper extremity conditions. The second purpose was to explore the MAM dimension of personal factors to learn from individuals who expressed incongruence between their QDASH and GROC scores; how they described their perceived change in therapy. The third purpose was to explore the MAM dimension of therapy-related factors to examine the effect of patient-therapist collaborative goal setting on patient adherence to treatment and QDASH outcomes. Results demonstrated in the first study that diagnosis specific MCID’s differed from the global MCID using multiple diagnoses. In the second study results demonstrated that patients expect to have a dedicated therapist who they can trust to work collaboratively with them to establish goals and spend time with them to achieve these goals. In the third study, our first hypothesis was not supported for all three measures of adherence. The median for home exercise program diary adherence was found to trend towards significance by 8.7 percent favoring the experimental group Mann-Whitney U (p \u3c .100). Our second hypothesis was not supported. The experimental group receiving collaborative goal setting intervention had similar QDASH mean change scores 45.9±27.6 compared to the control group 46.1±23.8, Mann-Whitney U (p \u3c .859)

Factors Influencing Final Outcomes in Patients with Shoulder Pain: A Retrospective Review

Study Design Retrospective cohort. Introduction Rehabilitation interventions are commonly prescribed for patients with shoulder pain, but it is unclear what factors may help clinicians\u27 prognosis for final outcomes. Purpose of the Study The purpose of this study is to determine what factors are the best predictors of improved patient-reported outcomes at discharge in patients with shoulder pain. Methods Retrospective chart review of 128 patients presenting with shoulder pain to an outpatient physical therapy clinic. Chart review captured data regarding patient demographics, treatment interventions, patient history, and patient-reported outcome scores. The primary dependent variable was the overall change score of the QuickDASH (initial to discharge). Thirty-eight predictor variables were entered into a forward stepwise multivariate linear regression model to determine which variables and to what degree contributed to the dependent variable. Results The linear regression model identified 5 predictor variables that yielded an R = 0.74 and adjusted R2 = 0.538 (P \u3c .001). The 5 predictor variables identified in order of explained variance are QuickDASH change at the fifth visit, a total number of visits, initial QuickDASH score, scapular retraction exercise, and age. Discussion Early change scores, equal to minimal detectable change scores on patient-reported outcomes appear to be strong indicators that patients with shoulder pain are on a positive trajectory to benefit from rehabilitation. Conclusion Using patient-reported outcomes throughout care, not just at the start and end of care, will provide therapist feedback regarding patient\u27s progress and indicate treatment effectiveness. Levels of Evidence 4

Specificity of the Minimal Clinically Important Difference of the Quick Disabilities of the Arm Shoulder and Hand (QDASH) for Distal Upper Extremity Conditions

Retrospective cohort design. The minimal clinically important difference (MCID) for the quick Disabilities of the Arm, Shoulder and Hand (QDASH) has been established using a pool of multiple conditions, and only exclusively for the shoulder. Understanding diagnoses-specific threshold change values can enhance the clinical decision-making process. Before and after QDASH scores for 406 participants with conditions of surgical distal radius fracture, non-surgical lateral epicondylitis, and surgical carpal tunnel release were obtained. The external anchor administered at each fourth visit was a 15-point global rating of change scale. The test-retest reliability of the QDASH was moderate for all diagnoses: intraclass correlation coefficient model 2, 1, for surgical distal radius = 0.71; non-surgical lateral epicondylitis = 0.69; and surgical carpal tunnel = 0.69. The minimum detectable change at the 90% confidence level was 25.28; 22.49; and 27.63 points respectively; and the MCID values were 25.8; 15.8 and 18.7, respectively. For these three distal upper extremity conditions, a QDASH MCID of 16-26 points could represent the estimate of change in score that is important to the patient and guide clinicians through the decision-making process

A Retrospective Cohort Study of QuickDASH Scores for Three Hand Therapy Acute Upper Limb Conditions

Introduction: The QuickDASH is a valid and reliable outcome measure widely used to assess the function and pain in arm, shoulder, and hand disabilities. A recent study introduced a QuickDASH 80% cut point test to gauge patients at risk of poor outcomes. However, the utility of this test has not been validated. Purpose: To determine typical QuickDASH scores for three upper limb conditions and to test the sensitivity and specificity of the QuickDASH 80% cut point test in predicting patients at risk of poor outcomes. Methods: This is a retrospective study with a total of 406 patient records for whom QuickDASH scores were examined. The sensitivity and specificity of the QuickDASH 80% cut point test was investigated for three acute upper limb conditions seen in hand therapy: surgical distal radius fracture, nonsurgical lateral epicondylitis, and carpal tunnel release. Results: Typical scores were determined for three upper limb conditions. The QuickDASH 80% cut point test per upper limb condition returned poor sensitivity between 28.57% and 41.67%. Conclusion: The results did not support the QuickDASH 80% cut point test as a predictor of final outcome in these three patient populations. Patients with the worse initial 20% scores were not correctly classified as worse 20% final scores. This study provides summary data from three upper limb conditions to provide clinicians with comparison data to establish goals and educate patients

Descriptive Analysis of Common Functional Limitations Identified by Patients with Shoulder Pain

Context: Recent establishment of G-codes by the US government requires therapists to report function limitations at initial evaluation. Limited information exists specific to the most common limitations in patients with shoulder pain. Objective: To describe the most commonly expressed shoulder limitations with activities and their severity/level of impairment from a patient’s perspective on the initial evaluation. Design: Descriptive. Setting: Patients reporting pain with overhead activity and seeking medical attention from one orthopedic surgeon were recruited as part of a cohort study. Patients: 176 with shoulder superior labral tear from anterior to posterior (SLAP), subacromial impingement, combined SLAP and rotator cuff, and nonspecific (female = 53, age = 41 ± 13 y; male = 123, age = 41 ± 12 y). Interventions: Data were obtained on the initial visit from the Patient-Specific Functional Scale (PSFS) questionnaire. Three researchers extracted meaningful concepts from the PSFS and linked them to the International Classification of Functioning (ICF) categories according to established ICF linking rules. Results: 176 participants yielded 765 meaningful concepts that were linked to the ICF with a 66% agreement between researchers before consensus. There were no differences between diagnoses. Of all patients, 88% reported functional limitations coded into meaningful concepts as represented by 10 ICF codes; 634 (83%) meaningful concepts were linked to the activities and participation domain while 129 (17%) were linked to the body function domain. Only 2 reported functional limitations that were considered nondefinable (nd). The overall average initial impairment score on the PSFS = 4 ± 2.5 out of 10 points. Conclusion: Meaningful concepts from the activities and participation domain were most commonly identified as functional limitations and were more prevalent than limitations from the body function domain. This information helps identify some of the most common limitations in patients with shoulder pain that therapists can use to efficiently document patient functional impairment

Adherence of Individuals in Upper Extremity Rehabilitation: A Qualitative Study

OBJECTIVE: To describe the rehabilitation experiences, expectations, and treatment adherence of patients receiving upper extremity (UE) rehabilitation who demonstrated discrepancy between functional gains and overall improvement. DESIGN: Qualitative (phenomenologic) interviews and analysis. SETTING: Outpatient UE rehabilitation. PARTICIPANTS: Patients with acute UE injuries (N=10). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Concerns related to UE rehabilitation patients demonstrating discrepancy between outcome measures. RESULTS: Five key themes emerged from the interviews of patients demonstrating discrepancy in their self-reported patient outcomes: (1) desire to return to normal, (2) initial anticipation of brief recovery, (3) trust of therapist, (4) cannot stop living, and (5) feelings of ambivalence. Challenges included living with the desire to move back into life. Multiple factors affected patient adherence: cost of treatment, patient-provider relation (difference between therapist and patient understanding on what is important for treatment), and patients expecting the treating therapists to be an expert and fix their problem. CONCLUSIONS: Patient adherence to UE rehabilitation presents many challenges. Patients view themselves as laypersons and seek the knowledge of a dedicated therapist who they trust to spend time with them to understand what they value as important and clarify their injury, collaboratively make goals, and explain the intervention to get them in essence, back into life, in the minimal required time. When categorized according to the World Health Organization\u27s multidimensional adherence model, domains identified in this model include social and economic, health care team and system, condition-related, therapy-related, and patient-related dimensions. Assessing factors identified to improve efficiency and effectiveness of clinical management can enhance patient adherence

3 years of liraglutide versus placebo for type 2 diabetes risk reduction and weight management in individuals with prediabetes: a randomised, double-blind trial

Background: Liraglutide 3·0 mg was shown to reduce bodyweight and improve glucose metabolism after the 56-week period of this trial, one of four trials in the SCALE programme. In the 3-year assessment of the SCALE Obesity and Prediabetes trial we aimed to evaluate the proportion of individuals with prediabetes who were diagnosed with type 2 diabetes. Methods: In this randomised, double-blind, placebo-controlled trial, adults with prediabetes and a body-mass index of at least 30 kg/m2, or at least 27 kg/m2 with comorbidities, were randomised 2:1, using a telephone or web-based system, to once-daily subcutaneous liraglutide 3·0 mg or matched placebo, as an adjunct to a reduced-calorie diet and increased physical activity. Time to diabetes onset by 160 weeks was the primary outcome, evaluated in all randomised treated individuals with at least one post-baseline assessment. The trial was conducted at 191 clinical research sites in 27 countries and is registered with ClinicalTrials.gov, number NCT01272219. Findings: The study ran between June 1, 2011, and March 2, 2015. We randomly assigned 2254 patients to receive liraglutide (n=1505) or placebo (n=749). 1128 (50%) participants completed the study up to week 160, after withdrawal of 714 (47%) participants in the liraglutide group and 412 (55%) participants in the placebo group. By week 160, 26 (2%) of 1472 individuals in the liraglutide group versus 46 (6%) of 738 in the placebo group were diagnosed with diabetes while on treatment. The mean time from randomisation to diagnosis was 99 (SD 47) weeks for the 26 individuals in the liraglutide group versus 87 (47) weeks for the 46 individuals in the placebo group. Taking the different diagnosis frequencies between the treatment groups into account, the time to onset of diabetes over 160 weeks among all randomised individuals was 2·7 times longer with liraglutide than with placebo (95% CI 1·9 to 3·9, p<0·0001), corresponding with a hazard ratio of 0·21 (95% CI 0·13–0·34). Liraglutide induced greater weight loss than placebo at week 160 (–6·1 [SD 7·3] vs −1·9% [6·3]; estimated treatment difference −4·3%, 95% CI −4·9 to −3·7, p<0·0001). Serious adverse events were reported by 227 (15%) of 1501 randomised treated individuals in the liraglutide group versus 96 (13%) of 747 individuals in the placebo group. Interpretation: In this trial, we provide results for 3 years of treatment, with the limitation that withdrawn individuals were not followed up after discontinuation. Liraglutide 3·0 mg might provide health benefits in terms of reduced risk of diabetes in individuals with obesity and prediabetes. Funding: Novo Nordisk, Denmark

Mitochondrial physiology

As the knowledge base and importance of mitochondrial physiology to evolution, health and disease expands, the necessity for harmonizing the terminology concerning mitochondrial respiratory states and rates has become increasingly apparent. The chemiosmotic theory establishes the mechanism of energy transformation and coupling in oxidative phosphorylation. The unifying concept of the protonmotive force provides the framework for developing a consistent theoretical foundation of mitochondrial physiology and bioenergetics. We follow the latest SI guidelines and those of the International Union of Pure and Applied Chemistry (IUPAC) on terminology in physical chemistry, extended by considerations of open systems and thermodynamics of irreversible processes. The concept-driven constructive terminology incorporates the meaning of each quantity and aligns concepts and symbols with the nomenclature of classical bioenergetics. We endeavour to provide a balanced view of mitochondrial respiratory control and a critical discussion on reporting data of mitochondrial respiration in terms of metabolic flows and fluxes. Uniform standards for evaluation of respiratory states and rates will ultimately contribute to reproducibility between laboratories and thus support the development of data repositories of mitochondrial respiratory function in species, tissues, and cells. Clarity of concept and consistency of nomenclature facilitate effective transdisciplinary communication, education, and ultimately further discovery