FINITE H-DIMENSION DOES NOT IMPLY EXPRESSIVE COMPLETENESS

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A qualitative evaluation of occupational therapy-led work rehabilitation for people with inflammatory arthritis : perspectives of therapists and their line managers

Introduction: Occupational therapy-led work rehabilitation for employed people with inflammatory arthritis and work problems was piloted in five hospitals in the United Kingdom. This qualitative study explored the views of participating occupational therapists and their line managers about the work rehabilitation training received and conducting the intervention, with particular focus on the structured interview used, the Work Experience Survey – Rheumatic Conditions. Method: Face-to-face semi-structured interviews were conducted with occupational therapists (n¼9), followed by telephone interviews with their line managers (n¼2). Interviews were audio-recorded, transcribed verbatim and thematically analysed by three researchers to maximize validity. Results: The main themes emerging from the occupational therapists’ interviews were: varying levels of prior knowledge and experience of work rehabilitation, initial concerns about the feasibility of a lengthy work assessment in practice and increased confidence in delivering work rehabilitation as the study progressed. The line managers’ interviews generated themes around the positive impact of the work rehabilitation training the occupational therapists received, and changes in their practice. Conclusion: The Work Experience Survey – Rheumatic Conditions was considered a good choice of work assessment which can be implemented in practice. Once therapists had provided the work intervention several times, their confidence and skills increase

Orientation and Alignment Echoes

We present what is probably the simplest classical system featuring the echo phenomenon - a collection of randomly oriented free rotors with dispersed rotational velocities. Following excitation by a pair of time-delayed impulsive kicks, the mean orientation/alignment of the ensemble exhibits multiple echoes and fractional echoes. We elucidate the mechanism of the echo formation by kick-induced filamentation of phase space, and provide the first experimental demonstration of classical alignment echoes in a thermal gas of CO_2 molecules excited by a pair of femtosecond laser pulses

C-GLOVES: An evaluation of the effectiveness of compression gloves in arthritis: a feasibility study : Hand assessment manual and glove treatment protocol 13.8.13v2

The C-Gloves compression glove feasibility study evaluated the effects of compression gloves on hand pain, stiffness, joint swelling, finger flexion, grip ability, grip strength and hand function. This manual includes the: inclusion/ exclusion criteria; glove treatment protocol; glove instruction sheet for patients; and protocols for conducting all assessments. These included: hand joint circumference (wrist, MCPs and PIP joints) using a Jobskin® tape measure; finger flexion measured using a 15cm ruler from the lateral nail fold to distal wrist crease (2nd=5th digits); and the Grip Ability Test (GAT). The latter was adapted for the right and left hands and the test procedure further standardised, including the use of the GAT MAT. The GAT MAT template is also located in the www.usir.salford.ac.uk depository and can be freely download

Revisiting the disabilities of the arm, shoulder and hand (DASH) and QuickDASH in rheumatoid arthritis

Background Limitations in upper limb functioning are common in Musculoskeletal disorders and the Disabilities of the Arm, Shoulder and Hand scale (DASH) has gained widespread use in this context. However, various concerns have been raised about its construct validity and so this study seeks to examine this and other psychometric aspects of both the DASH and QuickDASH from a modern test theory perspective. Methods Participants in the study were eligible if they had a confirmed diagnosis of Rheumatoid Arthritis (RA). They were mailed a questionnaire booklet which included the DASH. Construct validity was examined by fit to the Rasch measurement model. The degree of precision of both the DASH and QuickDASH were considered through their Standard Error of Measurement (SEM). Results Three hundred and thirty-seven subjects with confirmed RA took part, with a mean age of 62.0 years (SD12.1); 73.6% (n = 252) were female. The median standardized score on the DASH was 33 (IQR 17.5–55.0). Significant misfit of the DASH and QuickDASH was observed but, after accommodating local dependency among items in a two-testlet solution, satisfactory fit was obtained, supporting the unidimensionality of the total sets and the sufficiency of the raw (ordinal or standardized) scores. Conclusion Having accommodated local response dependency in the DASH and QuickDASH item sets, their total scores are shown to be valid, given they satisfy the Rasch model assumptions. The Rasch transformation should be used whenever all items are used to calculate a change score, or to apply parametric statistics within an RA population. Significance and innovations Most previous modern psychometric analyses of both the DASH and QuickDASH have failed to fully address the effect of a breach of the local independence assumption upon construct validity. Accommodating this problem by creating ‘super items’ or testlets, removes this effect and shows that both versions of the scale are valid and unidimensional, as applied with a bi-factor equivalent solution to an RA population. The Standard Error of Measurement of a scale can be biased by failing to take into account the local dependency in the data which inflates reliability and thus making the SEM appear better (i.e. smaller) than the true value without bias. </ul

The effects of arthritis gloves on hand pain in people with rheumatoid or inflammatory arthritis : a randomised controlled trial (A-GLOVES TRIAL)

Background: Arthritis (compression) gloves are commonly provided to people with rheumatoid arthritis (RA) and undifferentiated inflammatory arthritis (IA) in the UK health service. These apply pressure and warmth to relieve hand pain, stiffness and improve hand function. A systematic review identified little evidence to support their use.[1] Objectives: This randomised controlled trial tested effectiveness and cost-effectiveness of mid-finger length compression (intervention) gloves (20% Lycra: commonest glove model provided) with control gloves (i.e. oedema gloves: 11% Lycra: fitted at least one size too big) in people with RA and IA. Methods: Both gloves, which had similar thermal qualities although the control gloves did not provide compression, were provided by rheumatology occupational therapists, following training.[2] Participants were also given brief advice on hand exercise and joint protection. Adults with RA/IA and persistent hand pain were randomised 1:1 to the two glove types, stratified by disease modifying anti-rheumatic drug (DMARD) change in previous 12 weeks. The primary outcome was dominant hand pain on activity Visual Analogue Scale (VAS:0–10); other outcomes included night hand pain, hand stiffness (both 0–10 VAS); Measure of Activity Performance Hand (MAP-HAND: 0–3). Multiple linear regression was undertaken to estimate the effect of group allocation on hand pain during activity, adjusting for the stratification variable and baseline values. Cost-effectiveness used individual patient level costs (intervention plus healthcare utilisation) and health benefit data (EQ-5D) to calculate costs and QALYs. Results: 206 participants were randomised (103 to each glove type): median age 59 years [IQR 51,67]; women:166 (81%); mean disease duration: 8.2 (SD 9.5) years; employed:76 (37%); right hand dominant:185 (90%). Of these, 163 (79%) completed 12 week follow-up questionnaires. Both groups reported similar adherence to glove wear (mean 5.2 days/week). At 12 w, hand pain scores in both groups similarly improved: the between-groups mean difference of 0.1 was not statistically significant (95% CI: −0.47 to 0.67; p=0.72). There were no significant differences between groups on any measures, with both groups improving similarly between baseline and 12 w. 73% in both groups considered gloves beneficial. Intervention gloves had higher costs (£552 (SD £464); control £391 (SD £543) but comparable benefits to control gloves. Intervention gloves would cost £83 700 to gain one QALY and were not likely to be cost-effective. Conclusions: Compression (intervention) and loose-fitting arthritis (control) gloves had similar effects on hand pain, stiffness and function. Therefore, compression is not the ‘active ingredient’ in arthritis gloves. Loose fitting gloves providing warmth were perceived as equally effective by participants. We do not know if the therapist effect is important or whether ordinary gloves providing warmth would provide similar results. References: Hammond, et al. Clin Rehabil 2016 30:213–24. Prior, et al. Rheumatology 2017. www.abstractsonline.com/pp8/#!/4205 Acknowledgements: This project was funded by the NIHR Research for Patient Benefit Programme (PB-PG-0214–33010). The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health

Inflammatory or rheumatoid arthritis patients’ perspectives on the effect of arthritis gloves on their hand pain and function (A-GLOVES TRIAL) : a qualitative study

Background: Arthritis (compression) gloves are frequently provided to people with inflammatory (IA) or rheumatoid arthritis (RA) in the NHS, to help reduce swelling and alleviate hand pain by providing compression and improving circulation. However evidence for their effectiveness is limited.[1] Objectives: Nested within a randomised controlled trial (RCT) testing the effectiveness of intervention (compression) gloves with control gloves (fitted at least one size too big) in people with RA and IA, this qualitative study aimed to explore patients’ perspectives on the effect of the arthritis gloves on their hand pain and function. Methods: Once randomised, participants were provided joint protection and hand exercise booklets and fitted with either the intervention or the control glove(s) by a trained occupational therapist.[2] Both gloves had similar thermal qualities but control gloves did not apply compression. Semi-structured interviews were conducted with 10 participants, purposively selected from each group (n=20) following 12 weeks of glove wear. Interviews were audio-recorded, transcribed and analysed by three researchers using thematic analysis with a critical realist perspective. Results: Participants’ perspectives on the effects of the arthritis gloves had three emergent sub-themes. These were: Usage: both groups predominantly used the gloves for activities such as wearing them outdoors to keep hands warm, night-time wear to help with sleep, and doing light domestic activities (e.g. dusting). Gloves were not used for cooking or washing-up or for personal activities of daily living (e.g. toileting, grooming) “What didn’t help as such, obviously was with washing etc. and toileting because I had to keep taking them off and putting them back on again”; Symptomatology: while some reported that gloves helped to keep their “hand pain in check” others said that gloves had no effect on their hand pain or that they’d found “it’s made them worse”. Participants from both groups frequently mentioned the warmth element of the gloves, as a positive attribute to help with their symptoms; Aesthetics: participants had opposing views on the appearance of the arthritis gloves. Some felt that the intervention gloves “look a bit ugly with the seams outside” or stated that they “would not want to wear that colour” but did not think they were obtrusive. Most noticeably, patients seemed to view the arthritis gloves as ordinary everyday gloves, rather than a medical device “if it was cold I wore them outside”. Conclusions: Trial participants reported experiencing similar effects from wearing either the intervention or control gloves, with varied perspectives on whether or not gloves affected hand pain and/or function. Overall, patients did not reflect on the compressive but rather the thermal qualities of the gloves, as warmth was the main effect perceived. References: Hammond, et al. Clin Rehabil 2016 30:213–24 Prior, et al. Rheum 2017(Supp1) Acknowledgements: This project was funded by the NIHR Research for Patient Benefit Programme (PB-PG-0214–33010). The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health

OP0083-HPR development of the evaluation of daily activities questionnaire in musculoskeletal conditions: Psychometric testing

Background The English Evaluation of Daily Activity Questionnaire (EDAQ) is a patient reported measure of activity limitations including 138 activities in 14 domains. It has been linguistically and culturally validated from the original Swedish to English. In rheumatoid arthritis: confirmatory factor analysis and Rasch analysis have confirmed its internal construct validity, unidimensionality and total scores can be summed in each domain. Twelve domains can be included in two components: Self-care (Eating; Personal Care; Dressing; Cooking; Cleaning the House; Laundry; Communication) and Mobility (Bathing, Moving Indoors, Transfers, Moving Outdoors, House/Garden Maintenance). All domains demonstrate concurrent and discriminative validity, and reliability. Objectives To test the validity and reliability of the EDAQ in people with one of seven musculoskeletal conditions (MSCs) in the UK: ankylosing spondylitis (AS); osteoarthritis (OA); systemic lupus (SLE); systemic sclerosis (SS); chronic pain (CP), chronic upper limb conditions (CUL); and Primary Sjogren's (PSS). Methods Participants from 20 Rheumatology clinics completed postal questionnaires of demographics, the EDAQ, HAQ, SF36v2, and severity of current condition. Three weeks later, the EDAQ was repeated to evaluate test-retest reliability. Rasch analysis was used to confirm domain and component structure. Cronbach's alpha evaluated internal consistency. Spearman's correlations assessed validity of the EDAQ domains against the other measures and reliability. Results 1205 people participated (AS n=165;OA n=184; SLE n=164; SS n=170; CP n=194; CUL n=157; PSS n=171); 942 (78%) were women; age =56.61 years (SD 13.84); condition duration =17.58 years (SD 14.45); 457 (38%) were employed; 172 (14%) had dependent children; average pain score was 4.98 (SD 3.70) and fatigue was 5.88 (SD 2.80). Rasch analysis confirmed the 12-domain, 2 component structure in all MSCs.For most conditions, most EDAQ domain scores correlated strongly with HAQ20 (rs =0.7-0.92) and at least moderately with SF36v2 Physical Functions (rs =-0.0.5 – -0.91), except in the Caring domain which were weak (rs = -0.23- -0.30) as it was applicable to few respondents. Internal consistency was good to excellent for all domains in all conditions, (α =0.82 to 0.98) meaning the EDAQ can be used for groups and individuals. Test-retest reliability (n=946, 79%) was strong for most domains (rs =0.7-0.91) except the Caring was moderate (rs =0.48-0.64). Although significant and acceptable, values were lower in CULs than other conditions. All EDAQ domains demonstrated significant (p<0.001) discriminant validity, apart from Caring (p=0.2 to 0.01). Conclusions The English EDAQ has been shown to be a valid, reliable, multi-domain measure of daily activity in a range of musculoskeletal disorders. It can therefore be used in both clinical practice and research. Acknowledgements This study was funded by the United Kingdom Occupational Therapy Research Fund

FRI0592-HPR Work rehabilitation in inflammatory arthritis: A pilot randomised controlled trial

Background Work problems are common in people with inflammatory arthritis (IA): with 28-40% of people with rheumatoid arthritis (RA) stopping work in 5y of diagnosis. There is little research into effectiveness of job retention vocational rehabilitation (JRVR)for employed people with IA. Brief JR-VR led to significantly fewer job losses at 3.5 years in the USA (Allaire et al, 2003) and a UK pilot trial demonstrated 6m improvements in work instability and work satisfaction (Macedo et al, 2009). Objectives: To conduct a pilot randomised controlled trial (RCT) evaluating a JR-VR intervention with employed people with IA,to facilitate planning a full RCT. Methods: Participants with IA were recruited from 6 Rheumatology departments and randomised to VR (delivered by Rheumatology OTs with VR training) or a control group. Both groups received written self-help information about managing work problems. The VR group could receive up to 6h JR-VR, including a work visit. Presenteeism outcomes included: RA-Work Instability Scale (RAWIS:0-23), Work Limitations Questionnaire Productivity Loss (WLQPL: %), Work Activities Limitations Scale (WALS:0-33). Absenteeism was measured using monthly work diaries. Health outcomes included: SF12v2 Physical component(SF12-PC), pain, fatigue and perceived health status VAS (0-100). Mean (SD) change scores and effect sizes were calculated. Results: 213 eligible employed patients with IA were identified, of whom 55 (26%) participated (34 with RA): 13M, 42F; aged 49y (SD 8.8); 7.9y (SD 8.9) disease duration; 33 worked full-time; job types were professional (27%), associated professional/skilled (15%), partly skilled/admin/caring/retain (53%), unskilled (5%). Both groups were comparable at baseline (see Table). At 9m: effect sizes were moderate to large for changes in work and health outcomes in the JR-VR group and none to small in the control group; %working days lost due to sickness: JR-VR =9.6% (SD 13.6); control = 20% (SD 27.1). JR-VR lasted on average 3.08 (SD 1.8)hours and cost £74.98 (SD £46.80) per patient. Conclusions: This pilot suggests brief JR-VR provided by Rheumatology OTs can improve presenteeism, absenteeism and health status, indicating a RCT is warranted. Recruitment was problematic, with many not consenting. Potential reasons include: fear about employers (in a recession) learning they have arthritis; concerns about time out of work attending VR; and not perceiving VR is needed as yet. JR-VR intends to prevent work problems. Support is needed to enable employed people with IA and work problems to attend JR-VR