If a joint is hot it’s not the time: health professionals’ views on developing an intervention to promote physical activity in rheumatoid arthritis

Candidacy 2.0 (CC) - an enhanced theory of access to healthcare for chronic conditions: lessons from a critical interpretive synthesis on access to rheumatoid arthritis care

BACKGROUND

The Dixon-Woods et al. Candidacy Framework, a valuable tool since its 2006 introduction, has been widely utilized to analyze access to various services in diverse contexts, including healthcare. This social constructionist approach examines micro, meso, and macro influences on access, offering concrete explanations for access challenges rooted in socially patterned influences. This study employed the Candidacy Framework to explore the experiences of individuals living with rheumatoid arthritis (RA) and their formal care providers. The investigation extended to assessing supports and innovations in RA diagnosis and management, particularly in primary care.

METHODS

This systematic review is a Critical Interpretive Synthesis (CIS) of qualitative and mixed methods literature. The CIS aimed to generate theory from identified constructs across the reviewed literature. The study found alignment between the seven dimensions of the Candidacy Framework and key themes emerging from the data. Notably absent from the framework was an eighth dimension, identified as the "embodied relational self." This dimension, central to the model, prompted the proposal of a revised framework specific to healthcare for chronic conditions.

RESULTS

The CIS revealed that the eight dimensions, including the embodied relational self, provided a comprehensive understanding of the experiences and perspectives of individuals with RA and their care providers. The proposed Candidacy 2.0 (Chronic Condition (CC)) model demonstrated how integrating approaches like Intersectionality, concordance, and recursivity enhanced the framework when the embodied self was central.

CONCLUSIONS

The study concludes that while the original Candidacy Framework serves as a robust foundation, a revised version, Candidacy 2.0 (CC), is warranted for chronic conditions. The addition of the embodied relational self dimension enriches the model, accommodating the complexities of accessing healthcare for chronic conditions.

TRIAL REGISTRATION

This study did not involve a health care intervention on human participants, and as such, trial registration is not applicable. However, our review is registered with the Open Science Framework at https://doi.org/10.17605/OSF.IO/ASX5C .

Promoting physical activity in rheumatoid arthritis through a physiotherapist led behaviour change-based intervention (PIPPRA): a feasibility randomised trial

Physical activity (PA) is recommended as a key component in the management of people with rheumatoid arthritis (RA). The objective of this study was to examine the feasibility of a physiotherapist led, behaviour change (BC) theory-informed, intervention to promote PA in people with RA who have low levels of current PA. A feasibility randomised trial (ClinicalTrials.gov NCT03644160) of people with RA over 18 years recruited from outpatient rheumatology clinics and classified as insufficiently physically active using the Godin-Shephard Leisure Time Physical Activity Questionnaire. Participants were randomised to intervention group (4 BC physiotherapy sessions in 8 weeks) delivered in person/virtually or control group (PA information leaflet only). Feasibility targets (eligibility, recruitment, and refusal), protocol adherence and acceptability were measured. Health care professionals (HCPs) involved in the study and patients in the intervention and control arms were interviewed to determine acceptability. Descriptive statistics were used to analyse the data with SPSS (v27) with interviews analysed using content analysis using NVivo (v14). Three hundred and twenty participants were identified as potentially eligible, with n = 183 (57%) eligible to participate, of which n = 58 (32%) consented to participate. The recruitment rate was 6.4 per month. Due to the impact of COVID-19 on the study, recruitment took place over two separate phases in 2020 and 2021. Of the 25 participants completing the full study, 23 were female (mean age 60 years (SD 11.5)), with n = 11 allocated to intervention group and n = 14 to control. Intervention group participants completed 100% of sessions 1 & 2, 88% of session 3 and 81% of session 4. The study design and intervention were acceptable overall to participants, with enhancements suggested. The PIPPRA study to improve promote physical activity in people with RA who have low PA levels was feasible, acceptable and safe. Despite the impact of COVID-19 on the recruitment and retention of patients, the study provides preliminary evidence that this physiotherapist led BC intervention is feasible and a full definitive intervention should be undertaken. Health care professionals involved in the study delivery and the patient participants described a number of positive aspects to the study with some suggestions to enhance the design. These findings hence inform the design of a future efficacy-focused clinical trial.

Physical activity guidance in the rheumatology clinic-what matters for patients with rheumatoid arthritis? A qualitative study

Higher proportions of patients with rheumatoid arthritis (RA) are physically inactive compared to the general population. A barrier to engaging in physical activity (PA) may be lack of consistent PA guidance from health professionals (HPRs). This qualitative study aimed to explore daily PA levels and the patients' perspectives on current and future PA guidance from HPRs. We recruited 20 participants from five rheumatology departments in Denmark. The participants differed in socio-demography and clinical characteristics based on results from an earlier cross-sectional study. The interviews were conducted by telephone, online platforms or face-to-face. Data analysis was based on reflexive thematic analysis. Thirteen participants were female and mean age was 55 years. We generated four themes; (1) Acceptance of the arthritis is a process, which attributed to acknowledging RA as part of life before fully engagement in PA and exercise. (2) Daily physical activity-motivation, barriers and benefits, reflecting the participants' preferred types of activities and motivations and barriers to PA. (3) Physical activity guidance-your own responsibility? This theme reflected how participants missed more comprehensive discussions with HPRs about PA. (4) It is essential how, when and where physical activity guidance is provided, referring to participants' preferences for future PA guidance in the rheumatology clinic. The study emphasizes that an integrated focus on PA should be part of the rheumatology clinic. However, HPRs may need adequate training in how to guide and motivate patients with RA towards increased PA.

The impact of COVID-19 on clinical research: the PIPPRA and MEDRA experience

Background

Coronavirus disease 2019 (COVID-19) has had a significant impact on clinical research. This paper aims to provide an insight into how the COVID-19 pandemic, associated public health restrictions and international guidance on the conduct of clinical research impacted two clinical rheumatology research trials - the Physiotherapist-led Intervention to Promote Physical Activity in Rheumatoid Arthritis (PIPPRA) and the MEDiterranean diet in Rheumatoid Arthritis (MEDRA) projects.

Methods

The March 2019 public health restrictions imposed to mitigate the risk of COVID-19 occurred at a time when PIPPRA was in the process of delivering assessment and intervention on a face-to-face basis (n=48) and MEDRA had commenced recruitment. Participants in PIPPRA and MEDRA had a diagnosis of rheumatoid arthritis, with some being immunosuppressed and thus at a higher risk for COVID-19. The decision-making processes of both trials is outlined to demonstrate the required amendments to continue in the context of the COVID-19 pandemic.

Results

Amendments to PIPPRA and MEDRA trial protocols were agreed and received ethical and funder approval. Both trials switched from a face-to-face delivery to a telehealth using online platforms. The PIPPRA study was paused for five months (April-August 2020), resulting in n=33 (60%) negative deviations from assessment protocol. MEDRA switched from face-to-face to online recruitment with 20% (n=35/44) negative deviations in recruitment. Of the n=18 participants who consented to participating in a face-to-face trial, just n=2 (11%) opted to engage with telehealth delivery of the intervention. MEDRA assessment and intervention deviations were 100% as no sessions were completed as planned in 2020.

Conclusions

The COVID-19 pandemic has severely impacted the PIPPRA and MEDRA clinical trials. Moving face-to-face clinical research to telehealth delivery may not be the panacea it is purported to be. Our experiences may be of benefit to researchers, clinicians, and funders in seeking to continue clinical research during a global pandemic.

Work disability and rheumatoid arthritis: Predictive factors

BACKGROUND

Rheumatoid arthritis is often associated with work disability, a term used to describe the inability to be or to remain employed. Work disability is a common implication of rheumatoid arthritis.

OBJECTIVE

This review aims to identify and analyze the predictive factors of work disability among patients with rheumatoid arthritis, as well as to group these factors into broader categories, based on the most current studies in this field.

METHODS

An electronic search was conducted using Google Scholar, MEDLINE and PsycINFO databases. Eighty-six international journal articles were finally selected.

RESULTS

The results suggest that occupational, personal, medical and societal factors are the main predictive categories of work disability for people with rheumatoid arthritis.

CONCLUSIONS

Medical progress has had a positive effect on the development and the rates of work disability among patients with RA. Work disability is, however, not only defined by medical factors. Occupational, personal and societal factors interact with each other and affect the development of work disability in RA. The results of this review emphasize the need for medical and vocational therapy interventions, social support and state policies that target the work status of patients with RA. Future holistic research approaches to the field are required for a complete picture and concrete solutions with the aim of keeping patients with RA employed.

The impact of COVID-19 on clinical research: the PIPPRA and MEDRA experience

Background: Coronavirus disease 2019 (COVID-19) has had a significant impact on clinical research. This paper aims to provide an insight into how the COVID-19 pandemic, associated public health restrictions and international guidance on the conduct of clinical research impacted two clinical rheumatology research trials - the Physiotherapist-led Intervention to Promote Physical Activity in Rheumatoid Arthritis (PIPPRA) and the MEDiterranean diet in Rheumatoid Arthritis (MEDRA) projects. Methods: The March 2019 public health restrictions imposed to mitigate the risk of COVID-19 occurred at a time when PIPPRA was in the process of delivering assessment and intervention on a face-to-face basis (n=48) and MEDRA had commenced recruitment. Participants in PIPPRA and MEDRA had a diagnosis of rheumatoid arthritis, with some being immunosuppressed and thus at a higher risk for COVID-19. The decision-making processes of both trials is outlined to demonstrate the required amendments to continue in the context of the COVID-19 pandemic. Results: Amendments to PIPPRA and MEDRA trial protocols were agreed and received ethical and funder approval. Both trials switched from a face-to-face delivery to a telehealth using online platforms. The PIPPRA study was paused for five months (April-August 2020), resulting in n=33 (60%) deviations from assessment protocol. MEDRA switched from face-to-face to online recruitment with 20% (n=35/44) deviation in recruitment. Of the n=18 participants who consented to participating in a face-to-face trial, just n=2 (11%) opted to engage with telehealth delivery of the intervention. MEDRA assessment and intervention deviations were 100% as no sessions were completed as planned in 2020. Conclusions: The COVID-19 pandemic has severely impacted the PIPPRA and MEDRA clinical trials. Moving face-to-face clinical research to telehealth delivery may not be the panacea it is purported to be. Our experiences may be of benefit to researchers, clinicians, and funders in seeking to continue clinical research during a global pandemic.

2019 EULAR recommendations for the generic core competences of health professionals in rheumatology

BACKGROUND/OBJECTIVES

To maintain and optimise the quality of care provided by health professionals in rheumatology (HPRs), adequate educational offerings are needed. This task force (TF) aimed to develop evidence-based recommendations for the generic core competences of HPRs, with specific reference to nurses, physical therapists (PTs) and occupational therapists (OTs) to serve as a basis for their postgraduate education.

METHODS

The EULAR standardised operating procedures for the development of recommendations were followed. A TF including rheumatologists, nurses, PTs, OTs, patient-representatives, an educationalist, methodologists and researchers from 12 countries met twice. In the first TF meeting, 13 research questions were defined to support a systematic literature review (SLR). In the second meeting, the SLR evidence was discussed and recommendations formulated. Subsequently, level of evidence and strength of recommendation were assigned and level of agreement (LoA) determined (0-10 rating scale).

RESULTS

Three overarching principles were identified and 10 recommendations were developed for the generic core competences of HPRs. The SLR included 79 full-text papers, 20 of which addressed the competences, knowledge, skills, attitudes and/or educational needs of HPRs from multiple professions. The average LoA for each recommendation ranged from 9.42 to 9.79. Consensus was reached both on a research and educational agenda.

CONCLUSION

Evidence and expert opinion informed a set of recommendations providing guidance on the generic core competences of HPRs. Implementation of these recommendations in the postgraduate education of HPRs at the international and national level is advised, considering variation in healthcare systems and professional roles.

Development of generic core competences of health professionals in rheumatology: a systematic literature review informing the 2018 EULAR recommendations

Objective

To identify generic competences on the desired knowledge, skills and of health professionals in rheumatology (HPRs) to inform the respective EULAR recommendations.

Methods

A systematic literature review was performed on the generic core competences (defined as knowledge, skills or attitudes) of HPRs (nurses, physical therapists (PTs) or occupational therapists (OTs)). Literature was obtained from electronic databases, published EULAR recommendations and via personal communication with representatives of national rheumatology societies and experts in the field. Qualitative, quantitative and mixed methods studies were included, and their methodological quality was scored using appropriate instruments.

Results

From 766 references reviewed, 79 fulfilled the inclusion criteria. Twenty studies addressed competences of multiple HPRs: 15 were of qualitative design, 1 quantitative, 1 mixed-methods, 2 systematic reviews and 1 opinion paper. The methodological quality of most studies was medium to high. Five studies concerned the development of a comprehensive set of competences. Key competences included: basic knowledge of rheumatic diseases, holistic approach to patient management, effective communication with colleagues and patients and provision of education to patients. The proposed competences were confirmed in studies focusing on one or more specific competences, on a rheumatic disease or on a specific profession (nurses, PTs or OTs).

Conclusion

Generic competences were identified for HPRs. Data were mostly derived from qualitative studies. All identified studies varied and were at national level, highlighting the need for the harmonisation of HPR competences across Europe. These findings underpin the development of EULAR recommendations for the core competences of HPRs.

Understanding exercise promotion in rheumatic diseases: A qualitative study among physical therapists

Background: Physical therapists have unique expertise in planning, prescribing, and supporting exercise for patients with rheumatic diseases. Promoting exercise can be a challenge, but descriptions of physical therapists' experiences within the field of rheumatology are limited.Objective: The purpose of this study was to explore and describe ways of understanding exercise promotion among physical therapists working in rheumatology.Design and Method: A phenomenographic approach was used to analyze semi-structured interviews with 25 physical therapists working primarily within the field of rheumatology from eight different physical therapy departments at hospitals across Sweden.Results: Four ways of understanding exercise promotion were identified. These were named: exercise promotion as information and monitoring of the behavior, as facilitation of skills building, as co-creation of awareness, and as the development of independence and self-reflection.Conclusion: Physical therapists in rheumatology understand exercise promotion in various ways that differ with respect to comprehensiveness and patient-centeredness. The physical therapists' use of behavior change techniques serves different purposes in exercise promotion, varying from external control to self-management. The present results might thus be used to develop awareness, knowledge, and skills for more deliberate exercise promotion among physical therapists working with patients having rheumatic diseases.

A survey across four European countries to determine rheumatology health professionals' awareness of physical activity measures in people with inflammatory joint diseases

OBJECTIVES

The objectives of this study were to determine rheumatology health professionals' (HPs)' awareness of and confidence in using physical activity (PA) measures in people with inflammatory joint diseases (IJDs), their own self-reported PA levels and to identify HP-related educational needs.

METHODS

Rheumatology HPs in Denmark, Sweden, Ireland and Belgium participated in an on-line survey. Descriptive statistics and latent class analysis (LCA) were undertaken SPSS (v21and SASv9.4) to describe data aggregates and range and to identify subclasses of groups with respect to use of PA measures.

RESULTS

322 (n=322, 75.5% women) HPs responded from Denmark (n=50, 15.5%), Sweden (n=66, 20.5%), Ireland (n=28, 8.7%) and Belgium (n=178, 55.3%) and the majority of respondents (n=286, 91.7%) reported it was important to measure PA in people with IJDs. Only 28.2% of HPs used simple body worn sensors to measure PA levels in their patients. The majority were interested in on-line education on measuring PA (82.9%). LCA, used to generate classes of PA measures employed by HPs, revealed three distinct classes reflecting differences in self-reported PA levels, awareness of PA measures, further education requirements and professional background.

CONCLUSIONS

The majority of respondents reported that they considered measuring PA as important in people with IJDs; however, the majority lacked confidence in how to measure it. There was strong interest in further education around measuring PA. Three distinct respondent classes were identified to inform targeted education on how to measure PA.

A survey of physiotherapists' current management and the promotion of physical activity, in people with rheumatoid arthritis

Purpose: Establishing physiotherapists' management of people with rheumatoid arthritis, in addition to their promotion of physical activity, is important to ascertain if there are educational needs in this area. Materials and methods: Physiotherapists from three Irish Chartered Physiotherapy clinical interest groups (N = 457) were invited to participate in a cross-sectional online questionnaire hosted on SurveyMonkey^(R)™. Results: One hundred and sixty-eight (168/457; 37%) responded. Exercise prescription and education were the most frequent treatments, with 84% always/regularly providing same. Physical activity is a component of treatment with 52% always/regularly advising. In addition, 69% agree that physical activity is attainable, 68% safe, and 67% an important goal. However, 62% never recommend the appropriate guidelines, while 14% define physical activity according to frequently used definitions. There was a statistically significant association between longer years qualified and more years working with people with RA, when using guidelines to guide physical activity and exercise prescription. Low-intensity exercises were prescribed by however, 67% never provide high-intensity. Conclusions: Current practice is in line with guidelines in which, exercise therapy and education are considered as the mainstay. Promotion of physical activity is strong; however, two-thirds never recommend the appropriate guidelines, and only a minority defined physical activity correctly. The majority never prescribe high-intensity exercise. There is a need to develop education and training for physiotherapists in the promotion of physical activity in people with rheumatoid arthritis. Implications for rehabilitation Exercise therapy and education are considered as the mainstay in the physiotherapy management of people with rheumatoid arthritis. Those physiotherapists' who are qualified longer and have more experience working with people with rheumatoid arthritis use the relevant physical activity guidelines. Overall there is a need to develop education and training for physiotherapists in the promotion of physical activity in people with rheumatoid arthritis.