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Sousa Filho LF, Farlie MK, Haines T, Borrelli B, Carroll C, Mathews C, Ribeiro DC, Fritz JM, Underwood M, Foster NE, Lamb SE, Sanchez ZM, Malliaras P. Developing an international consensus Reporting guideline for intervention Fidelity in Non-Drug, non-surgical trials: The ReFiND protocol. Contemp Clin Trials 2024; 142:107575. [PMID: 38750951 DOI: 10.1016/j.cct.2024.107575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Revised: 04/23/2024] [Accepted: 05/11/2024] [Indexed: 05/21/2024]
Abstract
BACKGROUND Inadequate reporting of fidelity to interventions in trials limits the transparency and interpretation of trial findings. Despite this, most trials of non-drug, non-surgical interventions lack comprehensive reporting of fidelity. If fidelity is poorly reported, it is unclear which intervention components were tested or implemented within the trial, which also hinders research reproducibility. This protocol describes the development process of a reporting guideline for fidelity of non-drug, non-surgical interventions (ReFiND) in the context of trials. METHODS The ReFiND guideline will be developed in six stages. Stage one: a guideline development group has been formed to oversee the guideline methodology. Stage two: a scoping review will be conducted to identify and summarize existing guidance documents on the fidelity of non-drug, non-surgical interventions. Stage three: a Delphi study will be conducted to reach consensus on reporting items. Stage four: a consensus meeting will be held to consolidate the reporting items and discuss the wording and structure of the guideline. Stage five: a guidance statement, an elaboration and explanation document, and a reporting checklist will be developed. Stage six: different strategies will be used to disseminate and implement the ReFiND guideline. DISCUSSION The ReFiND guideline will provide a set of items developed through international consensus to improve the reporting of intervention fidelity in trials of non-drug, non-surgical interventions. This reporting guideline will enhance transparency and reproducibility in future non-drug, non-surgical intervention research.
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Affiliation(s)
| | - Melanie K Farlie
- School of Primary and Allied Health Care, Monash University, Melbourne, Australia.
| | - Terry Haines
- School of Primary and Allied Health Care, Monash University, Melbourne, Australia.
| | - Belinda Borrelli
- Center for Behavioral Science Research, Department of Health Policy and Health Services Research, Boston University, Henry M. Goldman School of Dental Medicine, Boston, MA, USA.
| | | | - Catherine Mathews
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa; School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.
| | - Daniel C Ribeiro
- Centre for Health, Activity and Rehabilitation Research, School of Physiotherapy, University of Otago, Dunedin, New Zealand.
| | - Julie M Fritz
- Department of Physical Therapy & Athletic Training, University of Utah, Salt Lake City, UT, USA.
| | - Martin Underwood
- Warwick Clinical Trials Unit, University of Warwick, Warwick, UK.; University Hospitals of Coventry and Warwickshire, Coventry, UK.
| | - Nadine E Foster
- STARS Education and Research Alliance, Surgical Treatment and Rehabilitation Service (STARS), The University of Queensland and Metro North Health, Brisbane, Australia; School of Medicine, Keele University, Keele, UK.
| | - Sarah E Lamb
- University of Exeter, St Luke's Campus, Exeter, UK.
| | - Zila M Sanchez
- Department of Preventive Medicine, Universidade Federal de São Paulo (UNIFESP), São Paulo, SP, Brazil.
| | - Peter Malliaras
- School of Primary and Allied Health Care, Monash University, Melbourne, Australia.
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Mahmoud A, Goodwin VA, Morley N, Whitney J, Lamb SE, Lyndon H, Creanor S, Frost J. How can we improve Comprehensive Geriatric Assessment for older people living with frailty in primary care and community settings? A qualitative study. BMJ Open 2024; 14:e081304. [PMID: 38548360 PMCID: PMC10982782 DOI: 10.1136/bmjopen-2023-081304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Accepted: 03/18/2024] [Indexed: 04/02/2024] Open
Abstract
OBJECTIVE With advancing age comes the increasing prevalence of frailty and increased risk of adverse outcomes (eg, hospitalisation). Evidence for comprehensive geriatric assessment (CGA), a multidimensional holistic model of care, is mixed in community settings. Uncertainties remain, such as the key components of CGA, who delivers it, and the use of technology. This study aimed to understand the perspectives, beliefs and experiences, of both older people and health professionals, to improve the current CGA and explore factors that may impact on CGA delivery in community settings. DESIGN A qualitative interview study was conducted with older people and healthcare professionals (HCPs) identified using a maximum variation strategy. Data were analysed using an abductive analysis approach. The non-adoption, abandonment, scale-up, spread and sustainability framework and the theoretical framework of acceptability guided the categorisation of the codes and identified categories were mapped to the two frameworks. SETTING England, UK. RESULTS 27 people were interviewed, constituting 14 older people and 13 HCPs. We identified limitations in the current CGA: a lack of information sharing between different HCPs who deliver CGA; poor communication between older people and their HCPs and a lack of follow-up as part of CGA. When we discussed the potential for CGA to use technology, HCPs and older people varied in their readiness to engage with it. CONCLUSIONS Viable solutions to address gaps in the current delivery of CGA include the provision of training and support to use digital technology and a designated comprehensive care coordinator. The next stage of this research will use these findings, existing evidence and stakeholder engagement, to develop and refine a model of community-based CGA that can be assessed for feasibility and acceptability.
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Affiliation(s)
- Aseel Mahmoud
- Faculty of Health and Life Sciences, University of Exeter, Exeter, UK
| | | | - Naomi Morley
- Faculty of Health and Life Sciences, University of Exeter, Exeter, UK
| | - Julie Whitney
- Life Sciences and Medicine, King's College London, London, UK
| | - Sarah E Lamb
- Faculty of Health and Life Sciences, University of Exeter, Exeter, UK
| | - Helen Lyndon
- Adult Community Services Specialist Services Directorate, Cornwall Partnership NHS Foundation Trust, Bodmin, UK
- Southwest Clinical School, University of Plymouth, Plymouth, UK
| | - Siobhan Creanor
- Faculty of Health and Life Sciences, University of Exeter, Exeter, UK
| | - Julia Frost
- Faculty of Health and Life Sciences, University of Exeter, Exeter, UK
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Comer C, Williamson E, McIlroy S, Srikesavan C, Dalton S, Melendez-Torres GJ, Lamb SE. Exercise treatments for lumbar spinal stenosis: A systematic review and intervention component analysis of randomised controlled trials. Clin Rehabil 2024; 38:361-374. [PMID: 37715644 PMCID: PMC10829420 DOI: 10.1177/02692155231201048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Accepted: 08/27/2023] [Indexed: 09/18/2023]
Abstract
OBJECTIVE To analyse the components used in exercise interventions for people with symptoms of neurogenic claudication due to lumbar spinal stenosis and identify components associated with successful interventions. DATA SOURCES Eligible papers published up to April 2023 from MEDLINE, EMBASE, CINAHL, PEDro, CENTRAL, Web of Science, and trial registry websites. REVIEW METHODS Literature searches were performed by an Information Specialist. We searched for randomised trials evaluating exercise interventions for people with neurogenic claudication symptoms (the primary symptom of lumbar spinal stenosis). Two authors independently performed study selection, data extraction, and quality assessments using the Cochrane Risk of Bias tool Version 2 and the TIDieR checklist for intervention reporting. Details of intervention components were extracted, tabulated, and synthesised using an intervention component analysis approach. RESULTS We found thirteen trials reporting 23 exercise interventions delivered to 1440 participants. These featured 60 different components. Most exercise interventions included supervision and flexion-based exercises. Balance exercises were rarely included. Exercise components featured more frequently in successful interventions included stretches, strength or trunk muscle exercises, fitness exercises, especially cycling, and psychologically informed approaches. Interpretation is limited by low study numbers and heterogeneity. No conclusions could be drawn about exercise supervision or dose. DISCUSSION Exercise interventions for people with neurogenic claudication typically feature multiple components. Common features such as supervision, lumbar flexion, and aerobic fitness exercises and also less common features such as stretches, strengthening exercises, and psychologically informed approaches warrant consideration for inclusion when designing and optimising exercise interventions for people with lumbar spinal stenosis.
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Affiliation(s)
- Christine Comer
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, Faculty of Medicine, University of Leeds, UK
- Leeds Community Healthcare Musculoskeletal and Rehabilitation Services, Leeds Community Healthcare NHS Trust, UK
| | - Esther Williamson
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, UK
- Faculty of Health and Life Sciences, University of Exeter, Exeter, UK
| | - Suzanne McIlroy
- Physiotherapy Department, King's College Hospital NHS Foundation Trust, UK
- Health Psychology Section, The Institute of Psychiatry, Psychology & Neuroscience (IoPPN), King's College London, UK
| | - Cynthia Srikesavan
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, UK
- Faculty of Health and Life Sciences, University of Exeter, Exeter, UK
| | | | | | - Sarah E Lamb
- Faculty of Health and Life Sciences, University of Exeter, Exeter, UK
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Ribeiro DC, Lamb SE, Abbott JH. Mediators of the effects of exercise and manual therapy for people with knee and hip osteoarthritis: A secondary, exploratory analysis of the MOA trial. Osteoarthr Cartil Open 2024; 6:100431. [PMID: 38304412 PMCID: PMC10832273 DOI: 10.1016/j.ocarto.2023.100431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 12/19/2023] [Accepted: 12/26/2023] [Indexed: 02/03/2024] Open
Abstract
Objective To explore whether pain beliefs and functional strength mediate the treatment effect of manual therapy (MT) and exercise therapy (ET) on the Western Ontario and McMaster Osteoarthritis Index (WOMAC) composite scores and its subscales in individuals with hip and/or knee osteoarthritis in the MOA trial. Design Secondary analysis of a randomised controlled trial that compared the incremental effects of supervised MT and ET in addition to usual care in patients with osteoarthritis of the hip or knee. 206 participants enrolled in the MOA trial were analysed. The primary outcome measure was the WOMAC composite score after 1 year. Results Pain belief mediated the effect of MT (b: -10.7, 95 % CI: -22.3, -0.9), ET (b: -14.5 95%CI: -26.0, -4.4). Functional strength did not mediate the effect of MT, ET, or MT + ET. Mediation sensitivity analyses suggest findings are likely to change if small confounding between those mediators and WOMAC composite score is present. Conclusions We identified possible mediators of MT and ET. Future confirmatory studies could be designed to assess the mechanisms through which manual therapy and exercise cause improvements in pain and function scores in patients with hip or knee osteoarthritis.
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Affiliation(s)
- Daniel Cury Ribeiro
- Centre for Health, Activity and Rehabilitation Research, School of Physiotherapy, University of Otago, Dunedin, New Zealand
| | - Sarah E. Lamb
- University of Exeter Medical School, St Luke's Campus, Heavitree Road, Exeter, EX1 2LU, UK
| | - J. Haxby Abbott
- Department of Surgical Sciences, University of Otago Medical School, Dunedin, New Zealand
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Ahern L, Timmons S, Lamb SE, McCullagh R. A systematic review of Behaviour Change Interventions to improve exercise self-efficacy and adherence in people with Parkinson's disease using the Theoretical Domains Framework. J Frailty Sarcopenia Falls 2024; 9:66-68. [PMID: 38444546 PMCID: PMC10910257 DOI: 10.22540/jfsf-09-066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/22/2023] [Indexed: 03/07/2024] Open
Abstract
Physical activity and exercise can limit the development of sarcopenia in Parkinson's Disease. This review aims to evaluate the potential effects of behavioural change (BC) interventions on exercise self-efficacy and adherence in people with Parkinson's. We searched nine databases and included randomised and non-randomised studies reporting exercise self-efficacy, quality of life (QoL), physical function and/or exercise adherence. Two reviewers independently screened, data extracted, and assessed risk of bias and certainty of evidence. The interventions were mapped to the Theoretical Domains Framework. Eleven studies (n=901) were included. Four were randomised trials and risk of bias was mixed. Most interventions were multi-component, including education, behavioural techniques, and support groups. The most effective domains appear to be Behavioural regulation, Belief about Capabilities, Social influences, Reinforcement and Goals. Future research should examine multi-component BC interventions encompassing the five most effective TDF domains.
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Affiliation(s)
- Leanne Ahern
- Discipline of Physiotherapy, School of Clinical Therapies, University College Cork, Cork, Ireland
| | - Suzanne Timmons
- Centre for Gerontology and Rehabilitation, School of Medicine, College of Medicine and Health, University College Cork, Cork, Ireland
| | - Sarah E. Lamb
- Faculty of Health and Life Sciences, University of Exeter, Exeter, UK
| | - Ruth McCullagh
- Discipline of Physiotherapy, School of Clinical Therapies, University College Cork, Cork, Ireland
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Ahern L, Timmons S, Lamb SE, McCullagh R. Behavioural change for Parkinson's Disease: A randomised controlled feasibility study to promote physical activity and exercise adherence among people with Parkinson's: study protocol. HRB Open Res 2024; 7:7. [PMID: 38784965 PMCID: PMC11109530 DOI: 10.12688/hrbopenres.13843.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/09/2024] [Indexed: 05/25/2024] Open
Abstract
Background Parkinson's is a common progressive neurological condition characterized by motor and non-motor deficits. Physical activity and exercise can improve health, but many people with Parkinson's (PwP) have trouble reaching the recommended dosage. Our recent literature review found improvements in exercise adherence with behavioural change interventions, but it remains unclear which are most effective. Further qualitative research and patient and public involvement has informed a novel behavioural change intervention to be tested alongside an existing exercise program. Objective To examine the feasibility of behavioural change techniques delivered alongside an exercise programme to improve physical activity, function, and self-efficacy in PwP (and study procedures) to inform a future pilot RCT trial. Methods A parallel-arm single blinded randomised feasibility study. Twenty participants with Parkinson's (Hoehn and Yahr stage 1-3) will be recruited from a physiotherapy primary-care waiting list. Following written consent, and baseline assessment, the participants will be randomly allocated to the intervention (n=10) or the control group (n=10). Both groups will receive usual care, which includes a weekly program of a multidisciplinary education, a supervised exercise class and a prescribed home exercise program. The intervention group will receive additional behavioural change techniques, targeting behaviour regulation, belief about capabilities and social influences. Class and home exercise adherence, behavioural component uptake and adherence, and negative events will be recorded. Outcomes will include enrolment and maintenance rates, physical function, falls, physical activity, and exercise self-efficacy measured pre- and post- the 12-week program (in-person). Surveys will be used to compare experiences and satisfaction between groups. Exit interviews will be completed with the intervention group only, exploring their experience of the behavioural change techniques. Discussion The results will help inform a future pilot RCT, based on the intervention acceptability, consent rate, maintenance, and protocol integrity. Trial Registration ClincialTrials.gov NCT06192628.
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Affiliation(s)
- Leanne Ahern
- Discipline of Physiotherapy, School of Clinical Therapies, University College Cork, Cork, Ireland
| | - Suzanne Timmons
- Centre for Gerontology and Rehabilitation, School of Medicine, College of Medicine and Health, University College Cork, Cork, County Cork, Ireland
| | - Sarah E. Lamb
- Faculty of Health and Life Sciences, University of Exeter, Exeter, England, UK
| | - Ruth McCullagh
- Discipline of Physiotherapy, School of Clinical Therapies, University College Cork, Cork, Ireland
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Lamb SE, Williams G, Young W. The science of falls and how to prevent them. Nat Med 2024; 30:35-36. [PMID: 38228912 DOI: 10.1038/s41591-023-02749-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2024]
Affiliation(s)
- Sarah E Lamb
- Department of Public Health and Sports Science, Exeter Medical School, University of Exeter, Exeter, UK.
| | - Genevieve Williams
- Department of Public Health and Sports Science, Exeter Medical School, University of Exeter, Exeter, UK
| | - Will Young
- Department of Public Health and Sports Science, Exeter Medical School, University of Exeter, Exeter, UK
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Hossain A, Lall R, Ji C, Bruce J, Underwood M, Lamb SE. Comparison of different statistical models for the analysis of fracture events: findings from the Prevention of Falls Injury Trial (PreFIT). BMC Med Res Methodol 2023; 23:216. [PMID: 37784050 PMCID: PMC10546684 DOI: 10.1186/s12874-023-02040-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Accepted: 09/22/2023] [Indexed: 10/04/2023] Open
Abstract
BACKGROUND Fractures are rare events and can occur because of a fall. Fracture counts are distinct from other count data in that these data are positively skewed, inflated by excess zero counts, and events can recur over time. Analytical methods used to assess fracture data and account for these characteristics are limited in the literature. METHODS Commonly used models for count data include Poisson regression, negative binomial regression, hurdle regression, and zero-inflated regression models. In this paper, we compare four alternative statistical models to fit fracture counts using data from a large UK based clinical trial evaluating the clinical and cost-effectiveness of alternative falls prevention interventions in older people (Prevention of Falls Injury Trial; PreFIT). RESULTS The values of Akaike information criterion and Bayesian information criterion, the goodness-of-fit statistics, were the lowest for negative binomial model. The likelihood ratio test of no dispersion in the data showed strong evidence of dispersion (chi-square = 225.68, p-value < 0.001). This indicates that the negative binomial model fits the data better compared to the Poisson regression model. We also compared the standard negative binomial regression and mixed effects negative binomial models. The LR test showed no gain in fitting the data using mixed effects negative binomial model (chi-square = 1.67, p-value = 0.098) compared to standard negative binomial model. CONCLUSIONS The negative binomial regression model was the most appropriate and optimal fit model for fracture count analyses. TRIAL REGISTRATION The PreFIT trial was registered as ISRCTN71002650.
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Affiliation(s)
- Anower Hossain
- Warwick Clinical Trials Unit, University of Warwick, Coventry, UK.
- Institute of Statistical Research and Training (ISRT), University of Dhaka, Dhaka, Bangladesh.
| | - Ranjit Lall
- Warwick Clinical Trials Unit, University of Warwick, Coventry, UK
| | - Chen Ji
- Warwick Clinical Trials Unit, University of Warwick, Coventry, UK
| | - Julie Bruce
- Warwick Clinical Trials Unit, University of Warwick, Coventry, UK
- University Hospital Coventry and Warwickshire NHS Trust, Clifford Bridge Road, Coventry, UK
| | - Martin Underwood
- Warwick Clinical Trials Unit, University of Warwick, Coventry, UK
- University Hospital Coventry and Warwickshire NHS Trust, Clifford Bridge Road, Coventry, UK
| | - Sarah E Lamb
- University of Exeter, St Luke's Campus, Exeter, UK
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Forde C, Nicolson PJ, Vye C, Pun JC, Sheehan W, Costa ML, Lamb SE, Keene DJ. Lower limb muscle strength and balance in older adults with a distal radius fracture: a systematic review. BMC Musculoskelet Disord 2023; 24:741. [PMID: 37723447 PMCID: PMC10506229 DOI: 10.1186/s12891-023-06711-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Accepted: 07/09/2023] [Indexed: 09/20/2023] Open
Abstract
BACKGROUND Distal radius fractures are common fractures in older adults and associated with increased risk of future functional decline and hip fracture. Whether lower limb muscle strength and balance are impaired in this patient population is uncertain. To help inform rehabilitation requirements, this systematic review aimed to compare lower limb muscle strength and balance between older adults with a distal radius fracture with matched controls, and to synthesise lower limb muscle strength and balance outcomes in older adults with a distal radius fracture. METHODS We searched Embase, MEDLINE, and CINAHL (1990 to 25 May 2022) for randomised and non-randomised controlled clinical trials and observational studies that measured lower limb muscle strength and/or balance using instrumented measurements or validated tests, in adults aged ≥ 50 years enrolled within one year after distal radius fracture. We appraised included observational studies using a modified Newcastle-Ottawa Scale and included randomised controlled trials using the Cochrane risk-of-bias tool. Due to the clinical and methodological heterogeneity in included studies, we synthesised results narratively in tables and text. RESULTS Nineteen studies (10 case-control studies, five case series, and four randomised controlled trials) of variable methodological quality and including 1835 participants (96% women, mean age 55-73 years, median sample size 82) were included. Twelve included studies (63%) assessed strength using 10 different methods with knee extension strength most commonly assessed (6/12 (50%) studies). Five included case-control studies (50%) assessed lower limb strength. Cases demonstrated impaired strength during functional tests (two studies), but knee extension strength assessment findings were conflicting (three studies). Eighteen included studies (95%) assessed balance using 14 different methods. Single leg balance was most commonly assessed (6/18 (33%) studies). All case-control studies assessed balance with inconsistent findings. CONCLUSION Compared to controls, there is some evidence that older adults with a distal radius fracture have impaired lower limb muscle strength and balance. A cautious interpretation is required due to inconsistent findings across studies and/or outcome measures. Heterogeneity in control participants' characteristics, study design, study quality, and assessment methods limited synthesis of results. Robust case-control and/or prospective observational studies are needed. REGISTRATION International prospective register of systematic reviews (date of registration: 02 July 2020, registration identifier: CRD42020196274).
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Affiliation(s)
- Colin Forde
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Philippa Ja Nicolson
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Charlotte Vye
- Therapies Department, Royal United Hospitals NHS Foundation Trust, Bath, UK
| | - Jessica Ch Pun
- Institute of Child Health, University College London, London, UK
| | - Warren Sheehan
- Physiotherapy Department, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Matthew L Costa
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Sarah E Lamb
- Exeter Medical School, University of Exeter, Exeter, UK
| | - David J Keene
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK.
- Exeter Medical School, University of Exeter, Exeter, UK.
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Tutton E, Gould J, Lamb SE, Costa ML, Keene DJ. Experience of patients and physiotherapists within the AFTER pilot randomised trial of two rehabilitation interventions for people aged 50 years and over post ankle fracture: a qualitative study. BMJ Open 2023; 13:e071678. [PMID: 37487681 PMCID: PMC10373749 DOI: 10.1136/bmjopen-2023-071678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/26/2023] Open
Abstract
OBJECTIVES To explore patient and staff experience of best-practice rehabilitation advice (one session of face-to-face self-management advice with up to two additional optional sessions) compared with progressive functional exercise (up to six sessions of face-to-face physiotherapy) after ankle fracture. DESIGN The study drew on phenomenology using interviews and a focus group. SETTING Participants were from three NHS Trusts in England, UK. PARTICIPANTS A purposive sample of 20 patients with ankle (malleolar) fractures from the Ankle Fracture Treatment: Enhancing Rehabilitation-pilot trial (now completed) were interviewed (median 50 min) from May 2019 to January 2020. They were 6 months post injury, over 50 years of age, (median 66, 12 females) and had received surgical or non-surgical treatment (seven internal fixation surgery, seven close contact casting, six walking boot). A focus group of five physiotherapists who had provided the study interventions (2.5 hours) was undertaken. RESULTS The findings show the acceptability of both interventions through the themes, 'being helped' (for patients) and 'developing expertise' (for staff) with subthemes of choosing and progressing. Progressive exercise added value with a perceived increase in strength, motion, ability to undertake activities and continued use of the workbook. Both staff and patients valued physiotherapy expertise demonstrated through interpersonal skills, advice, individualised exercise plans and active monitoring of progression. Best practice advice was particularly helpful in the early stages of recovery and with the use of mobility aids. CONCLUSION Both interventions were acceptable but progressive exercise was highly valued by patients. Developing expertise through experiential learning enabled staff to facilitate progression. Adjustments to the workbook and the addition of exercises for continued recovery in the best practice advice would enhance a future study. Research during treatment provision may provide further insights into the challenges of facilitating progression of exercise. TRIAL REGISTRATION ISRCTN16612336; AFTER-pilot trial).
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Affiliation(s)
- Elizabeth Tutton
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Kadoorie Centre, Level 3, John Radcliffe Hospital, OX3 9DU, University of Oxford, Oxford, UK
- Major Trauma Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Jenny Gould
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Kadoorie Centre, Level 3, John Radcliffe Hospital, OX3 9DU, University of Oxford, Oxford, UK
| | - Sarah E Lamb
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Kadoorie Centre, Level 3, John Radcliffe Hospital, OX3 9DU, University of Oxford, Oxford, UK
- Faculty of Health and Life Sciences, Exeter Medical School, University of Exeter, Exeter, UK
| | - Matthew L Costa
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Kadoorie Centre, Level 3, John Radcliffe Hospital, OX3 9DU, University of Oxford, Oxford, UK
| | - David J Keene
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Kadoorie Centre, Level 3, John Radcliffe Hospital, OX3 9DU, University of Oxford, Oxford, UK
- Faculty of Health and Life Sciences, Exeter Medical School, University of Exeter, Exeter, UK
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Ribeiro DC, Wilkinson A, Voney M, Sole G, Lamb SE, Abbott JH. Clinicians' perspectives on planned interventions tested in the Otago MASTER feasibility trial: an implementation-based process evaluation study. BMJ Open 2023; 13:e067745. [PMID: 37094901 PMCID: PMC10151965 DOI: 10.1136/bmjopen-2022-067745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/26/2023] Open
Abstract
OBJECTIVES This study reports a process evaluation of the Otago MASTER (MAnagement of Subacromial disorders of The shouldER) feasibility trial. This mixed-methods, process evaluation study was conducted parallel to the Otago MASTER feasibility trial. Our aims were to investigate: (1) supervised treatment fidelity of the interventions and (2) clinicians' perceptions of the trial interventions through a focus group. DESIGN Nested process evaluation study using a mixed-methods approach. SETTING Outpatient clinic. PARTICIPANTS Five clinicians (two men, three women) aged 47-67 years, with clinical experience of 18-43 years and a minimum of postgraduate certificate training, were involved with the delivery of interventions within the feasibility trial. We assessed treatment fidelity for supervised exercises through audit of clinicians' records and compared those with the planned protocol. Clinicians took part in a focus group that lasted for approximately 1 hour. The focus group was transcribed verbatim and focus group discussion was analysed thematically using an iterative approach. RESULTS The fidelity score for the tailored exercise and manual therapy intervention was 80.3% (SD: 7.7%) and for the standardised exercise intervention, 82.9% (SD: 5.9%). Clinicians' perspectives about the trial and planned intervention were summarised by one main theme 'conflict experienced between individual clinical practice and the intervention protocol', which was supported by three subthemes: (1) programme strengths and weaknesses; (2) design-related and administrative barriers; and (3) training-related barriers. CONCLUSION This mixed-methods study assessed supervised treatment fidelity of interventions and clinicians' perceptions on planned interventions tested in the Otago MASTER feasibility trial. Overall, treatment fidelity was acceptable for both intervention arms; however, we observed low fidelity for certain domains within the tailored exercise and manual therapy intervention. Our focus group identified several barriers clinicians faced while delivering the planned interventions. Those findings are of relevance for planning the definite trial and for researchers conducting feasibility trials. TRIAL REGISTRATION NUMBER ANZCTR: 12617001405303.
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Affiliation(s)
- Daniel C Ribeiro
- Centre for Health, Activity and Rehabilitation Research, School of Physiotherapy, University of Otago, Dunedin, New Zealand
| | - Amanda Wilkinson
- Centre for Health, Activity and Rehabilitation Research, School of Physiotherapy, University of Otago, Dunedin, New Zealand
- Centre for Postgraduate Nursing Studies, University of Otago, Christchurch, New Zealand
| | - Melanie Voney
- Centre for Health, Activity and Rehabilitation Research, School of Physiotherapy, University of Otago, Dunedin, New Zealand
| | - Gisela Sole
- Centre for Health, Activity and Rehabilitation Research, School of Physiotherapy, University of Otago, Dunedin, New Zealand
| | - Sarah E Lamb
- The University of Exeter Medical School, University of Exeter, Exeter, UK
| | - J Haxby Abbott
- Centre for Musculoskeletal Outcomes Research, Department of Surgical Sciences, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
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Maredza M, Khan K, Marian IR, Dutton SJ, Williamson E, Lamb SE, Petrou S. Correction to: Economic costs, health-related quality of life outcomes and cost-utility of a physical and psychological group intervention targeted at older adults with neurogenic claudication. Cost Eff Resour Alloc 2023; 21:24. [PMID: 37041559 PMCID: PMC10088106 DOI: 10.1186/s12962-023-00431-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/13/2023] Open
Affiliation(s)
- Mandy Maredza
- Division of Health Sciences, Warwick Medical School, The University of Warwick, Coventry, UK.
| | - Kamran Khan
- Warwick Clinical Trials Unit, University of Warwick, Warwick, UK
| | - Ioana R Marian
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Oxford Clinical Trials Research Unit, University of Oxford, Oxford, UK
| | - Susan J Dutton
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Oxford Clinical Trials Research Unit, University of Oxford, Oxford, UK
| | - Esther Williamson
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Oxford Clinical Trials Research Unit, University of Oxford, Oxford, UK
- Exeter Medical School, University of Exeter, Devon, UK
| | - Sarah E Lamb
- Exeter Medical School, University of Exeter, Devon, UK
| | - Stavros Petrou
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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Nicolson PJA, Holden MA, Marian IR, Williamson E, Dutton SJ, Garrett A, Hopewell S, Lamb SE. Tailored exercise management (TEMPO) versus usual care for people aged 80 years or older with hip/knee osteoarthritis: study protocol for a feasibility randomised controlled trial. Pilot Feasibility Stud 2023; 9:56. [PMID: 37005698 PMCID: PMC10067159 DOI: 10.1186/s40814-023-01275-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Accepted: 03/10/2023] [Indexed: 04/04/2023] Open
Abstract
BACKGROUND Exercise is recommended for all people with osteoarthritis. However, these recommendations are based on randomised clinical trials including people with an average age between 60 and 70 years, and these findings cannot reliably be generalised to people aged 80 years or older. Rapid loss of muscle occurs after 70 years of age, and older people are more likely to also have other health conditions that contribute to difficulties with daily activities and impact on their response to exercise. To improve care for people aged 80 or older with osteoarthritis, it is thought that a tailored exercise intervention targeting both osteoarthritis and any other health conditions they have, may be needed. The aim of this study will be to test if it is possible to conduct a randomised controlled trial (RCT) for people over 80 years of age with hip/knee osteoarthritis of a tailored exercise intervention. METHODS A multicentre, parallel, 2-group, feasibility RCT with embedded qualitative study, conducted in ≥ 3 UK NHS physiotherapy outpatient services. Participants (n ≥ 50) with clinical knee and/or hip osteoarthritis and ≥ 1 comorbidity will be recruited by screening referrals to participating NHS physiotherapy outpatient services, via screening of general practice records and via identification of eligible individuals from a cohort study run by our research group. Participants will be randomised (computer-generated: 1:1) to receive either: a 12-week education and tailored exercise intervention (TEMPO); or usual care and written information. The primary feasibility objectives are to estimate: (1) ability to screen and recruit eligible participants; (2) retention of participants, measured by the proportion of participants who provide outcome data at 14-week follow-up. Secondary quantitative objectives are to estimate: (1) participant engagement assessed by physiotherapy session attendance and home exercise adherence; (2) sample size calculation for a definitive RCT. One-to-one semi-structured interviews will explore the experiences of trial participants and physiotherapists delivering the TEMPO programme. DISCUSSION Progression criteria will be used to determine whether a definitive trial to evaluate the clinical and cost-effectiveness of the TEMPO programme is considered feasible with or without modifications to the intervention or trial design. TRIAL REGISTRATION ISRCTN75983430. Registered 3/12/2021. https://www.isrctn.com/ISRCTN75983430.
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Affiliation(s)
- Philippa J A Nicolson
- Centre for Rehabilitation Research, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), , University of Oxford, Oxford, UK.
| | - Melanie A Holden
- Primary Care Centre Versus Arthritis, School of Medicine, Keele University, Keele, UK
| | - Ioana R Marian
- Oxford Clinical Trials Research Unit, Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford, UK
| | - Esther Williamson
- Centre for Rehabilitation Research, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), , University of Oxford, Oxford, UK
- College of Medicine and Health, University of Exeter, Exeter, UK
| | - Susan J Dutton
- Oxford Clinical Trials Research Unit, Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford, UK
| | - Angela Garrett
- Centre for Rehabilitation Research, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), , University of Oxford, Oxford, UK
| | - Sally Hopewell
- Oxford Clinical Trials Research Unit, Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford, UK
| | - Sarah E Lamb
- Centre for Rehabilitation Research, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), , University of Oxford, Oxford, UK
- College of Medicine and Health, University of Exeter, Exeter, UK
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Smith TO, Garrett A, Liu T, Morris A, Gallyer V, Fordham BA, Dutton SJ, Chester-Jones M, Lamb SE, Winter SC. Getting Recovery Right After Neck Dissection (GRRAND-F): Mixed-methods feasibility study to design a pragmatic randomised controlled trial. Front Oncol 2023; 13:1110500. [PMID: 37007098 PMCID: PMC10061058 DOI: 10.3389/fonc.2023.1110500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 02/24/2023] [Indexed: 03/18/2023] Open
Abstract
ObjectiveTo determine the feasibility of a randomised controlled trial to estimate the effectiveness and cost-effectiveness of a rehabilitation intervention following neck dissection (ND) after head and neck cancer (HNC).DesignTwo-arm, open, pragmatic, parallel, multicentre, randomised controlled feasibility trial.SettingTwo UK NHS hospitals.ParticipantsPeople who had HNC in whom a ND was part of their care. We excluded those with a life expectancy of six months or less, pre-existing, long-term neurological disease affecting the shoulder and cognitive impairment.InterventionUsual care (standard care supplemented with a booklet on postoperative self-management) was received by all participants. The GRRAND intervention programme consisted of usual care plus up to six individual physiotherapy sessions including neck and shoulder range of motion and progressive resistance exercises, advice and education. Between sessions, participants were advised to complete a home exercise programme.Randomisation1:1 randomisation. Allocation was based on minimisation, stratified by hospital site and spinal accessory nerve sacrifice. It was not possible to mask treatment received.Main outcome measuresPrimary: Participant recruitment, retention and fidelity to the study protocol and interventions from study participants and staff at six months post-randomisation (and 12 months for those reaching that time-point). Secondary: clinical measures of pain, function, physical performance, health-related quality of life, health utilisation and adverse events.Results36 participants were recruited and enrolled. The study achieved five of its six feasibility targets. These included consent - 70% of eligible participants were consented; intervention fidelity - 78% participants discharged completed the intervention sessions; contamination - none - no participants in the control arm received the GRRAND-F intervention and retention - 8% of participants were lost to follow-up. The only feasibility target that was not achieved was the recruitment target where only 36 of the planned 60 participants were recruited over 18 months. This was principally due to the COVID-19 pandemic which caused all research activity to be paused or reduced, with a subsequent reduction in.ConclusionsBased on the findings a full-trial can now be designed to better understand whether this proposed intervention is effective.Clinical Trial Registrationhttps://www.isrctn.com/ISRCTN1197999, identifier ISRCTN11979997.
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Affiliation(s)
- Toby O. Smith
- Warwick Clinical Trials Unit, University of Warwick, Coventry, United Kingdom
- School of Health Sciences, University of East Anglia, Norwich, United Kingdom
| | - Angela Garrett
- Oxford Clinical Trials Research Unit, Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
| | - Tianshu Liu
- Oxford Clinical Trials Research Unit, Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
| | - Alana Morris
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Medical Sciences Division, University of Oxford, Oxford, United Kingdom
| | - Victoria Gallyer
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Medical Sciences Division, University of Oxford, Oxford, United Kingdom
| | - Bethany A. Fordham
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Medical Sciences Division, University of Oxford, Oxford, United Kingdom
| | - Susan J. Dutton
- Oxford Clinical Trials Research Unit, Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
| | - Mae Chester-Jones
- Oxford Clinical Trials Research Unit, Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
| | - Sarah E. Lamb
- University of Exeter Medical School, University of Exeter, Exeter, United Kingdom
| | - Stuart Charles Winter
- Nuffield Department of Surgical Sciences, Medical Sciences Division, University of Oxford, Oxford, United Kingdom
- Oxford Cancer Centre, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
- *Correspondence: Stuart Charles Winter,
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15
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Clemson L, Stark S, Pighills AC, Fairhall NJ, Lamb SE, Ali J, Sherrington C. Environmental interventions for preventing falls in older people living in the community. Cochrane Database Syst Rev 2023; 3:CD013258. [PMID: 36893804 PMCID: PMC9998238 DOI: 10.1002/14651858.cd013258.pub2] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/11/2023]
Abstract
BACKGROUND Falls and fall-related injuries are common. A third of community-dwelling people aged over 65 years fall each year. Falls can have serious consequences including restricting activity or institutionalisation. This review updates the previous evidence for environmental interventions in fall prevention. OBJECTIVES To assess the effects (benefits and harms) of environmental interventions (such as fall-hazard reduction, assistive technology, home modifications, and education) for preventing falls in older people living in the community. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, other databases, trial registers, and reference lists of systematic reviews to January 2021. We contacted researchers in the field to identify additional studies. SELECTION CRITERIA We included randomised controlled trials evaluating the effects of environmental interventions (such as reduction of fall hazards in the home, assistive devices) on falls in community-residing people aged 60 years and over. DATA COLLECTION AND ANALYSIS: We used standard methodological procedures expected by Cochrane. Our primary outcome was rate of falls. MAIN RESULTS We included 22 studies from 10 countries involving 8463 community-residing older people. Participants were on average 78 years old, and 65% were women. For fall outcomes, five studies had high risk of bias and most studies had unclear risk of bias for one or more risk of bias domains. For other outcomes (e.g. fractures), most studies were at high risk of detection bias. We downgraded the certainty of the evidence for high risk of bias, imprecision, and/or inconsistency. Home fall-hazard reduction (14 studies, 5830 participants) These interventions aim to reduce falls by assessing fall hazards and making environmental safety adaptations (e.g. non-slip strips on steps) or behavioural strategies (e.g. avoiding clutter). Home fall-hazard interventions probably reduce the overall rate of falls by 26% (rate ratio (RaR) 0.74, 95% confidence interval (CI) 0.61 to 0.91; 12 studies, 5293 participants; moderate-certainty evidence); based on a control group risk of 1319 falls per 1000 people a year, this is 343 (95% CI 118 to 514) fewer falls. However, these interventions were more effective in people who are selected for higher risk of falling, with a reduction of 38% (RaR 0.62, 95% CI 0.56 to 0.70; 9 studies, 1513 participants; 702 (95% CI 554 to 812) fewer falls based on a control risk of 1847 falls per 1000 people; high-certainty evidence). We found no evidence of a reduction in rate of falls when people were not selected for fall risk (RaR 1.05, 95% CI 0.96 to 1.16; 6 studies, 3780 participants; high-certainty evidence). Findings were similar for the number of people experiencing one or more falls. These interventions probably reduce the overall risk by 11% (risk ratio (RR) 0.89, 95% CI 0.82 to 0.97; 12 studies, 5253 participants; moderate-certainty evidence); based on a risk of 519 per 1000 people per year, this is 57 (95% CI 15 to 93) fewer fallers. However, for people at higher risk of falling, we found a 26% decrease in risk (RR 0.74, 95% CI 0.65 to 0.85; 9 studies, 1473 participants), but no decrease for unselected populations (RR 0.99, 95% CI 0.92 to 1.07; 6 studies, 3780 participants) (high-certainty evidence). These interventions probably make little or no important difference to health-related quality of life (HRQoL) (standardised mean difference 0.09, 95% CI -0.10 to 0.27; 5 studies, 1848 participants; moderate-certainty evidence). They may make little or no difference to the risk of fall-related fractures (RR 1.00, 95% 0.98 to 1.02; 2 studies, 1668 participants), fall-related hospitalisations (RR 0.96, 95% CI 0.87 to 1.06; 3 studies, 325 participants), or in the rate of falls requiring medical attention (RaR 0.91, 95% CI 0.58 to 1.43; 3 studies, 946 participants) (low-certainty evidence). The evidence for number of fallers requiring medical attention was unclear (2 studies, 216 participants; very low-certainty evidence). Two studies reported no adverse events. Assistive technology Vision improvement interventions may make little or no difference to the rate of falls (RaR 1.12, 95% CI 0.84 to 1.50; 3 studies, 1489 participants) or people experiencing one or more falls (RR 1.09, 95% CI 0.79 to 1.50) (low-certainty evidence). We are unsure of the evidence for fall-related fractures (2 studies, 976 participants) and falls requiring medical attention (1 study, 276 participants) because the certainty of the evidence is very low. There may be little or no difference in HRQoL (mean difference 0.40, 95% CI -1.12 to 1.92) or adverse events (falls while switching glasses; RR 1.00, 95% CI 0.98 to 1.02) (1 study, 597 participants; low-certainty evidence). Results for other assistive technology - footwear and foot devices, and self-care and assistive devices (5 studies, 651 participants) - were not pooled due to the diversity of interventions and contexts. Education We are uncertain whether an education intervention to reduce home fall hazards reduces the rate of falls or the number of people experiencing one or more falls (1 study; very low-certainty evidence). These interventions may make little or no difference to the risk of fall-related fractures (RR 1.02, 95% CI 0.96 to 1.08; 1 study, 110 participants; low-certainty evidence). Home modifications We found no trials of home modifications that measured falls as an outcome for task enablement and functional independence. AUTHORS' CONCLUSIONS We found high-certainty evidence that home fall-hazard interventions are effective in reducing the rate of falls and the number of fallers when targeted to people at higher risk of falling, such as having had a fall in the past year and recently hospitalised or needing support with daily activities. There was evidence of no effect when interventions were targeted to people not selected for risk of falling. Further research is needed to examine the impact of intervention components, the effect of awareness raising, and participant-interventionist engagement on decision-making and adherence. Vision improvement interventions may or may not impact the rate of falls. Further research is needed to answer clinical questions such as whether people should be given advice or take additional precautions when changing eye prescriptions, or whether the intervention is more effective when targeting people at higher risk of falls. There was insufficient evidence to determine whether education interventions impact falls.
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Affiliation(s)
- Lindy Clemson
- Sydney School of Health Sciences, Faculty of Medicine & Health, The University of Sydney, Sydney, Australia
| | - Susan Stark
- Participation, Environment and Performance Laboratory, Program in Occupational Therapy, Washington University, St Louis, MO, USA
| | - Alison C Pighills
- Mackay Institute of Research and Innovation, Mackay Hospital and Health Service, Mackay, Australia
- College of Healthcare Sciences, James Cook University, Townsville, Australia
| | - Nicola J Fairhall
- Institute for Musculoskeletal Health, School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Sarah E Lamb
- College of Medicine and Health , University of Exeter, Exeter, UK
| | - Jinnat Ali
- Faculty of Health Science, The University of Sydney, Sydney, Australia
| | - Catherine Sherrington
- Institute for Musculoskeletal Health, School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
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Tutton E, Gould J, Lamb SE, Costa ML, Keene DJ. 'It Makes Me Feel Old': Understanding the Experience of Recovery From Ankle Fracture at 6 Months in People Aged 50 Years and Over. Qual Health Res 2023; 33:308-320. [PMID: 36745107 PMCID: PMC10061622 DOI: 10.1177/10497323231153605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/18/2023]
Abstract
Ankle fracture is a common injury, and depending on injury severity, treatment may be a support boot, cast or surgery. Older people, particularly those with severe injuries who are asked to restrict weight bearing, struggle with early recovery. To elicit older peoples' experience of recovery 6 months after injury, we drew on a phenomenological approach using interviews. Findings revealed that getting on with life was a way of accepting what it feels like to 'be vulnerable', needing to 'be safe' while determinedly working hard to 'be myself'. Being vulnerable identified endurance of inactivity, loneliness and dependency in the non-weight bearing period of recovery, followed by a struggle to weight bear while lacking confidence and being fearful of falling and causing further damage. Being safe conveyed fragility where sensations, pain and stiffness acted as bodily reminders of injury. Lack of function and awareness of danger led to carefulness where planning or curtailing of activities ensured their safety. Being myself showed a determination to push away from a disrupted self-identify of being older or disabled while being challenged by the continuous process of learning to be more mobile. A lack of readiness for old age created a drive to age well. Despite loss of ability, participants hoped to regain their pre-injury way of living. This study challenges practice that disregards the hard work required to recover from ankle fracture. As comorbidity increases with age, failure to consider this aspect may contribute to frailty in this group of older people.
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Affiliation(s)
- Elizabeth Tutton
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- Major Trauma Centre, Oxford UniversityHospitals NHS Foundation Trust, Oxford, UK
| | - Jenny Gould
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Sarah E. Lamb
- Faculty of Health and Life Sciences, University of Exeter, Exeter, UK
| | - Matthew L. Costa
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - David J. Keene
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- Faculty of Health and Life Sciences, University of Exeter, Exeter, UK
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17
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Mandy M, Kamran K, Marian IR, Dutton SJ, Esther W, Lamb SE, Stavros P. Economic costs, health-related quality of life outcomes and cost-utility of a physical and psychological group intervention targeted at older adults with neurogenic claudication. Cost Eff Resour Alloc 2023; 21:14. [PMID: 36755265 PMCID: PMC9906820 DOI: 10.1186/s12962-022-00410-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 12/16/2022] [Indexed: 02/10/2023] Open
Abstract
BACKGROUND Emerging evidence suggests that structured and progressive exercise underpinned by a cognitive behavioural approach can improve functional outcomes in patients with neurogenic claudication (NC). However, evidence surrounding its economic benefits is lacking. OBJECTIVES To estimate the economic costs, health-related quality of life outcomes and cost-effectiveness of a physical and psychological group intervention (BOOST programme) versus best practice advice (BPA) in older adults with NC. METHODS An economic evaluation was conducted based on data from a pragmatic, multicentre, superiority, randomised controlled trial. The base-case economic evaluation took the form of an intention-to-treat analysis conducted from a UK National Health Service (NHS) and personal social services (PSS) perspective and separately from a societal perspective. Costs (£ 2018-2019 prices) were collected prospectively over a 12 month follow-up period. A bivariate regression of costs and quality-adjusted life-years (QALYs), with multiple imputation of missing data, was conducted to estimate the incremental cost per QALY gained and the incremental net monetary benefit (INMB) of the BOOST programme in comparison to BPA. Sensitivity and pre-specified subgroup analyses explored uncertainty and heterogeneity in cost-effectiveness estimates. RESULTS Participants (N = 435) were randomised to the BOOST programme (n = 292) or BPA (n = 143). Mean (standard error [SE]) NHS and PSS costs over 12 months were £1,974 (£118) in the BOOST arm versus £1,827 (£169) in the BPA arm (p = 0.474). Mean (SE) QALY estimates were 0.620 (0.009) versus 0.599 (0.006), respectively (p = 0.093). The probability that the BOOST programme is cost-effective ranged between 67 and 83% (NHS and PSS perspective) and 79-89% (societal perspective) at cost-effectiveness thresholds between £15,000 and £30,000 per QALY gained. INMBs ranged between £145 and £464 at similar cost-effectiveness thresholds. The cost-effectiveness results remained robust to sensitivity analyses. CONCLUSIONS The BOOST programme resulted in modest QALY gains over the 12 month follow-up period. Future studies with longer intervention and follow-up periods are needed to address uncertainty around the health-related quality of life impacts and cost-effectiveness of such programmes. Trial registration This study has been registered in the International Standard Randomised Controlled Trial Number registry, reference number ISRCTN12698674. Registered on 10 November 2015.
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Affiliation(s)
- Maredza Mandy
- Division of Health Sciences, Warwick Medical School, The University of Warwick, Coventry, UK.
| | - Khan Kamran
- grid.7372.10000 0000 8809 1613Warwick Clinical Trials Unit, University of Warwick, Warwick, UK
| | - Ioana R. Marian
- grid.4991.50000 0004 1936 8948Oxford Clinical Trials Research Unit, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Susan J. Dutton
- grid.4991.50000 0004 1936 8948Oxford Clinical Trials Research Unit, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Williamson Esther
- grid.4991.50000 0004 1936 8948Oxford Clinical Trials Research Unit, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK ,grid.8391.30000 0004 1936 8024Exeter Medical School, University of Exeter, Devon, UK
| | - Sarah E. Lamb
- grid.8391.30000 0004 1936 8024Exeter Medical School, University of Exeter, Devon, UK
| | - Petrou Stavros
- grid.4991.50000 0004 1936 8948Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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Bruce J, Hossain A, Ji C, Lall R, Arnold S, Padfield E, Underwood M, Lamb SE. Falls and fracture risk screening in primary care: update and validation of a postal screening tool for community dwelling older adults recruited to UK Prevention of Falls Injury Trial (PreFIT). BMC Geriatr 2023; 23:42. [PMID: 36690953 PMCID: PMC9872287 DOI: 10.1186/s12877-022-03649-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Accepted: 11/23/2022] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Postal screening has not previously been validated as a method for identifying fall and fracture risk in community-dwelling populations. We examined prognostic performance of a postal risk screener used in the UK Prevention of Falls Injury Trial (PreFIT; ISRCTN71002650), to predict any fall, recurrent falls, and fractures over 12 months. We tested whether adding variables would improve screener performance. METHODS Nine thousand eight hundred and eight community-dwelling participants, aged 70 years and older, and 63 general practices in the UK National Health Service (NHS) were included in a large, pragmatic cluster randomised trial comparing screen and treat fall prevention interventions. The short postal screener was sent to all participants in the trial intervention arms as an A4 sheet to be completed and returned to the GP (n = 6,580). The postal screener items were embedded in the baseline pre-randomisation postal questionnaire for all arms of the trial (n = 9,808). We assessed discrimination and calibration using area under the curve (AUC). We identified additional predictors using data from the control arm and applied these coefficients to internal validation models in the intervention arm participants. We used logistic regression to identify additional predictor variables. FINDINGS A total of 10,743 falls and 307 fractures were reported over 12 months. Over one third of participants 3,349/8,136 (41%) fell at least once over 12 month follow up. Response to the postal screener was high (5,779/6,580; 88%). Prediction models showed similar discriminatory ability in both control and intervention arms, with discrimination values for any fall AUC 0.67 (95% CI 0.65 to 0.68), and recurrent falls (AUC 0.71; 95% CI 0.69, 0.72) but poorer discrimination for fractures (AUC 0.60; 95% CI 0.56, 0.64). Additional predictor variables improved prediction of falls but had modest effect on fracture, where AUC rose to 0.71 (95% CI 0.67 to 0.74). Calibration slopes were very close to 1. CONCLUSION A short fall risk postal screener was acceptable for use in primary care but fall prediction was limited, although consistent with other tools. Fracture and fall prediction were only partially reliant on fall risk although were improved with the additional variables.
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Affiliation(s)
- Julie Bruce
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK.
- University Hospitals Coventry and Warwickshire, Coventry, CV2 2DX, UK.
| | - Anower Hossain
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK
| | - Chen Ji
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK
| | - Ranjit Lall
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK
| | - Susanne Arnold
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK
| | - Emma Padfield
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK
| | - Martin Underwood
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK
- University Hospitals Coventry and Warwickshire, Coventry, CV2 2DX, UK
| | - Sarah E Lamb
- South Cloisters, University of Exeter, St Luke's Campus, Heavitree Road, Exeter, EX1 2LU, UK
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Ullrich P, Werner C, Schönstein A, Bongartz M, Eckert T, Beurskens R, Abel B, Bauer JM, Lamb SE, Hauer K. Effects of a Home-Based Physical Training and Activity Promotion Program in Community-Dwelling Older Persons with Cognitive Impairment after Discharge from Rehabilitation: A Randomized Controlled Trial. J Gerontol A Biol Sci Med Sci 2022; 77:2435-2444. [PMID: 35022728 DOI: 10.1093/gerona/glac005] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Older people with cognitive impairment (CI) are at high risk for mobility limitations and adverse outcomes after discharge from geriatric rehabilitation settings. The aim was to estimate the effects of a specifically designed home-based physical training and activity promotion program on physical capacity, different aspects of physical activity (PA), and psychosocial status. METHODS Patients with mild to moderate CI (Mini-Mental State Examination [MMSE]: 17-26 points) discharged home after rehabilitation were included in this randomized, double-blind, placebo-controlled trial with a 12-week intervention and 12-week follow-up period. The intervention group performed a CI-specific, autonomous, home-based strength, balance, and walking training supported by tailored motivational strategies to foster training adherence and promote PA. The control group participated in an unspecific motor placebo activity. Primary outcomes were physical capacity (Short Physical Performance Battery [SPPB]) and PA (sensor-based activity time). RESULTS Among 118 randomized participants (82.3 ± 6.0 years) with CI (MMSE: 23.3 ± 2.4) and high levels of multimorbidity, those participants undergoing home-based training demonstrated superior outcomes to the control group in SPPB (mean difference between groups 1.9 points; 95% CI: 1.0-2.8; p < .001), with persistent benefits over the follow-up (1.3 points; 95% CI: 0.4-2.2; p < .001). There were no differences in PA across any time points. Among secondary outcomes, fear of falling and activity avoidance behavior were reduced in the intervention group at all time points, life-space mobility improved short-term. CONCLUSIONS The results demonstrate clinically important benefits of an individually tailored autonomous physical training and activity promotion program on physical capacity and secondary outcomes in different domains in a vulnerable, multimorbid population. CLINICAL TRIAL REGISTRATION ISRCTN82378327.
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Affiliation(s)
- Phoebe Ullrich
- AGAPLESION Bethanien Hospital Heidelberg/Center for Geriatric Medicine at Heidelberg University, Heidelberg, Germany
| | - Christian Werner
- AGAPLESION Bethanien Hospital Heidelberg/Center for Geriatric Medicine at Heidelberg University, Heidelberg, Germany
| | - Anton Schönstein
- Network Aging Research, Heidelberg University, Heidelberg, Germany
| | - Martin Bongartz
- AGAPLESION Bethanien Hospital Heidelberg/Center for Geriatric Medicine at Heidelberg University, Heidelberg, Germany
| | - Tobias Eckert
- AGAPLESION Bethanien Hospital Heidelberg/Center for Geriatric Medicine at Heidelberg University, Heidelberg, Germany
| | - Rainer Beurskens
- AGAPLESION Bethanien Hospital Heidelberg/Center for Geriatric Medicine at Heidelberg University, Heidelberg, Germany.,FHM Bielefeld, University of Applied Sciences, Bielefeld, Germany
| | - Bastian Abel
- AGAPLESION Bethanien Hospital Heidelberg/Center for Geriatric Medicine at Heidelberg University, Heidelberg, Germany
| | - Jürgen M Bauer
- AGAPLESION Bethanien Hospital Heidelberg/Center for Geriatric Medicine at Heidelberg University, Heidelberg, Germany
| | - Sarah E Lamb
- College of Medicine and Health, University of Exeter, Exeter, UK
| | - Klaus Hauer
- AGAPLESION Bethanien Hospital Heidelberg/Center for Geriatric Medicine at Heidelberg University, Heidelberg, Germany
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20
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Taleshi N, Brownjohn JMW, Lamb SE, Zivanovic S, Williams GKR. Vector coding reveals the underlying balance control strategies used by humans during translational perturbation. Sci Rep 2022; 12:21030. [PMID: 36470936 PMCID: PMC9722668 DOI: 10.1038/s41598-022-24731-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Accepted: 11/18/2022] [Indexed: 12/12/2022] Open
Abstract
Postural control research has focused on standing balance experiments on platforms moving with relatively large amplitudes (0.1-0.2 m). This study investigated balance strategies while standing on a platform moving 4 mm in anterior-posterior direction with frequency scaled linearly from 0.4 to 6 Hz. Platform motion and kinematic and kinetic information for nine healthy participants were recorded using motion capture and force plate systems. Coordination between hip, knee and ankle joint torque, and centre of mass (COM) and centre of pressure (COP) motion was quantified by vector coding. Significant main effect of platform frequency for knee-ankle and COP-COM phase relationship was observed (p = 0.023, p = 0.016). At frequencies below 2.11 and 2.34 Hz, ankle strategy was recruited. With ankle strategy, in-phase COP-COM motion with COP dominancy occurred at frequencies below 2.19 and 2.23 Hz during scaling up and down, respectively. As platform frequency passed these values, COM dominated over COP which was followed by anti-phase knee-ankle torque, called a knee strategy, and anti-phase motion between the COP and COM that allowed COP to regain dominance over COM. Collectively, we reveal knee strategy as a new and relevant strategy in real-life settings, and transition between ankle and knee strategies that underpinned transition between COP-COM relative motion.
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Affiliation(s)
- Naser Taleshi
- grid.8391.30000 0004 1936 8024Public Health and Sports Sciences Department, University of Exeter Medical School, Exeter, EX1 2LU UK
| | - James M. W. Brownjohn
- grid.8391.30000 0004 1936 8024Vibration Engineering Section, College of Engineering, Mathematics and Physical Sciences, University of Exeter, Exeter, EX4 4QF UK
| | - Sarah E. Lamb
- grid.8391.30000 0004 1936 8024Public Health and Sports Sciences Department, University of Exeter Medical School, Exeter, EX1 2LU UK
| | - Stana Zivanovic
- grid.8391.30000 0004 1936 8024Vibration Engineering Section, College of Engineering, Mathematics and Physical Sciences, University of Exeter, Exeter, EX4 4QF UK
| | - Genevieve K. R. Williams
- grid.8391.30000 0004 1936 8024Public Health and Sports Sciences Department, University of Exeter Medical School, Exeter, EX1 2LU UK
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21
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Sanchez-Santos MT, Williamson E, Nicolson PJA, Bruce J, Collins GS, Mallen CD, Griffiths F, Garret A, Morris A, Slark M, Lamb SE. Development and validation of a prediction model for self-reported mobility decline in community-dwelling older adults. J Clin Epidemiol 2022; 152:70-79. [PMID: 36108957 DOI: 10.1016/j.jclinepi.2022.09.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 07/26/2022] [Accepted: 09/06/2022] [Indexed: 01/25/2023]
Abstract
OBJECTIVES The aim of this study is to develop and validate two models to predict 2-year risk of self-reported mobility decline among community-dwelling older adults. STUDY DESIGN AND SETTING We used data from a prospective cohort study of people aged 65 years and over in England. Mobility status was assessed using the EQ-5D-5L mobility question. The models were based on the outcome: Model 1, any mobility decline at 2 years; Model 2, new onset of persistent mobility problems over 2 years. Least absolute shrinkage and selection operator logistic regression was used to select predictors. Model performance was assessed using C-statistics, calibration plot, Brier scores, and decision curve analyses. Models were internally validated using bootstrapping. RESULTS Over 18% of participants who could walk reported mobility decline at year 2 (Model 1), and 7.1% with no mobility problems at baseline, reported new onset of mobility problems after 2 years (Model 2). Thirteen and 6 out of 31 variables were selected as predictors in Models 1 and 2, respectively. Models 1 and 2 had a C-statistic of 0.740 and 0.765 (optimism < 0.013), and Brier score = 0.136 and 0.069, respectively. CONCLUSION Two prediction models for mobility decline were developed and internally validated. They are based on self-reported variables and could serve as simple assessments in primary care after external validation.
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Affiliation(s)
- Maria T Sanchez-Santos
- Centre for Rehabilitation Research, Nuffield Department of Rheumatology, Orthopaedics and Musculoskeletal Sciences, University of Oxford, Oxford, UK; Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Musculoskeletal Sciences, University of Oxford, Oxford, UK.
| | - Esther Williamson
- Centre for Rehabilitation Research, Nuffield Department of Rheumatology, Orthopaedics and Musculoskeletal Sciences, University of Oxford, Oxford, UK; College of Medicine and Health, University of Exeter, UK
| | - Philippa J A Nicolson
- Centre for Rehabilitation Research, Nuffield Department of Rheumatology, Orthopaedics and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Julie Bruce
- Warwick Clinical Trials Unit, Division of Health Sciences, University of Warwick, Coventry, UK
| | - Gary S Collins
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Christian D Mallen
- Primary Care Centre Versus Arthritis, School of Medicine, Keele University, Keele, UK
| | - Frances Griffiths
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Angela Garret
- Centre for Rehabilitation Research, Nuffield Department of Rheumatology, Orthopaedics and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Alana Morris
- Centre for Rehabilitation Research, Nuffield Department of Rheumatology, Orthopaedics and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Mandy Slark
- Centre for Rehabilitation Research, Nuffield Department of Rheumatology, Orthopaedics and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Sarah E Lamb
- College of Medicine and Health, University of Exeter, UK
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22
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Boniface G, Sanchez-Santos MT, Norris M, OConnell N, Williamson E, Lamb SE. Understanding prescribed dose in hand strengthening exercise for rheumatoid arthritis: A secondary analysis of the SARAH trial. Musculoskeletal Care 2022; 20:899-907. [PMID: 35574971 PMCID: PMC10084296 DOI: 10.1002/msc.1646] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 05/02/2022] [Indexed: 01/01/2023]
Abstract
OBJECTIVE 1) To identify therapist or participant characteristics associated with prescribed dose of hand strengthening exercise in adults with rheumatoid arthritis and 2) To determine the impact of dose prescribed on outcome (hand function and grip strength). METHODS Overall dose was calculated using area under the curve (AUC). Analysis 1 assessed the association between therapist professional background, therapist grade, baseline participant physical and psychological characteristics and prescribed dose. Analyses 2 and 3 estimated the relationship between prescribed dose and overall hand function and grip strength. Generalised estimating equation linear regression analysis was used. RESULTS Analysis 1: Being treated by an occupational therapist (β = -297.0, 95% CI -398.6, -195.4), metacarpophalangeal joint deformity (β = -24.1, 95% CI -42.3, -5.9), a higher number of swollen wrist/hand joints (β = -11.4, 95% CI -21.6, -1.2) and the participant feeling downhearted and low all of the time (β = -293.6, 95% CI -436.1, -151.1) were associated with being prescribed a lower dose. Being treated by a grade 6 therapist (β = 159.1, 95% CI 65.7, 252.5), higher baseline grip strength (β = 0.15, 95% CI 0.02, 0.28) and greater participant confidence to exercise without fear of making symptoms worse (β = 18.9, 95% CI 1.5, 36.3) were associated with being prescribed a higher dose. Analyses 2 and 3: Higher dose was associated with greater overall hand function (β = 0.005, 95% CI 0.001, 0.010) and full-hand grip strength (β = 0.014, 95% CI 0.000, 0.025) at 4-month. CONCLUSION Higher dose was associated with better clinical outcomes. Prescription of hand strengthening exercise is associated with both therapist and participant characteristics.
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Affiliation(s)
- Graham Boniface
- Department of Health Sciences, Centre for Health and Wellbeing across the Lifecourse, Brunel University London, Uxbridge, UK
| | - Maria T Sanchez-Santos
- Nuffield Department of Orthopaedics Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford, UK
| | - Meriel Norris
- Department of Health Sciences, Centre for Health and Wellbeing across the Lifecourse, Brunel University London, Uxbridge, UK
| | - Neil OConnell
- Department of Health Sciences, Centre for Health and Wellbeing across the Lifecourse, Brunel University London, Uxbridge, UK
| | - Esther Williamson
- Nuffield Department of Orthopaedics Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford, UK
| | - Sarah E Lamb
- Nuffield Department of Orthopaedics Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford, UK.,College of Medicine and Health, University of Exeter, Exeter, UK
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23
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Keene DJ, Costa ML, Peckham N, Tutton E, Barber VS, Dutton SJ, Hopewell S, Redmond AC, Willett K, Lamb SE. Progressive exercise versus best practice advice for adults aged 50 years or over after ankle fracture: the AFTER pilot randomised controlled trial. BMJ Open 2022; 12:e059235. [PMID: 36424115 PMCID: PMC9693648 DOI: 10.1136/bmjopen-2021-059235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
OBJECTIVE The aim of the Ankle Fracture Treatment: Enhancing Rehabilitation (AFTER) study, a multicentre external pilot parallel-group randomised controlled trial (RCT), was to assess feasibility of a definitive trial comparing rehabilitation approaches after ankle fracture. SETTING Five UK National Health Service hospitals. PARTICIPANTS Participants were aged 50 years and over with an ankle fracture requiring immobilisation for at least 4 weeks. INTERVENTIONS Participants were allocated 1:1 via a central web-based randomisation system to: (1) best practice advice (one session of physiotherapy, up to two optional additional advice sessions) or (2) progressive exercise (up to six sessions of physiotherapy). PRIMARY OUTCOME MEASURES Feasibility: (1) participation rate, (2) intervention adherence and (3) retention. RESULTS Sixty-one of 112 (54%) eligible participants participated, exceeding progression criteria for participation of 25%. Recruitment progression criteria was 1.5 participants per site per month and 1.4 was observed. At least one intervention session was delivered for 28/30 (93%) of best practice advice and 28/31 (90%) of progressive exercise participants, exceeding the 85% progression criteria. For those providing follow-up data, the proportion of participants reporting performance of home exercises in the best practice advice and the progressive exercise groups at 3 months was 20/23 (87%) and 21/25 (84%), respectively. Mean time from injury to starting physiotherapy was 74.1 days (95% CI 53.9 to 94.1 days) for the best practice advice and 72.7 days (95% CI 54.7 to 88.9) for the progressive exercise group. Follow-up rate (6-month Olerud and Molander Ankle Score) was 28/30 (93%) for the best practice advice group and 26/31 (84%) in the progressive exercise group with an overall follow-up rate of 89%. CONCLUSIONS This pilot RCT demonstrated that a definitive trial would be feasible. The main issues to address for a definitive trial are intervention modifications to enable earlier provision of rehabilitation and ensuring similar rates of follow-up in each group. TRIAL REGISTRATION NUMBER ISRCTN16612336.
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Affiliation(s)
- David J Keene
- Oxford Trauma and Emergency Care, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- Faculty of Health and Life Sciences, University of Exeter, Exeter, UK
| | - Matthew L Costa
- Oxford Trauma and Emergency Care, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Nicholas Peckham
- Oxford Clinical Trials Research Unit, University of Oxford, Oxford, UK
| | - Elizabeth Tutton
- Oxford Trauma and Emergency Care, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- Kadoorie Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Vicki S Barber
- Oxford Clinical Trials Research Unit, University of Oxford, Oxford, UK
| | - Susan J Dutton
- Oxford Clinical Trials Research Unit, University of Oxford, Oxford, UK
| | - Sally Hopewell
- Oxford Clinical Trials Research Unit, University of Oxford, Oxford, UK
| | - Anthony C Redmond
- Leeds Institute of Rheumatology and Musculoskeletal Medicine, University of Leeds, Leeds, UK
| | - Keith Willett
- Oxford Trauma and Emergency Care, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Sarah E Lamb
- Faculty of Health and Life Sciences, University of Exeter, Exeter, UK
- Oxford Clinical Trials Research Unit, University of Oxford, Oxford, UK
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24
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Dakin H, Rombach I, Dritsaki M, Gray A, Ball C, Lamb SE, Nanchahal J. Cost-effectiveness of adalimumab for early-stage Dupuytren’s disease. Bone Jt Open 2022; 3:898-906. [DOI: 10.1302/2633-1462.311.bjo-2022-0103.r2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Aims To estimate the potential cost-effectiveness of adalimumab compared with standard care alone for the treatment of early-stage Dupuytren’s disease (DD) and the value of further research from an NHS perspective. Methods We used data from the Repurposing anti-TNF for Dupuytren’s disease (RIDD) randomized controlled trial of intranodular adalimumab injections in patients with early-stage progressive DD. RIDD found that intranodular adalimumab injections reduced nodule hardness and size in patients with early-stage DD, indicating the potential to control disease progression. A within-trial cost-utility analysis compared four adalimumab injections with no further treatment against standard care alone, taking a 12-month time horizon and using prospective data on EuroQol five-dimension five-level questionnaire (EQ-5D-5L) and resource use from the RIDD trial. We also developed a patient-level simulation model similar to a Markov model to extrapolate trial outcomes over a lifetime using data from the RIDD trial and a literature review. This also evaluated repeated courses of adalimumab each time the nodule reactivated (every three years) in patients who initially responded. Results The within-trial economic evaluation found that adalimumab plus standard care cost £503,410 per quality-adjusted life year (QALY) gained versus standard care alone over a 12-month time horizon. The model-based extrapolation suggested that, over a lifetime, repeated courses of adalimumab could cost £14,593 (95% confidence interval £7,534 to £42,698) per QALY gained versus standard care alone. If the NHS was willing to pay £20,000/QALY gained, there is a 77% probability that adalimumab with retreatment is the best value for money. Conclusion Repeated courses of adalimumab are likely to be a cost-effective treatment for progressive early-stage DD. The value of perfect parameter information that would eliminate all uncertainty around the parameters estimated in RIDD and the duration of quiescence was estimated to be £105 per patient or £272 million for all 2,584,411 prevalent cases in the UK. Cite this article: Bone Jt Open 2022;3(11):898–906.
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Affiliation(s)
- Helen Dakin
- Health Economics Research Centre, University of Oxford, Oxford, UK
| | - Ines Rombach
- Health Economics Research Centre, University of Oxford, Oxford, UK
- Centre for Statistics in Medicine, Oxford Clinical Trials Research Unit, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Botnar Research Centre, Oxford, UK
- School of Health and Related Research (ScHARR), The University of Sheffield, Sheffield, UK
| | - Melina Dritsaki
- Oxford Clinical Trials Research Unit, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- Department of Economics & Laboratory of Applied Economics, University of Western Macedonia, Kastoria, Greece
| | - Alastair Gray
- Health Economics Research Centre, University of Oxford, Oxford, UK
| | - Catherine Ball
- Kennedy Institute, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Sarah E. Lamb
- Oxford Clinical Trials Research Unit, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- Faculty of Health and Life Sciences, University of Exeter, Exeter, UK
| | - Jagdeep Nanchahal
- Kennedy Institute, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
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25
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Png ME, Petrou S, Achten J, Ooms A, Lamb SE, Hedley H, Dias J, Costa ML. Cost-utility analysis of surgical fixation with Kirschner wire versus casting after fracture of the distal radius. Bone Joint J 2022; 104-B:1225-1233. [DOI: 10.1302/0301-620x.104b11.bjj-2022-0386.r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Abstract
Aims The aim of this study was to compare the cost-effectiveness of surgical fixation with Kirschner (K-)wire ersus moulded casting after manipulation of a fracture of the distal radius in an operating theatre setting. Methods An economic evaluation was conducted based on data collected from the Distal Radius Acute Fracture Fixation Trial 2 (DRAFFT2) multicentre randomized controlled trial in the UK. Resource use was collected at three, six, and 12 months post-randomization using trial case report forms and participant-completed questionnaires. Cost-effectiveness was reported in terms of incremental cost per quality-adjusted life year (QALY) gained from an NHS and personal social services perspective. Sensitivity analyses were conducted to examine the robustness of cost-effectiveness estimates, and decision uncertainty was handled using confidence ellipses and cost-effectiveness acceptability curves. Results In the base case analysis, surgical fixation with K-wire was more expensive (£29.65 (95% confidence interval (CI) -94.85 to 154.15)) and generated lower QALYs (0.007 (95% CI -0.03 to 0.016)) than moulded casting, but this difference was not statistically significant. The probability of K-wire being cost-effective at a £20,000 per QALY cost-effectiveness threshold was 24%. The cost-effectiveness results remained robust in the sensitivity analyses. Conclusion The findings suggest that surgical fixation with K-wire is unlikely to be a cost-effective alternative to a moulded cast in adults, following manipulation of a fracture of the distal radius in a theatre setting. Cite this article: Bone Joint J 2022;104-B(11):1225–1233.
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Affiliation(s)
- May Ee Png
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Stavros Petrou
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Juul Achten
- Oxford Trauma and Emergency Care, Nuffield Department of Orthopaedics, Rheumatology & Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Alexander Ooms
- Oxford Clinical Trials Research Unit, Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology & Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Sarah E. Lamb
- College of Medicine and Health, South Cloisters, University of Exeter, Exeter, UK
| | - Helen Hedley
- Department of Trauma and Orthopaedics, University Hospital Coventry and Warwickshire NHS Trust, University Hospitals Coventry and Warwickshire, Coventry, UK
| | - Joseph Dias
- Department of Health Sciences, George Davies Centre, University of Leicester, Leicester, UK
| | - Matthew L. Costa
- Oxford Trauma and Emergency Care, Nuffield Department of Orthopaedics, Rheumatology & Musculoskeletal Sciences, University of Oxford, Oxford, UK
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Keene DJ, Alsousou J, Harrison P, O’Connor HM, Wagland S, Dutton SJ, Hulley P, Lamb SE, Willett K. Platelet-rich plasma injection for acute Achilles tendon rupture : two-year follow-up of the PATH-2 randomized, placebo-controlled, superiority trial. Bone Joint J 2022; 104-B:1256-1265. [PMID: 36317349 PMCID: PMC9621093 DOI: 10.1302/0301-620x.104b11.bjj-2022-0653.r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Aims To determine whether platelet-rich plasma (PRP) injection improves outcomes two years after acute Achilles tendon rupture. Methods A randomized multicentre two-arm parallel-group, participant- and assessor-blinded superiority trial was undertaken. Recruitment commenced on 28 July 2015 and two-year follow-up was completed in 21 October 2019. Participants were 230 adults aged 18 years and over, with acute Achilles tendon rupture managed with non-surgical treatment from 19 UK hospitals. Exclusions were insertion or musculotendinous junction injuries, major leg injury or deformity, diabetes, platelet or haematological disorder, medication with systemic corticosteroids, anticoagulation therapy treatment, and other contraindicating conditions. Participants were randomized via a central online system 1:1 to PRP or placebo injection. The main outcome measure was Achilles Tendon Rupture Score (ATRS) at two years via postal questionnaire. Other outcomes were pain, recovery goal attainment, and quality of life. Analysis was by intention-to-treat. Results A total of 230 participants were randomized, 114 to PRP and 116 to placebo. Two-year questionnaires were sent to 216 participants who completed a six-month questionnaire. Overall, 182/216 participants (84%) completed the two-year questionnaire. Participants were aged a mean of 46 years (SD 13.0) and 25% were female (57/230). The majority of participants received the allocated intervention (219/229, 96%). Mean ATRS scores at two years were 82.2 (SD 18.3) in the PRP group (n = 85) and 83.8 (SD 16.0) in the placebo group (n = 92). There was no evidence of a difference in the ATRS at two years (adjusted mean difference -0.752, 95% confidence interval -5.523 to 4.020; p = 0.757) or in other secondary outcomes, and there were no re-ruptures between 24 weeks and two years. Conclusion PRP injection did not improve patient-reported function or quality of life two years after acute Achilles tendon rupture compared with placebo. The evidence from this study indicates that PRP offers no patient benefit in the longer term for patients with acute Achilles tendon rupture. Cite this article: Bone Joint J 2022;104-B(11):1256–1265.
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Affiliation(s)
- David J. Keene
- Kadoorie Research Centre, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK,Correspondence should be sent to David J. Keene. E-mail:
| | - Joseph Alsousou
- Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Manchester, UK
| | - Paul Harrison
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
| | - Heather M. O’Connor
- Oxford Clinical Trials Research Unit, Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Susan Wagland
- Kadoorie Research Centre, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Susan J. Dutton
- Oxford Clinical Trials Research Unit, Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Philippa Hulley
- Botnar Research Centre, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Sarah E. Lamb
- Kadoorie Research Centre, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK,College of Medicine and Health, University of Exeter, Exeter, UK
| | - Keith Willett
- Kadoorie Research Centre, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
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Williams JAE, Chester-Jones M, Minns Lowe C, Goff MV, Francis A, Brewer G, Marian I, Morris SL, Warwick D, Eldridge L, Julier P, Gulati M, Barker KL, Barber VS, Black J, Woollacott S, Mackworth-Young C, Glover V, Lamb SE, Vincent TL, Vincent K, Dutton SJ, Watt FE. Hormone replacement therapy (conjugated oestrogens plus bazedoxifene) for post-menopausal women with symptomatic hand osteoarthritis: primary report from the HOPE-e randomised, placebo-controlled, feasibility study. Lancet Rheumatol 2022; 4:e725-e737. [PMID: 36341025 PMCID: PMC9620575 DOI: 10.1016/s2665-9913(22)00218-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Background Symptomatic hand osteoarthritis is more common in women than in men, and its incidence increases around the age of menopause, implicating oestrogen deficiency. No randomised controlled trials of hormone replacement therapy (HRT) have been done in people with hand osteoarthritis. We aimed to determine the feasibility and acceptability of a form of HRT (conjugated oestrogens plus bazedoxifene) in post-menopausal women with painful hand osteoarthritis. Methods The HOPE-e feasibility study was a randomised, double-blind, placebo-controlled trial, for which we recruited women aged 40-65 years, for whom 1-10 years had passed after their final menstrual period, with definite hand osteoarthritis and at least two painful hand joints. Participants were recruited across three primary or secondary care sites and from the community and were randomly assigned (1:1) to receive conjugated oestrogens plus bazedoxifene or placebo, orally once every day for 24 weeks, before weaning for 4 weeks until the end of the study. The primary feasibility outcomes were rates of identification, recruitment, randomisation, retention, and compliance of eligible participants, and the likelihood of unmasking. The secondary objective was to generate proof-of-concept quantitative and qualitative data on the acceptability of proposed clinical outcomes for a full trial and adverse events. We used an intention-to-treat analysis, and criteria for progression to a full trial were pre-defined as recruitment of at least 30 participants across all sites in 18 months; a dropout rate of less than or equal to 30% of randomised individuals; and acceptability to the majority of participants, including acceptable rates of adverse events. Due to the COVID-19 pandemic, the recruitment window was reduced to 12-15 months. A proportionately reduced minimum sample size of 22 was judged to be sufficient to test feasibility. This trial was registered at ISRCTN, ISRCTN12196200. Findings From May 9, 2019 to Dec 31, 2020, 434 enquiries or referrals were received. We did 96 telephone pre-screens; of the 35 eligible participants, seven were excluded as ineligible at the telephone or face-to-face screening and 28 (80% [95% CI 63-92]) were randomly assigned. Of the 406 who were not randomly assigned, 250 (62%) were ineligible (with contraindicated medications accounting for 50 [20%] of these), 101 (25%) did not respond to further enquiries, and 55 (14%) chose not to proceed (with the most common reason being not wanting to take a hormone-based drug). All 28 randomised participants completed all follow-up assessments with high compliance and outcome measure completeness. All three adverse event-related treatment withdrawals were in the placebo group. No serious adverse events were reported. Participants and investigators were successfully masked (participant Bang's blinding index placebo group 0·50 [95% CI 0·25-0·75]). The trial met the prespecified criteria for progression to a full trial. Interpretation This first-ever feasibility study of a randomised controlled trial of HRT for post-menopausal women with painful hand osteoarthritis met its progression criteria, although it was not powered to detect a clinical effect. This outcome indicates that a full trial of an HRT in this population is feasible and acceptable and identifies potential refinements with regard to the design of such a trial. Funding Research for Patient Benefit programme, National Institute for Health Research.
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Affiliation(s)
- Jennifer A E Williams
- Oxford Clinical Trials Research Unit (OCTRU), Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford, UK
- Centre for Osteoarthritis Pathogenesis Versus Arthritis, Kennedy Institute of Rheumatology, NDORMS, University of Oxford, Oxford, UK
| | - Mae Chester-Jones
- OCTRU, Centre for Statistics in Medicine, NDORMS, University of Oxford, Oxford, UK
| | - Catherine Minns Lowe
- Physiotherapy Research Unit, Physiotherapy Department, Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Megan V Goff
- Oxford Clinical Trials Research Unit (OCTRU), Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford, UK
- Centre for Osteoarthritis Pathogenesis Versus Arthritis, Kennedy Institute of Rheumatology, NDORMS, University of Oxford, Oxford, UK
- Cancer Prevention Trials Unit, King's College London Guy's Campus, London, UK
| | - Anne Francis
- Oxford Clinical Trials Research Unit (OCTRU), Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford, UK
| | - Gretchen Brewer
- Centre for Osteoarthritis Pathogenesis Versus Arthritis, Kennedy Institute of Rheumatology, NDORMS, University of Oxford, Oxford, UK
| | - Ioana Marian
- OCTRU, Centre for Statistics in Medicine, NDORMS, University of Oxford, Oxford, UK
| | - Susan L Morris
- National Institute for Health and Care Research Clinical research Network (Thames Valley and South Midlands), Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | | | - Lucy Eldridge
- Oxford Clinical Trials Research Unit (OCTRU), Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford, UK
| | - Patrick Julier
- Oxford Clinical Trials Research Unit (OCTRU), Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford, UK
| | - Malvika Gulati
- Centre for Osteoarthritis Pathogenesis Versus Arthritis, Kennedy Institute of Rheumatology, NDORMS, University of Oxford, Oxford, UK
| | - Karen L Barker
- Physiotherapy Research Unit, Physiotherapy Department, Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Vicki S Barber
- Oxford Clinical Trials Research Unit (OCTRU), Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford, UK
| | - Joanna Black
- Oxford Clinical Trials Research Unit (OCTRU), Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford, UK
| | - Sue Woollacott
- Centre for Osteoarthritis Pathogenesis Versus Arthritis, Kennedy Institute of Rheumatology, NDORMS, University of Oxford, Oxford, UK
| | - Charles Mackworth-Young
- Rheumatology Department, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, UK
| | | | - Sarah E Lamb
- Centre for Rehabilitation Research, NDORMS, Oxford, University of Oxford, UK
- College of Medicine and Health, University of Exeter, Exeter, UK
| | - Tonia L Vincent
- Centre for Osteoarthritis Pathogenesis Versus Arthritis, Kennedy Institute of Rheumatology, NDORMS, University of Oxford, Oxford, UK
- Rheumatology Department, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Katy Vincent
- Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford, UK
| | - Susan J Dutton
- OCTRU, Centre for Statistics in Medicine, NDORMS, University of Oxford, Oxford, UK
| | - Fiona E Watt
- Centre for Osteoarthritis Pathogenesis Versus Arthritis, Kennedy Institute of Rheumatology, NDORMS, University of Oxford, Oxford, UK
- Rheumatology Department, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, UK
- Centre for Inflammatory Disease, Department of Immunology and Inflammation, Imperial College London, London, UK
- Correspondence to: Dr Fiona E Watt, Centre for Inflammatory Disease, Department of Immunology and Inflammation, Imperial College London, London W12 0NN, UK
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Griffiths F, Srikesavan C, Ward L, Boniface G, Williamson E, Lamb SE. Longitudinal qualitative study of living with neurogenic claudication. BMJ Open 2022; 12:e060128. [PMID: 36104131 PMCID: PMC9476140 DOI: 10.1136/bmjopen-2021-060128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVES Neurogenic claudication (NC) causes pain and reduced mobility, particularly in older people, and can negatively affect mental and social well-being, so limiting successful ageing. This qualitative study explored how people with NC changed over 12 months. DESIGN A longitudinal qualitative study using semi-structured interviews. SETTING Participants were recruited from a UK clinical trial of a physiotherapy intervention for NC. PARTICIPANTS Interviews were undertaken at baseline, 1 month after receiving any intervention and at 12 months. We analysed 30 sets of three interviews. RESULTS Interview data were summarised for each time point into biopsychosocial domains: pain, mobility and activities of daily living, psychological impact, and social and recreational participation. Through comparative analysis we explored participant trajectories over time.Progressive improvement in at least one domain was experienced by 13 participants, but there was variability in trajectories with early improvements that remained the same, transient changes and no change also commonly observed.Eleven participants described co-present improvement trajectories in all domains. Three participants described co-present improvement in all domains except participation; one had never stopped their participation and two had unattainable expectations. Five participants described co-present improvement in one domain and deterioration in another and 14 participants described co-present no change in one domain and change in another.There was evidence of interaction between domains; for example, improved mobility led to improved participation and for some participants, specific factors influenced change. Of the 15 participants who experienced improved participation, 10 reported improvements in all other domains and five participants did not; for two, pain did not prevent participation, one used a walking aid and two had a positive psychological outlook. CONCLUSION The daily lived experiences of older adults with NC are variable and include interaction between biopsychosocial domains. Therapist understanding of these trajectories and their interactions may help to provide personalised therapy TRIAL REGISTRATION NUMBER: ISRCTN12698674.
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Affiliation(s)
- Frances Griffiths
- Warwick Medical School, University of Warwick, Coventry, West Midlands, UK
| | - Cynthia Srikesavan
- Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, Oxfordshire, UK
| | - Lesley Ward
- Department of Sport, Exercise & Rehabilitation, Northumbria University, Newcastle upon Tyne, Tyne and Wear, UK
| | - Graham Boniface
- Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, Oxfordshire, UK
| | - Esther Williamson
- Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, Oxfordshire, UK
- College of Medicine and Health, University of Exeter, Exeter, Devon, UK
| | - Sarah E Lamb
- Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, Oxfordshire, UK
- College of Medicine and Health, University of Exeter, Exeter, Devon, UK
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29
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Montero-Odasso M, van der Velde N, Martin FC, Petrovic M, Tan MP, Ryg J, Aguilar-Navarro S, Alexander NB, Becker C, Blain H, Bourke R, Cameron ID, Camicioli R, Clemson L, Close J, Delbaere K, Duan L, Duque G, Dyer SM, Freiberger E, Ganz DA, Gómez F, Hausdorff JM, Hogan DB, Hunter SMW, Jauregui JR, Kamkar N, Kenny RA, Lamb SE, Latham NK, Lipsitz LA, Liu-Ambrose T, Logan P, Lord SR, Mallet L, Marsh D, Milisen K, Moctezuma-Gallegos R, Morris ME, Nieuwboer A, Perracini MR, Pieruccini-Faria F, Pighills A, Said C, Sejdic E, Sherrington C, Skelton DA, Dsouza S, Speechley M, Stark S, Todd C, Troen BR, van der Cammen T, Verghese J, Vlaeyen E, Watt JA, Masud T. World guidelines for falls prevention and management for older adults: a global initiative. Age Ageing 2022; 51:afac205. [PMID: 36178003 PMCID: PMC9523684 DOI: 10.1093/ageing/afac205] [Citation(s) in RCA: 223] [Impact Index Per Article: 111.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 08/26/2022] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND falls and fall-related injuries are common in older adults, have negative effects on functional independence and quality of life and are associated with increased morbidity, mortality and health related costs. Current guidelines are inconsistent, with no up-to-date, globally applicable ones present. OBJECTIVES to create a set of evidence- and expert consensus-based falls prevention and management recommendations applicable to older adults for use by healthcare and other professionals that consider: (i) a person-centred approach that includes the perspectives of older adults with lived experience, caregivers and other stakeholders; (ii) gaps in previous guidelines; (iii) recent developments in e-health and (iv) implementation across locations with limited access to resources such as low- and middle-income countries. METHODS a steering committee and a worldwide multidisciplinary group of experts and stakeholders, including older adults, were assembled. Geriatrics and gerontological societies were represented. Using a modified Delphi process, recommendations from 11 topic-specific working groups (WGs), 10 ad-hoc WGs and a WG dealing with the perspectives of older adults were reviewed and refined. The final recommendations were determined by voting. RECOMMENDATIONS all older adults should be advised on falls prevention and physical activity. Opportunistic case finding for falls risk is recommended for community-dwelling older adults. Those considered at high risk should be offered a comprehensive multifactorial falls risk assessment with a view to co-design and implement personalised multidomain interventions. Other recommendations cover details of assessment and intervention components and combinations, and recommendations for specific settings and populations. CONCLUSIONS the core set of recommendations provided will require flexible implementation strategies that consider both local context and resources.
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Affiliation(s)
- Manuel Montero-Odasso
- Gait and Brain Lab, Parkwood Institute, Lawson Health Research Institute, London, ON, Canada
- Division of Geriatric Medicine, Department of Medicine, Schulich School of Medicine & Dentistry, University of Western Ontario, London, ON, Canada
- Department of Epidemiology and Biostatistics, Schulich School of Medicine & Dentistry, University of Western Ontario, London, ON, Canada
| | - Nathalie van der Velde
- Amsterdam UMC location University of Amsterdam, Internal Medicine, Section of Geriatric Medicine, Amsterdam, The Netherlands
- Amsterdam Public Health, Aging and Later Life, Amsterdam, The Netherlands
| | - Finbarr C Martin
- Population Health Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Mirko Petrovic
- Department of Internal Medicine and Paediatrics, Section of Geriatrics, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Maw Pin Tan
- Centre for Innovation in Medical Engineering (CIME), Faculty of Engineering, University of Malaya, Kuala Lumpur 50603, Malaysia
- Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur 50603, Malaysia
| | - Jesper Ryg
- Department of Geriatric Medicine, Odense University Hospital, Odense, Denmark
- Geriatric Research Unit, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Sara Aguilar-Navarro
- Department of Geriatric Medicine, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Neil B Alexander
- Department of Internal Medicine, Division of Geriatric and Palliative Medicine, University of Michigan; Veterans Administration Ann Arbor Healthcare System Geriatrics Research Education Clinical Center, Ann Arbor, MI, USA
| | - Clemens Becker
- Department of Clinical Gerontology and Geriatric Rehabilitation, Robert Bosch Hospital, Stuttgart, Germany
| | - Hubert Blain
- Department of Geriatrics, Montpellier University hospital and MUSE, Montpellier, France
| | - Robbie Bourke
- Department of Medical Gerontology Trinity College Dublin and Mercers Institute for Successful Ageing, St James’s Hospital, Dublin, Ireland
| | - Ian D Cameron
- John Walsh Centre for Rehabilitation Research, Northern Sydney Local Health District and Faculty of Medicine and Health, University of Sydney. Department of Medicine (Neurology) and Neuroscience and Mental Health, Sydney, NSW, Australia
| | - Richard Camicioli
- Department of Medicine (Neurology), Neuroscience and Mental Health Institute, University of Alberta, Edmonton, AB, Canada
| | - Lindy Clemson
- Sydney School of Health Sciences, Faculty of Medicine & Health, The University of Sydney, Sydney, Australia
| | - Jacqueline Close
- Falls, Balance and Injury Research Centre, Neuroscience Research Australia, University of New South Wales, Sydney, NSW, Australia
- Prince of Wales Clinical School, Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Kim Delbaere
- Falls, Balance and Injury Research Centre, Neuroscience Research Australia, Sydney, NSW, Australia; School of Population Health, University of New South Wales, Kensington, NSW, Australia
| | - Leilei Duan
- National Centre for Chronic and Noncommunicable Disease Control and Prevention, Chinese Centre for Disease Control and Prevention, Beijing, China
| | - Gustavo Duque
- Research Institute of the McGill University HealthCentre, Montreal, Quebec, Canada
| | - Suzanne M Dyer
- Flinders Health and Medical Research Institute, Flinders University, Adelaide, SA, Australia
| | - Ellen Freiberger
- Friedrich-Alexander-University Erlangen-Nürnberg, Institute for Biomedicine of Aging, Nürnberg, Germany
| | - David A Ganz
- Multicampus Program in Geriatric Medicine and Gerontology, David Geffen School of Medicine at UCLA and Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Fernando Gómez
- Research Group on Geriatrics and Gerontology, International Association of Gerontology and Geriatrics Collaborative Center, University Caldas, Manizales, Colombia
| | - Jeffrey M Hausdorff
- Center for the Study of Movement, Cognition and Mobility, Neurological Institute, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Department of Physical Therapy, Sackler Faculty of Medicine, and Sagol School of Neuroscience, Tel Aviv University, Tel Aviv, Israel
- Department of Orthopaedic Surgery, Rush Alzheimer's Disease Center, Rush University Medical Center, Chicago, IL, USA
| | - David B Hogan
- Brenda Strafford Centre on Aging, O’BrienInstitute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Susan M W Hunter
- School of Physical Therapy, Faculty of Health Sciences, Elborn College, University of Western Ontario, London, ON, Canada
| | - Jose R Jauregui
- Ageing Biology Unit, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Nellie Kamkar
- Gait and Brain Lab, Parkwood Institute, Lawson Health Research Institute, London, ON, Canada
| | - Rose-Anne Kenny
- Department of Medical Gerontology Trinity College Dublin and Mercers Institute for Successful Ageing, St James’s Hospital, Dublin, Ireland
| | - Sarah E Lamb
- Faculty of Health and Life Sciences, Mireille Gillings Professor of Health Innovation, Medical School Building, Exeter, England, UK
| | | | - Lewis A Lipsitz
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Teresa Liu-Ambrose
- Djavad Mowafaghian Centre for Brain Health, Center for Hip Health and Mobility, Vancouver Coastal Health Research Institute, University of British Columbia, Vancouver, BC, Canada
| | - Pip Logan
- School of Medicine, University of Nottingham, Nottingham, England, UK
| | - Stephen R Lord
- Falls, Balance and Injury Research Centre, Neuroscience Research Australia, Sydney, NSW, Australia
- School of Public Health and Community Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Louise Mallet
- Department of Pharmacy, Faculty of Pharmacy, McGill University Health Center, Université de Montréal, Montreal, QC, Canada
| | - David Marsh
- University College London, London, England, UK
| | - Koen Milisen
- Department of Public Health and Primary Care, Academic Centre for Nursing and Midwifery, KU Leuven, Leuven, Belgium
- Department of Geriatric Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Rogelio Moctezuma-Gallegos
- Geriatric Medicine & Neurology Fellowship, Instituto Nacional de Ciencias Médicas y Nutrición “Salvador Zubirán”. Mexico City, Mexico
- Geriatric Medicine Program, Tecnologico de Monterrey, School of Medicine and Health Sciences. Monterrey, Nuevo León, Mexico
| | - Meg E Morris
- Healthscope and Academic and Research Collaborative in Health (ARCH), La Trobe University, Australia
| | - Alice Nieuwboer
- Department of Rehabilitation Sciences, Neurorehabilitation Research Group (eNRGy), KU Leuven, Leuven, Belgium
| | - Monica R Perracini
- Master’s and Doctoral programs in Physical Therapy, Universidade Cidade de Sao Paulo (UNICID), Sao Paulo, Brazil
| | - Frederico Pieruccini-Faria
- Gait and Brain Lab, Parkwood Institute, Lawson Health Research Institute, London, ON, Canada
- Division of Geriatric Medicine, Department of Medicine, Schulich School of Medicine & Dentistry, University of Western Ontario, London, ON, Canada
| | - Alison Pighills
- Mackay Institute of Research and Innovation, Mackay Hospital and Health Service, Mackay, QLD, Australia
| | - Catherine Said
- Western Health, University of Melbourne, Parkville, Melbourne, VIC, Australia
- Australian Institute for Musculoskeletal Science (AIMSS), The University of Melbourne and Western Health, St Albans, VIC, Australia
- Melbourne School of Health Sciences The University of Melbourne, Parkville, Australia
| | - Ervin Sejdic
- Department of Electrical and Computer Engineering, Swanson School of Engineering, University of Pittsburgh, Pittsburgh, PA, USA
| | - Catherine Sherrington
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, Australia
| | - Dawn A Skelton
- School of Health and Life Sciences, Research Centre for Health (ReaCH), Glasgow Caledonian University, Cowcaddens Road, Glasgow, Scotland, UK
| | - Sabestina Dsouza
- Department of Occupational Therapy, Manipal College of Health Professions, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Mark Speechley
- Department of Epidemiology and Biostatistics, Schulich School of Medicine & Dentistry, University of Western Ontario, London, ON, Canada
- Schulich Interfaculty Program in Public Health, Schulich School of Medicine & Dentistry, University of Western Ontario, London, ON, Canada
| | - Susan Stark
- Program in Occupational Therapy, School of Medicine, Washington University in St. Louis, St. Louis, MO, USA
| | - Chris Todd
- School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, England, UK
- Manchester University NHS Foundation Trust, Manchester M13 9WL, UK
| | - Bruce R Troen
- Division of Geriatrics and Palliative Medicine, Department of Medicine, Jacobs School of Medicine & Biomedical Sciences, University of Buffalo; Research Service, Veterans Affairs Western New York Healthcare System, Buffalo, New York, USA
| | - Tischa van der Cammen
- Department of Human-Centred Design, Faculty of Industrial Design Engineering, Delft University of Technology, Delft, The Netherlands
- Section of Geriatric Medicine, Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Joe Verghese
- Division of Geriatrics, Department of Medicine, Albert Einstein College of Medicine, Bronx, New York, USA
- Department of Neurology, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Ellen Vlaeyen
- Department of Public Health and Primary Care, Academic Centre for Nursing and Midwifery, KU Leuven, Leuven, Belgium
- Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium
| | - Jennifer A Watt
- Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, ON, Canada
- Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Tahir Masud
- Department of Geriatric Medicine, The British Geriatrics Society, Nottingham University Hospitals NHS Trust, Nottingham, England, UK
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Korall AMB, Steliga D, Lamb SE, Lord SR, Rabbani R, Sibley KM. Factors associated with reporting of the Prevention of Falls Network Europe (ProFaNE) core outcome set domains in randomized trials on falls in older people: a citation analysis and correlational study. Trials 2022; 23:710. [PMID: 36028912 PMCID: PMC9419335 DOI: 10.1186/s13063-022-06642-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 08/06/2022] [Indexed: 11/10/2022] Open
Abstract
Background Core outcome sets are advocated as a means to standardize outcome reporting across randomized controlled trials (RCTs) and reduce selective outcome reporting. In 2005, the Prevention of Falls Network Europe (ProFaNE) published a core outcome set identifying five domains that should be measured and reported, at a minimum, in RCTs or meta-analysis on falls in older people. As reporting of all five domains of the ProFaNE core outcome set has been minimal, we set out to investigate factors associated with reporting of the ProFaNE core outcome set domains in a purposeful sample of RCTs on falls in older people. Methods We conducted a systematic citation analysis to identify all reports of RCTs focused on falls in older people that cited the ProFaNE core outcome set between October 2005 and July 2021. We abstracted author-level, study-level, and manuscript-level data and whether each domain of the ProFaNE core outcome set was reported. We used penalized LASSO regression to identify factors associated with the mean percentage of ProFaNE core outcome set domains reported. Results We identified 85 eligible reports of RCTs. Articles were published between 2007 and 2021, described 75 unique RCTs, and were authored by 76 unique corresponding authors. The percentage of ProFaNE core outcome set domains reported ranged from 0 to 100%, with a median of 40% and mean (standard deviation, SD) of 52.2% (25.1). RCTs funded by a non-industry source reported a higher mean percentage of domains than RCTs without a non-industry funding source (estimated mean difference = 17.5%; 95% confidence interval (CI) 1.8–33.2). RCTs examining exercise (15.4%; 95% CI 1.9–28.9) or multi-component/factorial (17.4%; 95% CI 4.7–30.1) interventions each reported a higher mean percentage of domains than RCTs examining other intervention types. Conclusions We found that RCTs funded by at least one non-industry source, examining exercise or multi-component/factorial interventions, reported the highest percentages of ProFaNE core outcome set domains. Findings may help inform strategies to increase the impact of the ProFaNE core outcome set. Ultimately, this may lead to enhanced knowledge of the effectiveness and safety of interventions to prevent and/or manage falls in older people. Supplementary Information The online version contains supplementary material available at 10.1186/s13063-022-06642-w.
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Affiliation(s)
- Alexandra M B Korall
- George & Fay Yee Centre for Healthcare Innovation, Third Floor, Chown Building, 753 McDermot Avenue, Winnipeg, MB, R3B 0V8, Canada.,Department of Community Health Sciences, Rady Faculty of Health Sciences, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Dawn Steliga
- Rady Faculty of Health Sciences, Interdisciplinary Health Program, University of Manitoba, Winnipeg, MB, Canada
| | - Sarah E Lamb
- College of Medicine and Health, University of Exeter, Exeter, UK
| | - Stephen R Lord
- Neuroscience Research Australia, New South Wales, Australia.,School of Public Health and Community Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Rasheda Rabbani
- George & Fay Yee Centre for Healthcare Innovation, Third Floor, Chown Building, 753 McDermot Avenue, Winnipeg, MB, R3B 0V8, Canada.,Department of Community Health Sciences, Rady Faculty of Health Sciences, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Kathryn M Sibley
- George & Fay Yee Centre for Healthcare Innovation, Third Floor, Chown Building, 753 McDermot Avenue, Winnipeg, MB, R3B 0V8, Canada. .,Department of Community Health Sciences, Rady Faculty of Health Sciences, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada.
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31
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Beard DJ, Davies L, Cook JA, Stokes J, Leal J, Fletcher H, Abram S, Chegwin K, Greshon A, Jackson W, Bottomley N, Dodd M, Bourke H, Shirkey BA, Paez A, Lamb SE, Barker K, Phillips M, Brown M, Lythe V, Mirza B, Carr A, Monk P, Morgado Areia C, O'Leary S, Haddad F, Wilson C, Price A. Rehabilitation versus surgical reconstruction for non-acute anterior cruciate ligament injury (ACL SNNAP): a pragmatic randomised controlled trial. Lancet 2022; 400:605-615. [PMID: 35988569 DOI: 10.1016/s0140-6736(22)01424-6] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Revised: 07/11/2022] [Accepted: 07/18/2022] [Indexed: 12/19/2022]
Abstract
BACKGROUND Anterior cruciate ligament (ACL) rupture is a common debilitating injury that can cause instability of the knee. We aimed to investigate the best management strategy between reconstructive surgery and non-surgical treatment for patients with a non-acute ACL injury and persistent symptoms of instability. METHODS We did a pragmatic, multicentre, superiority, randomised controlled trial in 29 secondary care National Health Service orthopaedic units in the UK. Patients with symptomatic knee problems (instability) consistent with an ACL injury were eligible. We excluded patients with meniscal pathology with characteristics that indicate immediate surgery. Patients were randomly assigned (1:1) by computer to either surgery (reconstruction) or rehabilitation (physiotherapy but with subsequent reconstruction permitted if instability persisted after treatment), stratified by site and baseline Knee Injury and Osteoarthritis Outcome Score-4 domain version (KOOS4). This management design represented normal practice. The primary outcome was KOOS4 at 18 months after randomisation. The principal analyses were intention-to-treat based, with KOOS4 results analysed using linear regression. This trial is registered with ISRCTN, ISRCTN10110685, and ClinicalTrials.gov, NCT02980367. FINDINGS Between Feb 1, 2017, and April 12, 2020, we recruited 316 patients. 156 (49%) participants were randomly assigned to the surgical reconstruction group and 160 (51%) to the rehabilitation group. Mean KOOS4 at 18 months was 73·0 (SD 18·3) in the surgical group and 64·6 (21·6) in the rehabilitation group. The adjusted mean difference was 7·9 (95% CI 2·5-13·2; p=0·0053) in favour of surgical management. 65 (41%) of 160 patients allocated to rehabilitation underwent subsequent surgery according to protocol within 18 months. 43 (28%) of 156 patients allocated to surgery did not receive their allocated treatment. We found no differences between groups in the proportion of intervention-related complications. INTERPRETATION Surgical reconstruction as a management strategy for patients with non-acute ACL injury with persistent symptoms of instability was clinically superior and more cost-effective in comparison with rehabilitation management. FUNDING The UK National Institute for Health Research Health Technology Assessment Programme.
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Affiliation(s)
- David J Beard
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Oxford, UK.
| | - Loretta Davies
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Oxford, UK
| | - Jonathan A Cook
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Oxford, UK
| | - Jamie Stokes
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Oxford, UK
| | - Jose Leal
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Heidi Fletcher
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Oxford, UK
| | - Simon Abram
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Oxford, UK
| | - Katie Chegwin
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Oxford, UK
| | - Akiko Greshon
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Oxford, UK
| | - William Jackson
- Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Nicholas Bottomley
- Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Matt Dodd
- Swansea Bay University Health Board, Swansea, UK
| | - Henry Bourke
- Heatherwood & Wexham Park Hospitals, Frimley Health NHS Foundation Trust, Slough, UK
| | - Beverly A Shirkey
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Oxford, UK
| | - Arsenio Paez
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Oxford, UK
| | - Sarah E Lamb
- College of Medicine and Health, University of Exeter, Swansea, UK
| | - Karen Barker
- Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | | | | | - Vanessa Lythe
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Burhan Mirza
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Andrew Carr
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Oxford, UK
| | - Paul Monk
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Oxford, UK
| | - Carlos Morgado Areia
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Oxford, UK
| | - Sean O'Leary
- Royal Berkshire Hospital, Royal Berkshire NHS Foundation Trust, Reading, UK
| | - Fares Haddad
- University College Hospitals, University College London Hospitals NHS Foundation Trust, London, UK
| | - Chris Wilson
- University Hospital of Wales, Cardiff and Vale University Health Board, Cardiff, UK
| | - Andrew Price
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Oxford, UK
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Hopewell S, Keene DJ, Heine P, Marian IR, Dritsaki M, Cureton L, Dutton SJ, Dakin H, Carr A, Hamilton W, Hansen Z, Jaggi A, Littlewood C, Barker K, Gray A, Lamb SE. Corrigendum: Progressive exercise compared with best-practice advice, with or without corticosteroid injection, for rotator cuff disorders: the GRASP factorial RCT. Health Technol Assess 2022; 25:159-160. [PMID: 35997045 DOI: 10.3310/ktcg3040-c202208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Abstract
Corrections to Table 15.
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Affiliation(s)
- Sally Hopewell
- Oxford Clinical Trials Research Unit, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - David J Keene
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Peter Heine
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Ioana R Marian
- Oxford Clinical Trials Research Unit, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Melina Dritsaki
- Oxford Clinical Trials Research Unit, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Lucy Cureton
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Susan J Dutton
- Oxford Clinical Trials Research Unit, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Helen Dakin
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Andrew Carr
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Willie Hamilton
- College of Medicine and Health, University of Exeter, Exeter, UK
| | - Zara Hansen
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Anju Jaggi
- Royal National Orthopaedic Hospital NHS Trust, Stanmore, UK
| | | | - Karen Barker
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Alastair Gray
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Sarah E Lamb
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK.,College of Medicine and Health, University of Exeter, Exeter, UK
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Srikesavan C, Williamson E, Thompson JY, Cranston T, Swales C, Lamb SE. The online version of an evidence-based hand exercise program for people with rheumatoid arthritis: A mixed-method, proof-of-concept study. J Hand Ther 2022; 35:468-476. [PMID: 33279362 DOI: 10.1016/j.jht.2020.10.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Revised: 09/17/2020] [Accepted: 10/19/2020] [Indexed: 02/03/2023]
Abstract
INTRODUCTION The Strengthening And stretching for Rheumatoid Arthritis of the Hand (SARAH) program is a tailored, 12-week hand and arm exercise program recommended in the National Institute for Health and Care Excellence guidelines. It includes seven mobility exercises and four strength exercises against resistance. An online version of the SARAH program (mySARAH) has been developed to allow direct access for people with rheumatoid arthritis. PURPOSE The purpose of this study was to assess the feasibility, acceptability, and clinical impact of mySARAH in people with rheumatoid arthritis. STUDY DESIGN This is a mixed-method, proof-of-concept study. METHODS mySARAH is a self-guided, online version of the SARAH program with six exercise training and review sessions. Participants were observed as they worked through four of the six online sessions. They were also asked to demonstrate the SARAH exercises. Participants undertook two sessions independently at home. At the baseline and 12 weeks, hand pain, hand function, and grip strength were measured. At 12 weeks, feedback on mySARAH, and perceived recovery were also collected. Approximately one month later, a telephone follow-up was conducted to explore participants' experiences with mySARAH. Pain, hand function, and perceived recovery were also assessed. RESULTS Eleven participants (males/females: 3/8) with a median (interquartile range) age of 63 (17) years took part. Six participants completed all mySARAH sessions. About 512 exercise and load-setting demonstrations were observed and 491 (96%) were performed correctly. Improvements in grip strength and hand function were observed with no increase in pain. Most of the participants reported improvement and provided positive feedback. All participants perceived mySARAH as a useful resource. Features to improve the online exercise diary such as recording and tracking exercise dose and face-to-face or remote support by phone or Skype from health professionals were suggested to optimize user engagement. CONCLUSIONS Initial evaluation of mySARAH indicates that mySARAH was feasible, acceptable, and beneficial to participants. Further iteration and evaluation are needed before large-scale implementation.
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Affiliation(s)
- Cynthia Srikesavan
- Centre for Rehabilitation Research in Oxford, Botnar Research Centre, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom.
| | - Esther Williamson
- Centre for Rehabilitation Research in Oxford, Botnar Research Centre, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
| | - Jacqueline Y Thompson
- Centre for Rehabilitation Research in Oxford, Botnar Research Centre, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
| | - Tim Cranston
- Oxford Clinical Trials Unit, Botnar Research Centre, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
| | - Catherine Swales
- University of Oxford Medical School, Botnar Research Centre, Nuffield Orthopaedic Centre, Oxford, United Kingdom
| | - Sarah E Lamb
- Centre for Rehabilitation Research in Oxford, Botnar Research Centre, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
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Nanchahal J, Ball C, Rombach I, Williams L, Kenealy N, Dakin H, O'Connor H, Davidson D, Werker P, Dutton SJ, Feldmann M, Lamb SE. Anti-tumour necrosis factor therapy for early-stage Dupuytren's disease (RIDD): a phase 2b, randomised, double-blind, placebo-controlled trial. The Lancet Rheumatology 2022; 4:E407-E416. [PMID: 35949922 PMCID: PMC7613263 DOI: 10.1016/s2665-9913(22)00093-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Background Dupuytren’s disease is a common fibrotic condition that causes the fingers to flex irreversibly into the palm. Treatments for late-stage disease all have limitations, and there is no approved treatment for early-stage disease. We identified tumour necrosis factor as a therapeutic target in Dupuytren’s disease, and in a dose ranging trial found 40 mg adalimumab in 0·4 mL to be most efficacious. Here we aimed to assess the effects of intranodular injection of adalimumab in early-stage disease. Methods In this phase 2b, randomised, double-blind, placebo-controlled trial adults with early-stage Dupuytren’s disease and an established clinically distinct nodule with a clear history of progression in the preceding 6 months were recruited from two clinical centres in the UK and were randomly assigned 1:1 to receive four injections of adalimumab or saline every 3 months. Participants and assessors were masked. The primary outcome was nodule hardness measured with a durometer at 12 months. Data were analysed by linear mixed effects regression models in the intention-to-treat population with multiple imputation for missing primary outcome data. The trial is registered at the ISRCTN registry, ISRCTN 27786905 and is complete. Findings Between Feb 17, 2017, and Jan 11, 2019, 284 participants were screened in the UK and 140 were enrolled. 47 (34%) participants were female and 93 (66%) were male. Mean age of participants was 59·7 years (SD 10·0). Primary outcome data were available from 113 participants. Nodule hardness was lower (−4·6 AU [95% CI −7·1 to −2·2], p=0·0002) in the adalimumab compared with the saline group at 12 months. There were no related serious adverse events; the most common adverse events were minor injection site reactions. Interpretation Intranodular injections of adalimumab in participants with early-stage Dupuytren’s disease resulted in softening and reduction in size of the nodules. Longer follow-up would be required to assess the effect of tumour necrosis factor inhibition on disease progression, extension deficit and hand function.
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Nicolson PJA, Duong V, Williamson E, Hopewell S, Lamb SE. The Effect of Therapeutic Exercise Interventions on Physical and Psychosocial Outcomes in Adults Aged 80 Years and Older: A Systematic Review and Meta-Analysis. J Aging Phys Act 2022; 30:517-534. [PMID: 34489362 DOI: 10.1123/japa.2021-0149] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 06/08/2021] [Accepted: 06/14/2021] [Indexed: 11/18/2022]
Abstract
This systematic review aimed to evaluate the effects of therapeutic exercise on physical and psychosocial outcomes in community-dwelling adults aged 80 years or older. Databases were searched from inception to July 8, 2020. Randomized controlled trials (RCTs) were screened by two reviewers who extracted data and assessed study quality. Sixteen RCTs (1,660 participants) were included. Compared to nonexercise controls there was no evidence of an effect of exercise on performance based (standardized mean differences: 0.58, 95% confidence interval: [-0.19, 1.36]; I2: 89%; six RCTs; 290 participants; very low-quality evidence) or self-reported physical function (standardized mean differences: 1.35, 95% confidence interval: [-0.78, 3.48]; I2: 96%; three RCTs; 280 participants; very low-quality evidence) at short-medium term follow-up. Four RCTs reporting psychosocial outcomes could not be combined in meta-analysis and reported varying results. Exercise appeared to reduce the risk of mortality during follow-up (risk ratio: 0.47, 95% confidence interval: [0.32, 0.70]; I2: 0.0%; six RCTs; 1,222 participants; low-quality evidence).
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Forde C, Nicolson PJA, Vye C, Pun JCH, Sheehan W, Costa M, Lamb SE, Keene DJ. P135 Lower limb muscle strength and balance in older adults with distal radius fracture: a systematic review. Rheumatology (Oxford) 2022. [DOI: 10.1093/rheumatology/keac133.134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background/Aims
Distal radius fractures (DRF) are common fall-related fragility fractures disproportionately affecting older females. After a DRF, there is an increased risk of future fragility fractures and functional decline. Systematic review evidence shows balance and muscle strengthening exercises reduce falls in older adults. Despite this, existing DRF rehabilitation trials have mainly focused on upper limb impairments. To inform rehabilitation requirements, we aimed to 1.) compare lower limb muscle strength and balance between older adults with a DRF with age- and sex-matched controls, and 2.) synthesise lower limb muscle strength and balance outcomes in older adults with a DRF.
Methods
We searched Embase, MEDLINE and CINAHL (1990 to August 2021). We included randomised and non-randomised controlled trials, and observational studies, that assessed lower limb strength and/or balance in adults aged ≥50 years enrolled within one year after a DRF. Strength and balance had to be assessed using validated instrumented or physical performance measures. Two reviewers independently screened titles and abstracts, and full-text reports of potentially eligible studies. One reviewer extracted data, then checked by another. Two reviewers independently appraised studies using the Cochrane risk-of-bias tool or Newcastle-Ottawa scale. We synthesised results narratively due to heterogeneity. PROSPERO registration: CRD42020196274.
Results
Seventeen studies (10 case-control studies, three RCTs and four case-series) including 1112 participants (95% women) with a DRF were included. Participants’ mean age ranged from 56 to 73 years; median sample size was 80 (IQR 54-106). Eleven (65%) studies assessed lower limb muscle strength using 10 different methods. Knee extensor strength assessment was most common (5/11 studies) followed by the 30-second and five times sit-to-stand tests (3/11 studies). All studies assessed balance, using 14 different methods. Single leg balance assessment was most common (6/17 studies) followed by functional reach and postural sway (3/17 studies). 5/10 case-control studies assessed lower limb muscle strength. Two studies found cases performed worse than controls during sit-to-stand tests; three studies assessed knee extensor strength with conflicting findings. All case-control studies assessed balance, with cases demonstrating impaired balance compared to controls on some measures. 4/17 studies assessed strength and 6/17 studies assessed balance at multiple timepoints. Over time, strength progressively improved in 3/4 studies but changes in balance were inconsistent across studies.
Conclusion
There is some evidence that older adults with a DRF have impaired lower limb muscle strength and balance compared to age- and sex-matched controls, but findings are inconsistent. Synthesis of results was limited by heterogeneity in the design, quality, and assessment methods used in included studies. Large-scale robust case-control and/or prospective observational studies are needed to better establish the rehabilitation requirements for this population.
Disclosure
C. Forde: Grants/research support; CF is supported by the NIHR Biomedical Research Centre, based at Oxford University Hospitals Trust, Oxford. P.J.A. Nicolson: Grants/research support; PN is supported by a Versus Arthritis Foundation Fellowship (ref. 22428). C. Vye: None. J.C.H. Pun: Grants/research support; JP received financial support from the NMAHPs Internship Versus Arthritis (Grant reference 22082). W. Sheehan: None. M. Costa: Grants/research support; MC receives grants from NIHR and related health charities. S.E. Lamb: Grants/research support; SL receives grants from NIHR and related health charities. D.J. Keene: Grants/research support; DK is supported by a National Institute of Health Research (NIHR) Postdoctoral Fellowship (ref. PDF-2016-09-056) and by the NIHR Biomedical Research Centre, based at Oxford University Hospitals Trust.
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Affiliation(s)
- Colin Forde
- Physiotherapy Department, Oxford University Hospitals NHS Foundation Trust, Oxford, UNITED KINGDOM
| | - Philippa J. A Nicolson
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UNITED KINGDOM
| | - Charlotte Vye
- Therapies Department, Royal United Hospitals NHS Foundation Trust, Bath, UNITED KINGDOM
| | - Jessica C. H Pun
- NMAHPs Internship Versus Arthritis, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UNITED KINGDOM
| | - Warren Sheehan
- Physiotherapy Department, Oxford University Hospitals NHS Foundation Trust, Oxford, UNITED KINGDOM
| | - Matthew Costa
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UNITED KINGDOM
| | - Sarah E Lamb
- Exeter Medical School, University of Exeter, Exeter, UNITED KINGDOM
| | - David J Keene
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UNITED KINGDOM
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Hamilton TW, Knight R, Stokes JR, Rombach I, Cooper C, Davies L, Dutton SJ, Barker KL, Cook J, Lamb SE, Murray DW, Poulton L, Wang A, Strickland LH, Van Duren BH, Leal J, Beard D, Pandit HG. Efficacy of Liposomal Bupivacaine and Bupivacaine Hydrochloride vs Bupivacaine Hydrochloride Alone as a Periarticular Anesthetic for Patients Undergoing Knee Replacement: A Randomized Clinical Trial. JAMA Surg 2022; 157:481-489. [PMID: 35385072 PMCID: PMC8988023 DOI: 10.1001/jamasurg.2022.0713] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Question Among patients undergoing knee replacement surgery, does liposomal bupivacaine and bupivacaine hydrochloride administered at the surgical site improve postoperative recovery at 72 hours and postoperative pain from 6 to 72 hours compared with bupivacaine hydrochloride alone? Findings In this randomized clinical trial of 533 patients undergoing knee replacement surgery, no difference in the coprimary outcomes of Quality of Recovery 40 score at 72 hours or pain visual analog scale score area under the curve from 6 to 72 hours was detected between patients receiving liposomal bupivacaine and bupivacaine hydrochloride and those receiving bupivacaine hydrochloride alone. In addition, liposomal bupivacaine was not found to be cost-effective. Meaning This study found that liposomal bupivacaine did not improve postoperative recovery or pain compared with bupivacaine hydrochloride alone among patients undergoing knee replacement surgery. Importance More than half of patients who undergo knee replacement surgery report substantial acute postoperative pain. Objective To evaluate the efficacy and cost-effectiveness of periarticular liposomal bupivacaine for recovery and pain management after knee replacement. Design, Setting, and Participants This multicenter, patient-blinded, pragmatic, randomized clinical superiority trial involved 533 participants at 11 institutions within the National Health Service in England. Adults undergoing primary unilateral knee replacement for symptomatic end-stage osteoarthritis were enrolled between March 29, 2018, and February 29, 2020, and followed up for 1 year after surgery. Follow-up was completed March 1, 2021. A per-protocol analysis for each coprimary outcome was performed in addition to the main intention-to-treat analysis. Interventions Two hundred sixty-six milligrams of liposomal bupivacaine admixed with 100 mg of bupivacaine hydrochloride compared with 100 mg of bupivacaine hydrochloride alone (control) administered by periarticular injection at the time of surgery. Main Outcome and Measures The coprimary outcomes were Quality of Recovery 40 (QoR-40) score at 72 hours and pain visual analog scale (VAS) score area under the curve (AUC) from 6 to 72 hours. Secondary outcomes included QoR-40 and mean pain VAS at days 0 (evening of surgery), 1, 2, and 3; cumulative opioid consumption for 72 hours; functional outcomes and quality of life at 6 weeks, 6 months, and 1 year; and cost-effectiveness for 1 year. Adverse events and serious adverse events up to 12 months after randomization were also assessed. Results Among the 533 participants included in the analysis, the mean (SD) age was 69.0 (9.7) years; 287 patients were women (53.8%) and 246 were men (46.2%). Baseline characteristics were balanced between study groups. There was no difference between the liposomal bupivacaine and control groups in QoR-40 score at 72 hours (adjusted mean difference, 0.54 [97.5% CI, −2.05 to 3.13]; P = .64) or the pain VAS score AUC at 6 to 72 hours (−21.5 [97.5% CI, −46.8 to 3.8]; P = .06). Analyses of pain VAS and QoR-40 scores demonstrated only 1 statistically significant difference, with the liposomal bupivacaine arm having lower pain scores the evening of surgery (adjusted difference −0.54 [97.5% CI, −1.07 to −0.02]; P = .02). No difference in cumulative opioid consumption and functional outcomes was detected. Liposomal bupivacaine was not cost-effective compared with the control treatment. No difference in adverse or serious adverse events was found between the liposomal bupivacaine and control groups. Conclusions and Relevance This study found no difference in postoperative recovery or pain associated with the use of periarticular liposomal bupivacaine compared with bupivacaine hydrochloride alone in patients who underwent knee replacement surgery. Trial Registration isrctn.com Identifier: ISRCTN54191675
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Affiliation(s)
- Thomas W Hamilton
- Oxford Orthopaedic Engineering Centre, Nuffield Department of Orthopaedics Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
| | - Ruth Knight
- Oxford Clinical Trials Research Unit, Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
| | - Jamie R Stokes
- Oxford Clinical Trials Research Unit, Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
| | - Ines Rombach
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Cushla Cooper
- Surgical Interventional Trials Unit, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
| | - Loretta Davies
- Surgical Interventional Trials Unit, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
| | - Susan J Dutton
- Oxford Clinical Trials Research Unit, Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
| | - Karen L Barker
- National Institute for Health Research-Biomedical Research Unit, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom.,Physiotherapy Research Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals, NHS (National Health Service) Foundation Trust, Oxford, United Kingdom
| | - Jonathan Cook
- Oxford Clinical Trials Research Unit, Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
| | - Sarah E Lamb
- Oxford Clinical Trials Research Unit, Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
| | - David W Murray
- Oxford Orthopaedic Engineering Centre, Nuffield Department of Orthopaedics Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
| | - Lisa Poulton
- Surgical Interventional Trials Unit, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
| | - Ariel Wang
- Oxford Clinical Trials Research Unit, Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
| | - Louise H Strickland
- Oxford Orthopaedic Engineering Centre, Nuffield Department of Orthopaedics Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
| | - Bernard H Van Duren
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, Chapel Allerton Hospital, University of Leeds, Leeds, United Kingdom
| | - Jose Leal
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - David Beard
- Oxford Clinical Trials Research Unit, Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
| | - Hemant G Pandit
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, Chapel Allerton Hospital, University of Leeds, Leeds, United Kingdom
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Williamson E, Boniface G, Marian IR, Dutton SJ, Garrett A, Morris A, Hansen Z, Ward L, Nicolson PJA, Rogers D, Barker KL, Fairbank J, Fitch J, French DP, Comer C, Mallen CD, Lamb SE. The clinical effectiveness of a physiotherapy delivered physical and psychological group intervention for older adults with neurogenic claudication: the BOOST randomised controlled trial. J Gerontol A Biol Sci Med Sci 2022; 77:1654-1664. [PMID: 35279025 PMCID: PMC9373932 DOI: 10.1093/gerona/glac063] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Indexed: 11/30/2022] Open
Abstract
Background Neurogenic claudication (NC) is a debilitating spinal condition affecting older adults’ mobility and quality of life. Methods A randomized controlled trial of 438 participants evaluated the effectiveness of a physical and psychological group intervention (BOOST program) compared to physiotherapy assessment and tailored advice (best practice advice [BPA]) for older adults with NC. Participants were identified from spinal clinics (community and secondary care) and general practice records and randomized 2:1 to the BOOST program or BPA. The primary outcome was the Oswestry Disability Index (ODI) at 12 months. Data were also collected at 6 months. Other outcomes included ODI walking item, 6-minute walk test (6MWT), and falls. The primary analysis was intention-to-treat. Results The average age of participants was 74.9 years (standard deviation [SD] 6.0) and 57% (246/435) were female. There was no significant difference in ODI scores between treatment groups at 12 months (adjusted mean difference [MD]: −1.4 [95% confidence intervals (CI) −4.03, 1.17]), but, at 6 months, ODI scores favored the BOOST program (adjusted MD: −3.7 [95% CI −6.27, −1.06]). At 12 months, the BOOST program resulted in greater improvements in walking capacity (6MWT MD: 21.7m [95% CI 5.96, 37.38]) and ODI walking item (MD: −0.2 [95% CI −0.45, −0.01]) and reduced falls risk (odds ratio: 0.6 [95% CI 0.40, 0.98]) compared to BPA. No serious adverse events were related to either treatment. Conclusions The BOOST program substantially improved mobility for older adults with NC. Future iterations of the program will consider ways to improve long-term pain-related disability. Clinical Trials Registration Number: ISRCTN12698674
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Affiliation(s)
- Esther Williamson
- Nuffield Department of Rheumatology, Orthopaedics and Musculoskeletal Sciences, University of Oxford, UK.,College of Medicine and Health, University of Exeter
| | - Graham Boniface
- Nuffield Department of Rheumatology, Orthopaedics and Musculoskeletal Sciences, University of Oxford, UK
| | - Ioana R Marian
- Oxford Clinical Trials Research Unit, Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, UK
| | - Susan J Dutton
- Oxford Clinical Trials Research Unit, Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, UK
| | - Angela Garrett
- Nuffield Department of Rheumatology, Orthopaedics and Musculoskeletal Sciences, University of Oxford, UK
| | - Alana Morris
- Nuffield Department of Rheumatology, Orthopaedics and Musculoskeletal Sciences, University of Oxford, UK
| | - Zara Hansen
- Nuffield Department of Rheumatology, Orthopaedics and Musculoskeletal Sciences, University of Oxford, UK
| | - Lesley Ward
- Department of Sport, Exercise and Rehabilitation, Northumbria University, UK
| | - Philippa J A Nicolson
- Nuffield Department of Rheumatology, Orthopaedics and Musculoskeletal Sciences, University of Oxford, UK
| | - David Rogers
- Royal Orthopaedic Hospital NHS Foundation Trust, Birmingham, UK
| | - Karen L Barker
- Nuffield Department of Rheumatology, Orthopaedics and Musculoskeletal Sciences, University of Oxford, UK.,Oxford University Hospitals NHS Trust, Oxford, UK
| | - Jeremy Fairbank
- Nuffield Department of Rheumatology, Orthopaedics and Musculoskeletal Sciences, University of Oxford, UK
| | | | - David P French
- Manchester Centre for Health Psychology, University of Manchester, UK
| | - Christine Comer
- University of Leeds, Leeds, UK.,Leeds Community Healthcare NHS Trust, Otley, UK
| | - Christian D Mallen
- Primary Care Centre Versus Arthritis, School of Medicine, Keele University, Keele, UK
| | - Sarah E Lamb
- College of Medicine and Health, University of Exeter
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Keene DJ, Srikesavan C, Achten J, Tutton E, Dutton SJ, Marian IR, Grant R, Gould J, Herbert K, Athwal A, Appelbe D, Lamb SE, Costa ML. Flexibility and resistance exercises versus usual care for improving pain and function after distal radius fracture in adults aged 50 years or over: protocol for the WISE randomised multicentre feasibility trial. Pilot Feasibility Stud 2022; 8:55. [PMID: 35256000 PMCID: PMC8898994 DOI: 10.1186/s40814-022-01011-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 02/18/2022] [Indexed: 11/26/2022] Open
Abstract
Background Distal radius fractures represent about 1 in 5 of all fractures treated in UK hospitals. Most distal radius fractures occur in women aged 50 years or over after a fall. Distal radius fractures are managed using splints or casting, some are also treated with surgical fixation. Patients often experience long-term muscle weakness of the hand and arm that may impact their ability to do daily activities such as personal hygiene, routine household chores and food preparation. We propose a structured and tailored flexibility and resistance exercise programme for the hand and arm supplemented with behaviour change strategies to help perform daily exercise. The main aim of our study is to assess the feasibility of conducting a definitive randomised controlled trial. Methods This study is a multicentre, parallel-group individually randomised feasibility trial. We will recruit a minimum of 72 adults aged 50 years or over with distal radius fracture treated surgically or non-surgically from at least three UK National Health Service (NHS) hospitals. They will be randomised 1:1:1 to receive usual care, usual care and independent exercise with a single therapy session or usual care and supervised exercise with three therapy sessions over 12 weeks. Our primary feasibility objectives are (1) patient engagement assessed by recruitment, (2) acceptability of the interventions assessed by adherence and patient and clinician experience and (3) retention of participants in the trial. Outcome measures will be assessed at baseline, 3 months and at 6 months after randomisation. A qualitative sub-study will explore the experiences of the trial participants and therapists delivering the exercises. Discussion A definitive trial will be considered feasible without major modifications if our progression criteria are met. If successful, the findings will inform the design of a future definitive RCT to evaluate the clinical and cost-effectiveness of the WISE exercise programme. Trial registration ISRCTN12290145.
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Costa ML, Achten J, Ooms A, Png ME, Cook J, Dritsaki M, Lamb SE, Lerner R, Draper K, Campolier M, Dakin H, McGibbon A, Parsons N, Hedley H, Dias J. Moulded cast compared with K-wire fixation after manipulation of an acute dorsally displaced distal radius fracture: the DRAFFT 2 RCT. Health Technol Assess 2022; 26:1-80. [PMID: 35152940 DOI: 10.3310/rlcf6332] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Patients with a displaced fracture of the distal radius are frequently offered surgical fixation. Manipulation of the fracture and moulded plaster casting is an alternative treatment that avoids metal implants, but evidence of its effectiveness is lacking. OBJECTIVE To compare functional outcomes, quality-of-life outcomes, complications and resource use among patients with a dorsally displaced fracture of the distal radius treated with manipulation and surgical fixation with Kirschner wires (K-wires) and those treated with manipulation and moulded cast. DESIGN Pragmatic, superiority, multicentre, randomised controlled trial with a health economic evaluation. SETTING A total of 36 orthopaedic trauma centres in the UK NHS. PARTICIPANTS Patients (aged ≥ 16 years) treated for an acute dorsally displaced fracture of the distal radius were potentially eligible. Patients were excluded if their injury had occurred > 2 weeks previously, if the fracture was open, if it extended > 3 cm from the radiocarpal joint or if it required open reduction, or if the participant was unable to complete questionnaires. INTERVENTIONS Participants were randomly assigned in theatre (1 : 1) to receive a moulded cast (i.e. the cast group) or surgical fixation with K-wires (i.e. the K-wire group) after fracture manipulation. MAIN OUTCOME MEASURES The primary outcome measure was the Patient-Rated Wrist Evaluation score at 12 months, analysed on an intention-to-treat basis. Health-related quality of life was recorded using the EuroQol-5 Dimensions, five-level version, and resource use was recorded from a health and personal social care perspective. RESULTS Between January 2017 and March 2019, 500 participants (mean age 60 years, 83% women) were randomly allocated to receive a moulded cast (n = 255) or surgical fixation with K-wire (n = 245) following a manipulation of their fracture. A total of 395 (80%) participants were included in the primary analysis at 12 months. There was no difference in the Patient-Rated Wrist Evaluation score at 1 year post randomisation [cast group: n = 200, mean score 21.2 (standard deviation 23.1); K-wire group: n = 195, mean score 20.7 (standard deviation 22.3); adjusted mean difference -0.34 (95% confidence interval -4.33 to 3.66); p = 0.87]. A total of 33 (13%) participants in the cast group required surgical fixation for loss of fracture position in the first 6 weeks, compared with one participant in the K-wire group (odds ratio 0.02, 95% confidence interval 0.001 to 0.10). The base-case cost-effectiveness analysis showed that manipulation and surgical fixation with K-wires had a higher mean cost than manipulation and a moulded cast, despite similar mean effectiveness. The use of K-wires is unlikely to be cost-effective, and sensitivity analyses found this result to be robust. LIMITATIONS Because the interventions were identifiable, neither patients nor clinicians could be blind to their treatment. CONCLUSIONS Surgical fixation with K-wires was not found to be superior to moulded casting following manipulation of a dorsally displaced fracture of the distal radius, as measured by Patient-Rated Wrist Evaluation score. However, one in eight participants treated in a moulded cast required surgery for loss of fracture reduction in the first 6 weeks. After a successful closed reduction, clinicians may consider a moulded cast as a safe and cost-effective alternative to surgical fixation with K-wires. FUTURE WORK Further research should focus on optimal techniques for immobilisation and manipulation of this type of fracture, including optimal analgesia, and for rehabilitation of the patient after immobilisation. TRIAL REGISTRATION This trial is registered as ISRCTN11980540 and UKCRN Portfolio 208830. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 11. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Matthew L Costa
- Oxford Trauma and Emergency Care, Kadoorie Research Centre, Nuffield Department of Orthopaedic, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Juul Achten
- Oxford Trauma and Emergency Care, Kadoorie Research Centre, Nuffield Department of Orthopaedic, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Alexander Ooms
- Centre for Statistics in Medicine, Oxford Clinical Trials Research Unit, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - May Ee Png
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Jonathan Cook
- Centre for Statistics in Medicine, Oxford Clinical Trials Research Unit, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Melina Dritsaki
- Centre for Statistics in Medicine, Oxford Clinical Trials Research Unit, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Sarah E Lamb
- Oxford Trauma and Emergency Care, Kadoorie Research Centre, Nuffield Department of Orthopaedic, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK.,College of Medicine and Health, St Luke's Campus, University of Exeter, Exeter, UK
| | - Robin Lerner
- Oxford Trauma and Emergency Care, Kadoorie Research Centre, Nuffield Department of Orthopaedic, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK.,Blizard Institute, Queen Mary University of London, London, UK
| | - Kylea Draper
- Oxford Trauma and Emergency Care, Kadoorie Research Centre, Nuffield Department of Orthopaedic, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Marta Campolier
- Oxford Trauma and Emergency Care, Kadoorie Research Centre, Nuffield Department of Orthopaedic, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Helen Dakin
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Alwin McGibbon
- Patient and public involvement group member, Wimbourne, UK
| | - Nicholas Parsons
- Statistics and Epidemiology Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | - Helen Hedley
- Department of Orthopaedics, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Joseph Dias
- AToMS Academic Team of Musculoskeletal Surgery, University Hospitals of Leicester NHS Trust, Leicester, UK
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Rapp K, Lamb SE, Roigk P, Becker C, Konnopka C, König HH, Peter RS, Rothenbacher D, Büchele G. Effect of an osteoporotic fracture prevention program on fracture incidence in routine care: a cluster-randomized trial. BMC Med 2022; 20:49. [PMID: 35114993 PMCID: PMC8815238 DOI: 10.1186/s12916-021-02226-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Accepted: 12/29/2021] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Fractures are a major health problem in aging societies. Preventive approaches combining bone health and fall prevention are rare. The osteoporotic fracture prevention program in rural areas (OFRA) is a health care fund-driven program for older people in randomly selected districts in Germany. The components of the program were falls prevention exercise classes, examination of bone health by a dual-energy X-ray absorptiometry (DXA) scan, and a consultation about "safety in the living environment." The aim of this study was to evaluate this complex preventive intervention in a routine health care setting. METHODS This cluster-randomized trial was performed from October 2015 to October 2018 and took place in 186 administrative districts in five federal states, 47 districts served as intervention districts, and 139, as controls. Within these districts, we included (a) all community-living women and men aged 70-85 years with prior fragility fractures and (b) all community-living women aged 75-80 years. The analysis used routine data collected by a health insurance company. The primary endpoint was all fragility fractures combined. Fracture types, mortality, and nursing home admission were explorative endpoints. Cox frailty models were used for comparative analyses with a median follow-up time of 365 days (interquartile range: 0 days). RESULTS Nine thousand four hundred eight individuals were approached to participate in one of the program components, 27,318 individuals served as controls. The mean age was 78.7 years. Of those approached to participate, nearly 30% joined the exercise classes. DXA measurement was reimbursed for 13.6%, and 51.8% received advice about measures to increase "safety in the living environment." The incidence of fragility fractures did not differ between the intervention and the control group (HR 0.94; 95% CI 0.80-1.11). However, femoral fractures, the most frequent fracture type, were reduced in the intervention group (HR 0.76; 95% CI 0.59-0.99). Mortality and nursing home admission did not differ between the intervention and the control group. CONCLUSIONS A comprehensive fracture prevention program for older people living in rural areas was implemented. The program did not affect the primary endpoint of all fragility fractures combined. It has to be considered that we used a modified intention to treat approach based on geographic randomization and information about endpoints relied exclusively on routine data of the health care insurance. TRIAL REGISTRATION German Clinical Trials Register DRKS-ID: 00009000.
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Affiliation(s)
- Kilian Rapp
- Department of Clinical Gerontology, Robert-Bosch-Hospital, Auerbachstr. 110, 70376, Stuttgart, Germany
| | - Sarah E Lamb
- College of Medicine and Health, St Lukes Campus, University of Exeter, Exeter, EX12LU, UK
| | - Patrick Roigk
- Department of Clinical Gerontology, Robert-Bosch-Hospital, Auerbachstr. 110, 70376, Stuttgart, Germany
| | - Clemens Becker
- Department of Clinical Gerontology, Robert-Bosch-Hospital, Auerbachstr. 110, 70376, Stuttgart, Germany
| | - Claudia Konnopka
- Department of Health Economics and Health Services Research, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Hans-Helmut König
- Department of Health Economics and Health Services Research, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Raphael S Peter
- Institute of Epidemiology and Medical Biometry, Ulm University, Helmholtzstr. 22, 89081, Ulm, Germany
| | - Dietrich Rothenbacher
- Institute of Epidemiology and Medical Biometry, Ulm University, Helmholtzstr. 22, 89081, Ulm, Germany
| | - Gisela Büchele
- Institute of Epidemiology and Medical Biometry, Ulm University, Helmholtzstr. 22, 89081, Ulm, Germany.
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Bruce J, Mazuquin B, Mistry P, Rees S, Canaway A, Hossain A, Williamson E, Padfield EJ, Lall R, Richmond H, Chowdhury L, Lait C, Petrou S, Booth K, Lamb SE, Vidya R, Thompson AM. Exercise to prevent shoulder problems after breast cancer surgery: the PROSPER RCT. Health Technol Assess 2022; 26:1-124. [PMID: 35220995 DOI: 10.3310/jknz2003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Upper limb problems are common after breast cancer treatment. OBJECTIVES To investigate the clinical effectiveness and cost-effectiveness of a structured exercise programme compared with usual care on upper limb function, health-related outcomes and costs in women undergoing breast cancer surgery. DESIGN This was a two-arm, pragmatic, randomised controlled trial with embedded qualitative research, process evaluation and parallel economic analysis; the unit of randomisation was the individual (allocated ratio 1 : 1). SETTING Breast cancer centres, secondary care. PARTICIPANTS Women aged ≥ 18 years who had been diagnosed with breast cancer and were at higher risk of developing shoulder problems. Women were screened to identify their risk status. INTERVENTIONS All participants received usual-care information leaflets. Those randomised to exercise were referred to physiotherapy for an early, structured exercise programme (three to six face-to-face appointments that included strengthening, physical activity and behavioural change strategies). MAIN OUTCOME MEASURES The primary outcome was upper limb function at 12 months as assessed using the Disabilities of Arm, Hand and Shoulder questionnaire. Secondary outcomes were function (Disabilities of Arm, Hand and Shoulder questionnaire subscales), pain, complications (e.g. wound-related complications, lymphoedema), health-related quality of life (e.g. EuroQol-5 Dimensions, five-level version; Short Form questionnaire-12 items), physical activity and health service resource use. The economic evaluation was expressed in terms of incremental cost per quality-adjusted life-year and incremental net monetary benefit gained from an NHS and Personal Social Services perspective. Participants and physiotherapists were not blinded to group assignment, but data collectors were blinded. RESULTS Between 2016 and 2017, we randomised 392 participants from 17 breast cancer centres across England: 196 (50%) to the usual-care group and 196 (50%) to the exercise group. Ten participants (10/392; 3%) were withdrawn at randomisation and 32 (8%) did not provide complete baseline data. A total of 175 participants (89%) from each treatment group provided baseline data. Participants' mean age was 58.1 years (standard deviation 12.1 years; range 28-88 years). Most participants had undergone axillary node clearance surgery (327/392; 83%) and 317 (81%) had received radiotherapy. Uptake of the exercise treatment was high, with 181 out of 196 (92%) participants attending at least one physiotherapy appointment. Compliance with exercise was good: 143 out of 196 (73%) participants completed three or more physiotherapy sessions. At 12 months, 274 out of 392 (70%) participants returned questionnaires. Improvement in arm function was greater in the exercise group [mean Disabilities of Arm, Hand and Shoulder questionnaire score of 16.3 (standard deviation 17.6)] than in the usual-care group [mean Disabilities of Arm, Hand and Shoulder questionnaire score of 23.7 (standard deviation 22.9)] at 12 months for intention-to-treat (adjusted mean difference Disabilities of Arm, Hand and Shoulder questionnaire score of -7.81, 95% confidence interval -12.44 to -3.17; p = 0.001) and complier-average causal effect analyses (adjusted mean difference -8.74, 95% confidence interval -13.71 to -3.77; p ≤ 0.001). At 12 months, pain scores were lower and physical health-related quality of life was higher in the exercise group than in the usual-care group (Short Form questionnaire-12 items, mean difference 4.39, 95% confidence interval 1.74 to 7.04; p = 0.001). We found no differences in the rate of adverse events or lymphoedema over 12 months. The qualitative findings suggested that women found the exercise programme beneficial and enjoyable. Exercise accrued lower costs (-£387, 95% CI -£2491 to £1718) and generated more quality-adjusted life years (0.029, 95% CI 0.001 to 0.056) than usual care over 12 months. The cost-effectiveness analysis indicated that exercise was more cost-effective and that the results were robust to sensitivity analyses. Exercise was relatively cheap to implement (£129 per participant) and associated with lower health-care costs than usual care and improved health-related quality of life. Benefits may accrue beyond the end of the trial. LIMITATIONS Postal follow-up was lower than estimated; however, the study was adequately powered. No serious adverse events directly related to the intervention were reported. CONCLUSIONS This trial provided robust evidence that referral for early, supported exercise after breast cancer surgery improved shoulder function in those at risk of shoulder problems and was associated with lower health-care costs than usual care and improved health-related quality of life. FUTURE WORK Future work should focus on the implementation of exercise programmes in clinical practice for those at highest risk of shoulder problems. TRIAL REGISTRATION This trial is registered as ISRCTN35358984. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 15. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Julie Bruce
- Warwick Clinical Trials Unit, Division of Health Sciences, University of Warwick, Coventry, UK
| | - Bruno Mazuquin
- Warwick Clinical Trials Unit, Division of Health Sciences, University of Warwick, Coventry, UK
| | - Pankaj Mistry
- Warwick Clinical Trials Unit, Division of Health Sciences, University of Warwick, Coventry, UK
| | - Sophie Rees
- Warwick Clinical Trials Unit, Division of Health Sciences, University of Warwick, Coventry, UK
| | - Alastair Canaway
- Warwick Clinical Trials Unit, Division of Health Sciences, University of Warwick, Coventry, UK
| | - Anower Hossain
- Warwick Clinical Trials Unit, Division of Health Sciences, University of Warwick, Coventry, UK
- Institute of Statistical Research and Training (ISRT), University of Dhaka, Dhaka, Bangladesh
| | - Esther Williamson
- Centre for Rehabilitation Research, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- College of Medicine and Health, University of Exeter, Exeter, UK
| | - Emma J Padfield
- Warwick Clinical Trials Unit, Division of Health Sciences, University of Warwick, Coventry, UK
| | - Ranjit Lall
- Warwick Clinical Trials Unit, Division of Health Sciences, University of Warwick, Coventry, UK
| | - Helen Richmond
- Primary Healthcare Research Unit, Faculty of Medicine, Memorial University of Newfoundland, St John's, NL, Canada
| | - Loraine Chowdhury
- Warwick Clinical Trials Unit, Division of Health Sciences, University of Warwick, Coventry, UK
| | - Clare Lait
- Gloucestershire Care Services NHS Trust, Gloucester, UK
| | - Stavros Petrou
- Warwick Clinical Trials Unit, Division of Health Sciences, University of Warwick, Coventry, UK
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Katie Booth
- Warwick Clinical Trials Unit, Division of Health Sciences, University of Warwick, Coventry, UK
| | - Sarah E Lamb
- College of Medicine and Health, University of Exeter, Exeter, UK
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Costa ML, Achten J, Ooms A, Png ME, Cook JA, Lamb SE, Hedley H, Dias J. Surgical fixation with K-wires versus casting in adults with fracture of distal radius: DRAFFT2 multicentre randomised clinical trial. BMJ 2022; 376:e068041. [PMID: 35045969 PMCID: PMC8767805 DOI: 10.1136/bmj-2021-068041] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To assess wrist function, quality of life, and complications in adult patients with a dorsally displaced fracture of the distal radius, treated with either a moulded cast or surgical fixation with K-wires. DESIGN Multicentre randomised clinical superiority trial, SETTING: 36 hospitals in the UK National Health Service (NHS). PARTICIPANTS 500 adults aged 16 or over with a dorsally displaced fracture of the distal radius, randomised after manipulation of their fracture (255 to moulded cast; 245 to surgical fixation). INTERVENTIONS Manipulation and moulded cast was compared with manipulation and surgical fixation with K-wires plus cast. Details of the application of the cast and the insertion of the K-wires were at the discretion of the treating surgeon, according to their normal clinical practice. MAIN OUTCOME MEASURES The primary outcome measure was the Patient Rated Wrist Evaluation (PRWE) score at 12 months (five questions about pain and 10 about function and disability; overall score out of 100 (best score=0 and worst score=100)). Secondary outcomes were PRWE score at three and six months, quality of life, and complications, including the need for surgery due to loss of fracture position in the first six weeks. RESULTS The mean age of participants was 60 years and 417 (83%) were women; 395 (79%) completed follow-up. No statistically significant difference in the PRWE score was seen at 12 months (cast group (n=200), mean 21.2 (SD 23.1); K-wire group (n=195), mean 20.7 (22.3); adjusted mean difference -0.34 (95% confidence interval -4.33 to 3.66), P=0.87). No difference was seen at earlier time points. In the cast group, 33 (13%) of participants needed surgical fixation for loss of fracture position in the first six weeks compared with one revision surgery in the K-wire group (odds ratio 0.02, 95% confidence interval 0.001 to 0.10). CONCLUSIONS Among patients with a dorsally displaced distal radius fracture that needed manipulation, surgical fixation with K-wires did not improve patients' wrist function at 12 months compared with a cast. TRIAL REGISTRATION ISRCTN registry ISRCTN11980540.
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Affiliation(s)
- Matthew L Costa
- Oxford Trauma and Emergency Care, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Trauma Unit, Kadoorie Centre, John Radcliffe Hospital, Oxford, UK
| | - Juul Achten
- Oxford Trauma and Emergency Care, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Trauma Unit, Kadoorie Centre, John Radcliffe Hospital, Oxford, UK
| | - Alexander Ooms
- Oxford Clinical Trials Research Unit, Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Botnar Research Centre, Oxford, UK
| | - May Ee Png
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Primary Care Building, Oxford, UK
| | - Jonathan A Cook
- Oxford Clinical Trials Research Unit, Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Botnar Research Centre, Oxford, UK
| | - Sarah E Lamb
- College of Medicine and Health, South Cloisters, University of Exeter, Exeter, UK
| | - Helen Hedley
- Department of Trauma and Orthopaedics, University Hospital Coventry and Warwickshire NHS Trust, University Hospital Coventry and Warwickshire, Coventry, UK
| | - Joseph Dias
- Department of Health Sciences, University of Leicester, George Davies Centre, Leicester, UK
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Prats-Uribe A, Kolovos S, Berencsi K, Carr A, Judge A, Silman A, Arden N, Petersen I, Douglas IJ, Wilkinson JM, Murray D, Valderas JM, Beard DJ, Lamb SE, Ali MS, Pinedo-Villanueva R, Strauss VY, Prieto-Alhambra D. Unicompartmental compared with total knee replacement for patients with multimorbidities: a cohort study using propensity score stratification and inverse probability weighting. Health Technol Assess 2021; 25:1-126. [PMID: 34812138 DOI: 10.3310/hta25660] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Although routine NHS data potentially include all patients, confounding limits their use for causal inference. Methods to minimise confounding in observational studies of implantable devices are required to enable the evaluation of patients with severe systemic morbidity who are excluded from many randomised controlled trials. OBJECTIVES Stage 1 - replicate the Total or Partial Knee Arthroplasty Trial (TOPKAT), a surgical randomised controlled trial comparing unicompartmental knee replacement with total knee replacement using propensity score and instrumental variable methods. Stage 2 - compare the risk benefits and cost-effectiveness of unicompartmental knee replacement with total knee replacement surgery in patients with severe systemic morbidity who would have been ineligible for TOPKAT using the validated methods from stage 1. DESIGN This was a cohort study. SETTING Data were obtained from the National Joint Registry database and linked to hospital inpatient (Hospital Episode Statistics) and patient-reported outcome data. PARTICIPANTS Stage 1 - people undergoing unicompartmental knee replacement surgery or total knee replacement surgery who met the TOPKAT eligibility criteria. Stage 2 - participants with an American Society of Anesthesiologists grade of ≥ 3. INTERVENTION The patients were exposed to either unicompartmental knee replacement surgery or total knee replacement surgery. MAIN OUTCOME MEASURES The primary outcome measure was the postoperative Oxford Knee Score. The secondary outcome measures were 90-day postoperative complications (venous thromboembolism, myocardial infarction and prosthetic joint infection) and 5-year revision risk and mortality. The main outcome measures for the health economic analysis were health-related quality of life (EuroQol-5 Dimensions) and NHS hospital costs. RESULTS In stage 1, propensity score stratification and inverse probability weighting replicated the results of TOPKAT. Propensity score adjustment, propensity score matching and instrumental variables did not. Stage 2 included 2256 unicompartmental knee replacement patients and 57,682 total knee replacement patients who had severe comorbidities, of whom 145 and 23,344 had linked Oxford Knee Scores, respectively. A statistically significant but clinically irrelevant difference favouring unicompartmental knee replacement was observed, with a mean postoperative Oxford Knee Score difference of < 2 points using propensity score stratification; no significant difference was observed using inverse probability weighting. Unicompartmental knee replacement more than halved the risk of venous thromboembolism [relative risk 0.33 (95% confidence interval 0.15 to 0.74) using propensity score stratification; relative risk 0.39 (95% confidence interval 0.16 to 0.96) using inverse probability weighting]. Unicompartmental knee replacement was not associated with myocardial infarction or prosthetic joint infection using either method. In the long term, unicompartmental knee replacement had double the revision risk of total knee replacement [hazard ratio 2.70 (95% confidence interval 2.15 to 3.38) using propensity score stratification; hazard ratio 2.60 (95% confidence interval 1.94 to 3.47) using inverse probability weighting], but half of the mortality [hazard ratio 0.52 (95% confidence interval 0.36 to 0.74) using propensity score stratification; insignificant effect using inverse probability weighting]. Unicompartmental knee replacement had lower costs and higher quality-adjusted life-year gains than total knee replacement for stage 2 participants. LIMITATIONS Although some propensity score methods successfully replicated TOPKAT, unresolved confounding may have affected stage 2. Missing Oxford Knee Scores may have led to information bias. CONCLUSIONS Propensity score stratification and inverse probability weighting successfully replicated TOPKAT, implying that some (but not all) propensity score methods can be used to evaluate surgical innovations and implantable medical devices using routine NHS data. Unicompartmental knee replacement was safer and more cost-effective than total knee replacement for patients with severe comorbidity and should be considered the first option for suitable patients. FUTURE WORK Further research is required to understand the performance of propensity score methods for evaluating surgical innovations and implantable devices. TRIAL REGISTRATION This trial is registered as EUPAS17435. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 66. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Albert Prats-Uribe
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, Nuffield Orthopaedic Centre, University of Oxford, Oxford, UK
| | - Spyros Kolovos
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, Nuffield Orthopaedic Centre, University of Oxford, Oxford, UK
| | - Klara Berencsi
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, Nuffield Orthopaedic Centre, University of Oxford, Oxford, UK
| | - Andrew Carr
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, Nuffield Orthopaedic Centre, University of Oxford, Oxford, UK
| | - Andrew Judge
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, Nuffield Orthopaedic Centre, University of Oxford, Oxford, UK.,Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Southmead Hospital, Bristol, UK
| | - Alan Silman
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, Nuffield Orthopaedic Centre, University of Oxford, Oxford, UK
| | - Nigel Arden
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, Nuffield Orthopaedic Centre, University of Oxford, Oxford, UK.,Centre for Sport, Exercise and Osteoarthritis Research Versus Arthritis, Botnar Research Centre, Nuffield Orthopaedic Centre, University of Oxford, Oxford, UK.,Medical Research Council Lifecourse Epidemiological Unit, University of Southampton, Southampton, UK
| | - Irene Petersen
- Department of Primary Care and Population Health, University College London, London, UK
| | - Ian J Douglas
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - J Mark Wilkinson
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK.,Research Committee, National Joint Registry for England, Wales, Northern Ireland and the Isle of Man, Hemel Hempstead, UK
| | - David Murray
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, Nuffield Orthopaedic Centre, University of Oxford, Oxford, UK
| | - Jose M Valderas
- College of Medicine and Health, University of Exeter, Exeter, UK
| | - David J Beard
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, Nuffield Orthopaedic Centre, University of Oxford, Oxford, UK
| | - Sarah E Lamb
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, Nuffield Orthopaedic Centre, University of Oxford, Oxford, UK.,University of Exeter Medical School, Institute of Health Research, College of Medicine and Health, Exeter, UK
| | - M Sanni Ali
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, Nuffield Orthopaedic Centre, University of Oxford, Oxford, UK.,Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Rafael Pinedo-Villanueva
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, Nuffield Orthopaedic Centre, University of Oxford, Oxford, UK
| | - Victoria Y Strauss
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, Nuffield Orthopaedic Centre, University of Oxford, Oxford, UK
| | - Daniel Prieto-Alhambra
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, Nuffield Orthopaedic Centre, University of Oxford, Oxford, UK
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Smith T, Clark L, Khoury R, Man MS, Hanson S, Welsh A, Clark A, Hopewell S, Pfeiffer K, Logan P, Crotty M, Costa M, Lamb SE. A feasibility study to assess the design of a multicentre randomized controlled trial of the clinical and cost-effectiveness of a caregiving intervention for people following hip fracture surgery. Bone Jt Open 2021; 2:909-920. [PMID: 34753296 PMCID: PMC8636304 DOI: 10.1302/2633-1462.211.bjo-2021-0136] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Aims This study aims to assess the feasibility of conducting a pragmatic, multicentre randomized controlled trial (RCT) to test the clinical and cost-effectiveness of an informal caregiver training programme to support the recovery of people following hip fracture surgery. Methods This will be a mixed-methods feasibility RCT, recruiting 60 patients following hip fracture surgery and their informal caregivers. Patients will be randomized to usual NHS care, versus usual NHS care plus a caregiver-patient dyad training programme (HIP HELPER). This programme will comprise of three, one-hour, one-to-one training sessions for the patient and caregiver, delivered by a nurse, physiotherapist, or occupational therapist. Training will be delivered in the hospital setting pre-patient discharge. It will include practical skills for rehabilitation such as: transfers and walking; recovery goal setting and expectations; pacing and stress management techniques; and introduction to the HIP HELPER Caregiver Workbook, which provides information on recovery, exercises, worksheets, and goal-setting plans to facilitate a ‘good’ recovery. After discharge, patients and caregivers will be supported in delivering rehabilitation through three telephone coaching sessions. Data, collected at baseline and four months post-randomization, will include: screening logs, intervention logs, fidelity checklists, quality assurance monitoring visit data, and clinical outcomes assessing quality of life, physical, emotional, adverse events, and resource use outcomes. The acceptability of the study intervention and RCT design will be explored through qualitative methods with 20 participants (patients and informal caregivers) and 12 health professionals. Discussion A multicentre recruitment approach will provide greater external validity across population characteristics in England. The mixed-methods approach will permit in-depth examination of the intervention and trial design parameters. The findings will inform whether and how a definitive trial may be undertaken to test the effectiveness of this caregiver intervention for patients after hip fracture surgery. Cite this article: Bone Jt Open 2021;2(11):909–920.
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Affiliation(s)
- Toby Smith
- Faculty of Medicine and Health Sciences, University of East Anglia, Norwich, UK.,Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Lucy Clark
- Faculty of Medicine and Health Sciences, University of East Anglia, Norwich, UK
| | - Reema Khoury
- Faculty of Medicine and Health Sciences, University of East Anglia, Norwich, UK
| | - Mei-See Man
- Faculty of Medicine and Health Sciences, University of East Anglia, Norwich, UK
| | - Sarah Hanson
- Faculty of Medicine and Health Sciences, University of East Anglia, Norwich, UK
| | - Allie Welsh
- Faculty of Medicine and Health Sciences, University of East Anglia, Norwich, UK
| | - Allan Clark
- Faculty of Medicine and Health Sciences, University of East Anglia, Norwich, UK
| | - Sally Hopewell
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Klaus Pfeiffer
- Department of Geriatric Rehabilitation, Robert-Bosch-Krankenhaus GmbH, Stuttgart, Germany
| | - Pip Logan
- School of Medicine, University of Nottingham, Nottingham, UK
| | - Maria Crotty
- College of Medicine and Public Health, Flinders University, Adelaide, Australia.,Flinders University, Adelaide, Australia
| | - Matthew Costa
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK.,University of Oxford, Oxford, UK
| | - Sarah E Lamb
- College of Medicine and Health, University of Exeter, Exeter, UK.,University of Exeter, Exeter, UK
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Bruce J, Mazuquin B, Canaway A, Hossain A, Williamson E, Mistry P, Lall R, Petrou S, Lamb SE, Rees S, Padfield E, Vidya R, Thompson AM. Exercise versus usual care after non-reconstructive breast cancer surgery (UK PROSPER): multicentre randomised controlled trial and economic evaluation. BMJ 2021; 375:e066542. [PMID: 34759002 PMCID: PMC8579424 DOI: 10.1136/bmj-2021-066542] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/22/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To evaluate whether a structured exercise programme improved functional and health related quality of life outcomes compared with usual care for women at high risk of upper limb disability after breast cancer surgery. DESIGN Multicentre, pragmatic, superiority, randomised controlled trial with economic evaluation. SETTING 17 UK National Health Service cancer centres. PARTICIPANTS 392 women undergoing breast cancer surgery, at risk of postoperative upper limb morbidity, randomised (1:1) to usual care with structured exercise (n=196) or usual care alone (n=196). INTERVENTIONS Usual care (information leaflets) only or usual care plus a physiotherapy led exercise programme, incorporating stretching, strengthening, physical activity, and behavioural change techniques to support adherence to exercise, introduced at 7-10 days postoperatively, with two further appointments at one and three months. MAIN OUTCOME MEASURES Disability of Arm, Hand and Shoulder (DASH) questionnaire at 12 months, analysed by intention to treat. Secondary outcomes included DASH subscales, pain, complications, health related quality of life, and resource use, from a health and personal social services perspective. RESULTS Between 26 January 2016 and 31 July 2017, 951 patients were screened and 392 (mean age 58.1 years) were randomly allocated, with 382 (97%) eligible for intention to treat analysis. 181 (95%) of 191 participants allocated to exercise attended at least one appointment. Upper limb function improved after exercise compared with usual care (mean DASH 16.3 (SD 17.6) for exercise (n=132); 23.7 (22.9) usual care (n=138); adjusted mean difference 7.81, 95% confidence interval 3.17 to 12.44; P=0.001). Secondary outcomes favoured exercise over usual care, with lower pain intensity at 12 months (adjusted mean difference on numerical rating scale -0.68, -1.23 to -0.12; P=0.02) and fewer arm disability symptoms at 12 months (adjusted mean difference on Functional Assessment of Cancer Therapy-Breast+4 (FACT-B+4) -2.02, -3.11 to -0.93; P=0.001). No increase in complications, lymphoedema, or adverse events was noted in participants allocated to exercise. Exercise accrued lower costs per patient (on average -£387 (€457; $533) (95% confidence interval -£2491 to £1718; 2015 pricing) and was cost effective compared with usual care. CONCLUSIONS The PROSPER exercise programme was clinically effective and cost effective and reduced upper limb disability one year after breast cancer treatment in patients at risk of treatment related postoperative complications. TRIAL REGISTRATION ISRCTN Registry ISRCTN35358984.
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Affiliation(s)
- Julie Bruce
- Warwick Clinical Trials Unit, Division of Health Sciences, University of Warwick, Coventry, UK
| | - Bruno Mazuquin
- Faculty of Health, Psychology and Social Care, Manchester Metropolitan University, Manchester, UK
| | - Alastair Canaway
- Warwick Clinical Trials Unit, Division of Health Sciences, University of Warwick, Coventry, UK
| | - Anower Hossain
- Institute of Statistical Research and Training (ISRT), University of Dhaka, Dhaka, Bangladesh
| | - Esther Williamson
- Nuffield Department of Orthopaedics Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Pankaj Mistry
- Warwick Clinical Trials Unit, Division of Health Sciences, University of Warwick, Coventry, UK
| | - Ranjit Lall
- Warwick Clinical Trials Unit, Division of Health Sciences, University of Warwick, Coventry, UK
| | - Stavros Petrou
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Sarah E Lamb
- Institute of Health Research, University of Exeter, Exeter, UK
| | - Sophie Rees
- Warwick Clinical Trials Unit, Division of Health Sciences, University of Warwick, Coventry, UK
| | - Emma Padfield
- Warwick Clinical Trials Unit, Division of Health Sciences, University of Warwick, Coventry, UK
| | | | - Alastair M Thompson
- Department of Surgery, Dan L Duncan Comprehensive Cancer Center, Baylor College of Medicine, Houston, TX 77030, USA
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Lee H, Lamb SE. Research Note: Transporting causal effects from randomised trials to target populations to improve external validity. J Physiother 2021; 67:315-318. [PMID: 34538588 DOI: 10.1016/j.jphys.2021.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Accepted: 08/17/2021] [Indexed: 11/29/2022] Open
Affiliation(s)
- Hopin Lee
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford, UK; School of Medicine and Public Health, University of Newcastle, Newcastle, Australia.
| | - Sarah E Lamb
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford, UK; College of Medicine and Health, University of Exeter Medical School, Exeter, UK
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Rex SS, Kottam L, McDaid C, Brealey S, Dias J, Hewitt CE, Keding A, Lamb SE, Wright K, Rangan A. Effectiveness of interventions for the management of primary frozen shoulder : a systematic review of randomized trials. Bone Jt Open 2021; 2:773-784. [PMID: 34555926 PMCID: PMC8479840 DOI: 10.1302/2633-1462.29.bjo-2021-0060.r1] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
AIMS This systematic review places a recently completed multicentre randomized controlled trial (RCT), UK FROST, in the context of existing randomized evidence for the management of primary frozen shoulder. UK FROST compared the effectiveness of pre-specified physiotherapy techniques with a steroid injection (PTSI), manipulation under anaesthesia (MUA) with a steroid injection, and arthroscopic capsular release (ACR). This review updates a 2012 review focusing on the effectiveness of MUA, ACR, hydrodilatation, and PTSI. METHODS MEDLINE, Embase, PEDro, Science Citation Index, Clinicaltrials.gov, CENTRAL, and the World Health Organization (WHO) International Clinical Trials Registry were searched up to December 2018. Reference lists of included studies were screened. No language restrictions applied. Eligible studies were RCTs comparing the effectiveness of MUA, ACR, PTSI, and hydrodilatation against each other, or supportive care or no treatment, for the management of primary frozen shoulder. RESULTS Nine RCTs were included. The primary outcome of patient-reported shoulder function at long-term follow-up (> 6 months and ≤ 12 months) was reported for five treatment comparisons across four studies. Standardized mean differences (SMD) were: ACR versus MUA: 0.21 (95% confidence interval (CI) 0.00 to 0.42), ACR versus supportive care: -0.13 (95% CI -1.10 to 0.83), and ACR versus PTSI: 0.33 (95% CI 0.07 to 0.59) and 0.25 (95% CI -0.34 to 0.85), all favouring ACR; MUA versus supportive care: 0 (95% CI -0.44 to 0.44) not favouring either; and MUA versus PTSI: 0.12 (95% CI -0.14 to 0.37) favouring MUA. None of these differences met the threshold of clinical significance agreed for the UK FROST and most confidence intervals included zero. CONCLUSION The findings from a recent multicentre RCT provided the strongest evidence that, when compared with each other, neither PTSI, MUA, nor ACR are clinically superior. Evidence from smaller RCTs did not change this conclusion. The effectiveness of hydrodilatation based on four RCTs was inconclusive and there remains an evidence gap. Cite this article: Bone Jt Open 2021;2(9):773-784.
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Affiliation(s)
- Saleema S Rex
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - Lucksy Kottam
- Department of Trauma & Orthopaedic Surgery, The James Cook University Hospital, Middlesbrough, UK
| | - Catriona McDaid
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - Stephen Brealey
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - Joseph Dias
- Leicester General Hospital, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Catherine E Hewitt
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - Ada Keding
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - Sarah E Lamb
- College of Medicine and Health, University of Exeter, Exeter, UK
| | - Kath Wright
- Centre for Reviews and Dissemination, University of York, York, UK
| | - Amar Rangan
- York Trials Unit, Department of Health Sciences, University of York, York, UK.,Department of Trauma & Orthopaedic Surgery, The James Cook University Hospital, Middlesbrough, UK.,Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
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49
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Lee H, Cashin AG, Lamb SE, Hopewell S, Vansteelandt S, VanderWeele TJ, MacKinnon DP, Mansell G, Collins GS, Golub RM, McAuley JH, Localio AR, van Amelsvoort L, Guallar E, Rijnhart J, Goldsmith K, Fairchild AJ, Lewis CC, Kamper SJ, Williams CM, Henschke N. A Guideline for Reporting Mediation Analyses of Randomized Trials and Observational Studies: The AGReMA Statement. JAMA 2021; 326:1045-1056. [PMID: 34546296 PMCID: PMC8974292 DOI: 10.1001/jama.2021.14075] [Citation(s) in RCA: 148] [Impact Index Per Article: 49.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Importance Mediation analyses of randomized trials and observational studies can generate evidence about the mechanisms by which interventions and exposures may influence health outcomes. Publications of mediation analyses are increasing, but the quality of their reporting is suboptimal. Objective To develop international, consensus-based guidance for the reporting of mediation analyses of randomized trials and observational studies (A Guideline for Reporting Mediation Analyses; AGReMA). Design, Setting, and Participants The AGReMA statement was developed using the Enhancing Quality and Transparency of Health Research (EQUATOR) methodological framework for developing reporting guidelines. The guideline development process included (1) an overview of systematic reviews to assess the need for a reporting guideline; (2) review of systematic reviews of relevant evidence on reporting mediation analyses; (3) conducting a Delphi survey with panel members that included methodologists, statisticians, clinical trialists, epidemiologists, psychologists, applied clinical researchers, clinicians, implementation scientists, evidence synthesis experts, representatives from the EQUATOR Network, and journal editors (n = 19; June-November 2019); (4) having a consensus meeting (n = 15; April 28-29, 2020); and (5) conducting a 4-week external review and pilot test that included methodologists and potential users of AGReMA (n = 21; November 2020). Results A previously reported overview of 54 systematic reviews of mediation studies demonstrated the need for a reporting guideline. Thirty-three potential reporting items were identified from 3 systematic reviews of mediation studies. Over 3 rounds, the Delphi panelists ranked the importance of these items, provided 60 qualitative comments for item refinement and prioritization, and suggested new items for consideration. All items were reviewed during a 2-day consensus meeting and participants agreed on a 25-item AGReMA statement for studies in which mediation analyses are the primary focus and a 9-item short-form AGReMA statement for studies in which mediation analyses are a secondary focus. These checklists were externally reviewed and pilot tested by 21 expert methodologists and potential users, which led to minor adjustments and consolidation of the checklists. Conclusions and Relevance The AGReMA statement provides recommendations for reporting primary and secondary mediation analyses of randomized trials and observational studies. Improved reporting of studies that use mediation analyses could facilitate peer review and help produce publications that are complete, accurate, transparent, and reproducible.
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Affiliation(s)
- Hopin Lee
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, England
- School of Medicine and Public Health, University of Newcastle, Callaghan, Australia
| | - Aidan G Cashin
- Prince of Wales Clinical School, Faculty of Medicine, University of New South Wales, Sydney, Australia
- Neuroscience Research Australia, Sydney
| | - Sarah E Lamb
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, England
- College of Medicine and Health, University of Exeter Medical School, Exeter, England
| | - Sally Hopewell
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, England
| | - Stijn Vansteelandt
- Department of Applied Mathematics, Computer Science, and Statistics, Ghent University, Ghent, Belgium
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, England
| | - Tyler J VanderWeele
- Departments of Epidemiology and Biostatistics, T. H. Chan School of Public Health, Harvard University, Boston, Massachusetts
| | | | - Gemma Mansell
- College of Health and Life Sciences, Aston University, Birmingham, England
| | - Gary S Collins
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, England
- NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, England
| | - Robert M Golub
- JAMA Editorial Office, Chicago, Illinois
- Division of General Internal Medicine and Geriatrics, Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - James H McAuley
- Neuroscience Research Australia, Sydney
- School of Health Sciences, Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - A Russell Localio
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Associate Editor, Annals of Internal Medicine
| | - Ludo van Amelsvoort
- Faculty of Health, Medicine, and Life Sciences, Maastricht University, Maastricht, the Netherlands
- Assoicate Editor, Journal of Clinical Epidemiology
| | - Eliseo Guallar
- Welch Center for Prevention, Epidemiology, and Clinical Research, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
- Deputy Editor, Annals of Internal Medicine
| | - Judith Rijnhart
- Department of Epidemiology and Data Science, Amsterdam Public Health Research Institute, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Kimberley Goldsmith
- Institute of Psychiatry, Psychology, and Neuroscience, King's College London, London, England
| | | | - Cara C Lewis
- Kaiser Permanente Washington Health Research Institute, Seattle
| | - Steven J Kamper
- School of Health Sciences, University of Sydney, Sydney, Australia
- Nepean Blue Mountains Local Health District, Kingswood, Australia
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Nicolson PJA, Sanchez-Santos MT, Bruce J, Kirtley S, Ward L, Williamson E, Lamb SE. Risk Factors for Mobility Decline in Community-Dwelling Older Adults: A Systematic Literature Review. J Aging Phys Act 2021; 29:1053-1066. [PMID: 34348224 DOI: 10.1123/japa.2020-0482] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Revised: 01/17/2021] [Accepted: 01/18/2021] [Indexed: 11/18/2022]
Abstract
Mobility is essential to maintaining independence for older adults. This systematic review aimed to summarize evidence about self-reported risk factors for self-reported mobility decline; and to provide an overview of published prognostic models for self-reported mobility decline among community-dwelling older adults. Databases were searched from inception to June 2, 2020. Studies were screened by two independent reviewers who extracted data and assessed study quality. Sixty-one studies (45,187 participants) were included, providing information on 107 risk factors. High-quality evidence and moderate/large effect sizes for the association with mobility decline were found for older age beyond 75 years, the presence of widespread pain, and mobility modifications. Moderate-high quality evidence and small effect sizes were found for a further 21 factors. Three model development studies demonstrated acceptable model performance, limited by high risk of bias. These findings should be considered in intervention development, and in developing a prediction instrument for practical application.
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