McMaster Toronto Arthritis Patient Preference Research Articles

Measuring important activities for patients with knee osteoarthritis: a cross-sectional study

Background/Aims Some patient-reported outcome measures ask questions about fixed (ie standardised) activities. Other patient-reported outcome measures ask questions about activities that patients choose or generate. However, patients' appraisals of the importance of fixed and generated activities have not been directly compared and little is known about the construct of activity importance. The aim of this study was to compare patients' importance ratings for fixed and generated activities. It also examined relationships among patients' ratings of activity importance, pain and physical function. Methods Within a prospective cross-sectional design, 60 participants with knee osteoarthritis completed the Brief Pain Inventory, Western Ontario and McMaster Universities Osteoarthritis Index, as well as the McMaster Toronto Arthritis Patient Preference Questionnaire and a Patient-Reported Outcomes Measurement Information System physical function short form, which were modified to measure the importance of generated or fixed activities respectively. Results Participants rated generated activities as more important than fixed activities (P<0.01). They also gave higher importance ratings for fixed activities that they performed than fixed activities that they did not perform (P<0.01). The importance of the generated activities correlated with the Brief Pain Inventory (P<0.05) and Western Ontario and McMaster Universities Osteoarthritis Index (P<0.01), but the fixed activities' importance did not. Participants preferred to rate generated activities more than fixed activities (63.8%) and believed that their ratings of generated activities would better inform physicians than fixed activities (55.0%). Conclusions The results from this study identified benefits of including generated activities within patient-reported outcome measures and clarified the construct of activity importance for patients with musculoskeletal pain. Implications for practice Allied health professionals may maximise activity importance for their patients by focusing on patient-generated activities. However, the best instructions for collecting patient-generated activities are unknown.

Impact de l’angiœdème héréditaire sur les activités de la vie quotidienne, la sphère émotionnelle et la qualité de vie des patients

IntroductionHereditary angioedema (HAE) is characterized by recurrent attacks of swelling of various locations and severity. An impaired quality of life of patients with HAE has been reported by several studies. We aimed at examining the overall impact of the disease in patients followed for type I HAE, particularly its impact on daily life activities, emotions and quality of life. MethodsA questionnaire was distributed to patients consulting for type I HAE, collecting demographics, disease characteristics, impact on professional life, Hospital Anxiety and Depression score (HAD), SF-36 score and the McMaster Toronto Arthritis Patient Preference Disability Questionnaire (MACTAR). ResultsThe 33 patients included reported an average of 5.17 attacks over the last year. Stress was the main trigger A long-term treatment was reported by 58% of patients, 72% received specific treatment in the event of a serious attack. Sick days were reported by 33% of patients during their studies, and by 34% during work. One patient suffered from depressive symptoms and ten from anxious symptoms, according to the HAD score. The areas most impacted on the SF-36 score were general health and vitality. The mean score for MACTAR was low. ConclusionHAE still has a significant impact on the daily and emotional lives of patients, despite the availability of prophylactic and crisis treatments.

Changes over Time and Responsiveness of the Cochin Hand Function Scale and Mouth Handicap in Systemic Sclerosis Scale in Patients with Systemic Sclerosis: A Prospective Observational Study.

To assess changes over time and responsiveness of the Cochin Hand Function Scale (CHFS) and Mouth Handicap In Systemic Sclerosis (MHISS) scale in patients with systemic sclerosis (SSc). This was a prospective longitudinal study. Participants were drawn from a convenience sample of individuals with SSc, who were attending the annual Congress of the Association des Sclérodermiques de France, the French SSc patients' association. Participants were evaluated twice by the CHFS, MHISS scale, Health Assessment Questionnaire, McMaster-Toronto Arthritis Patient Preference Disability Questionnaire, and other outcome measures. Differences in measures over time were evaluated using the Wilcoxon signed rank test. Responsiveness was assessed by the effect size and standardized response mean. Nonparametric Spearman rank correlation (r) was used to assess correlation between outcome measures. Forty-nine patients were assessed. The CHFS and MHISS scores worsened over time (mean [SD] differences 2.7 [10.7], P = 0.08, and 3.5 [9.8], P = 0.14, respectively). The CHFS effect size and standardized response mean values were -0.16 and -0.24, respectively, and MHISS values were -0.53 and -0.52, respectively. The correlation between change in the CHFS score and change in Health Assessment Questionnaire and McMaster-Toronto Arthritis Patient Preference Disability Questionnaire scores was fair to moderate, whereas changes in MHISS score were poorly or not correlated to other measures. For patients considering their state deteriorated, the MHISS scale was the most responsive instrument. The CHFS and MHISS scores may be useful in detecting changes in location-specific limitations in activity for SSc patients.

Patient-preference disability assessment for disabling knee osteoarthritis: Validity and responsiveness of the McMaster-Toronto Arthritis Patient Preference Disability Questionnaire

BackgroundThe McMaster-Toronto Arthritis Patient Preference Disability Questionnaire (MACTAR) measurement of function may be more comprehensive and add useful information about disability than traditional fixed-item questionnaires, especially about issues that really matter to the patient, for developing personalized medicine. ObjectivesWe aimed to assess priorities in disability and restriction in participation in patients with disabling knee osteoarthritis (OA) by the MACTAR and evaluate its validity and responsiveness. MethodsWe evaluated 127 in- and outpatients with knee OA in two tertiary care teaching hospitals between August 2010 and July 2012 by using the MACTAR, the Western Ontario and McMaster Universities Osteoarthritis Index, Lequesne scale, Fear Avoidance Beliefs Questionnaire, a life satisfaction score and pain, global assessment of disease activity and functional impairment scores on a numerical rating scale. Validity was assessed by Pearson correlation and responsiveness by the standardized response mean (SRM) and effect size (ES). ResultsPatients ranked 35 different activities by the MACTAR; the 3 domains of the International Classification of Functioning, Disability and Health most often identified were mobility (cited 233 times, 52.3%); community, social and civic life (cited 122 times, 27.4%); and domestic life (cited 64 times, 14.4%). The MACTAR score was best correlated with functional impairment (r=0.5). Convergent and divergent validity was as expected. In all, 108 patients completed a 6-month follow-up evaluation: 27 patients shifted their priorities at 6 months, for a decrease in SRM and ES. The SRM (0.64) and ES (0.92) for the MACTAR without shifts in priorities were the highest among the outcome measures tested; for patients considering their condition improved, the values were 0.85 and 1.17, respectively. ConclusionsFor assessing priorities in disability and restriction in participation among patients with knee OA, the MACTAR has acceptable validity and responsiveness.

Systemic sclerosis: Sexual dysfunction and lower urinary tract symptoms in 73 patients

To estimate the frequency of lower urinary tract symptoms (LUTS) and sexual dysfunction in patients with systemic sclerosis (SSc) and associate these symptoms with clinical and functional parameters including disability and quality of life. Patients with SSc seen in Cochin hospital, Paris, between February and April 2010 were assessed for disease type, LUTS by the Urinary Symptom Profile scale, sexual dysfunction by the Feminine Sexual Function Index (FSFI) and International Index for the Erectile Function (IIEF-5), global disability by the Health Assessment Questionnaire and McMaster Toronto Arthritis Patient Preference Disability Questionnaire, anxiety and depression by the Hospital Anxiety and Depression scale, and quality of life by the Medical Outcomes Survey Short Form 36. The most frequent LUTS among the 73 patients included (13 males) were overactive bladder (n=11, 84.6%) and dysuria (n=8, 61.5%) for males and overactive bladder (n=51, 85%) and incontinence (n=29, 48.3%) for females. Among women, 32 (53.2%) were sexually active: 20 (62.5%) had sexual disorders (mean [SD] FSFI score 16.3 [6.2]), the most compromised domains being desire (mean score 2.6 [1.3]) and arousal (mean score 2.5 [1.4]). Sexual disorders were associated with short disease duration (P=0.01) and high depression (P=0.04) scores. For men, 7/8 (87.5%) had erectile dysfunction (mean IIEF-5 score 16 [5.3]). LUTS seem to be more frequent in SSc patients than in the general population. The most frequent symptom was overactive bladder.

Patient-preference disability assessment for disabling knee osteoarthritis: Validity and responsiveness of the Mcmaster-Toronto arthritis patient preference disability questionnaire

Patient-preference disability assessment for disabling knee osteoarthritis: Validity and responsiveness of the Mcmaster-Toronto arthritis patient preference disability questionnaire

Patient-reported outcomes and adult patients' disease experience in the idiopathic inflammatory myopathies. report from the OMERACT 11 Myositis Special Interest Group.

The newly formed Outcome Measures in Rheumatology (OMERACT) Myositis Special Interest Group (SIG) was established to examine patient-reported outcome measures (PROM) in myositis. At OMERACT 11, a literature review of PROM used in the idiopathic inflammatory myopathies (IIM) and other neuromuscular conditions was presented. The group examined in more detail 2 PROM more extensively evaluated in patients with IIM, the Myositis Activities Profile, and the McMaster-Toronto Arthritis Patient Preference Disability Questionnaire, through the OMERACT filter of truth, discrimination, and feasibility. Preliminary results from a qualitative study of patients with myositis regarding their symptoms were discussed that emphasized the range of symptoms experienced: pain, physical tightness/stiffness, fatigue, disease effect on emotional life and relationships, and treatment-related side effects. Following discussion of these results and following additional discussions since OMERACT 11, a research agenda was developed. The next step in evaluating PROM in IIM will require additional focus groups with a spectrum of patients with different myositis disease phenotypes and manifestations across a range of disease activity, and from multiple international settings. The group will initially focus on dermatomyositis and polymyositis in adults. Qualitative analysis will facilitate the identification of commonalities and divergent patient-relevant aspects of disease, insights that are critical given the heterogeneous manifestations of these diseases. Based on these qualitative studies, existing myositis PROM can be examined to more thoroughly assess content validity, and will be important to identify gaps in domain measurement that will be required to develop a preliminary core set of patient-relevant domains for IIM.

Disabilities of importance for patients to improve – using a patient preference tool in rheumatoid arthritis

Purpose: To investigate, using the McMaster Toronto Arthritis patient preference disability questionnaire (MACTAR), disabilities most important to improve in Swedish patients with rheumatoid arthritis (RA) and to compare these with the pre-defined activities in the International Classification of Functioning (ICF) comprehensive core set for RA and the Stanford Health Assessment Questionnaire (HAQ). Also to categorize patient preference selected disabilities using the ICF, to correlate the MACTAR score to RA core set measures and to evaluate the MACTAR’s test–retest reliability. Methods: 45 patients with RA (median (md) age 59 years, diagnosis duration md 10 years) were included. Assessments included disease activity score (DAS28), timed-stands test (TST), shoulder function assessment (SFA), visual analogue scale for pain (VAS), HAQ, patients’ global assessment of well-being (PGA) and the MACTAR. Results: 58 disabilities were identified of which 17 were identified by at least 5 patients. 47% of them were represented in the Comprehensive ICF RA core set and 53% in the HAQ. 16/17 were categorized in the ICF activities and participation component. Correlations between the MACTAR and other measures were: DAS28 (rs −0.65), TST (rs −0.19), SFA (rs 0.38), VAS (rs −0.61), HAQ (rs −0.51) and PGA (rs −0.61). Weighted κ was 0.59. Conclusions: Half of the disabilities patients with RA identified by use of the MACTAR are not evaluated in the Comprehensive ICF core set for RA or the HAQ. MACTAR has moderate test–retest reliability. MACTAR can be considered to be used in addition to traditional RA outcomes and may potentially improve clinical assessment of patients with RA.Implications for RehabilitationRA has an impact on personal life areas.The MACTAR helps identify individual disease-related disabilities of importance to improve.The MACTAR provides an opportunity for individualized goal-setting in rehabilitation and can thus promote adherence in rehabilitation.MACTAR may potentially improve clinical assessment for patients with RA.

Improvement in Health and Possible Reduction in Disease Activity Using Endurance Exercise in Patients With Established Polymyositis and Dermatomyositis: A Multicenter Randomized Controlled Trial With a 1‐Year Open Extension Followup

To determine the effects of a 12-week endurance exercise program on health, disability, VO2 max, and disease activity in a multicenter randomized controlled trial in patients with established polymyositis (PM) and dermatomyositis (DM), and to evaluate health and disability in a 1-year open extension study. Patients were randomized into a 12-week endurance exercise program group (EG; n = 11) or a control group (CG; n = 10). Assessments of health (Short Form 36 [SF-36]), muscle performance (5 voluntary repetition maximum [5 VRM]), activities of daily living (ADL), patient preference (McMaster Toronto Arthritis Patient Preference Disability Questionnaire), VO2 max, and disease activity (International Myositis Assessment and Clinical Studies criteria of improvement of the 6-item core set) were performed at 0 and 12 weeks. Disability assessments were performed again at 52 weeks in an open extension period. All assessments were performed by blinded observers. The EG improved compared to the CG in SF-36 physical function and vitality (P = 0.010 and P = 0.046, respectively), ADL score (P = 0.035), 5 VRM (P = 0.026), and VO2 max (P = 0.010). More patients in the EG (7 of 11) were responders with reduced disease activity compared to none in the CG (P = 0.002). Correlations between VO2 max and SF-36 physical function were 0.90 and 0.91 at 0 and 12 weeks, respectively (P < 0.05). The EG improvement in 5 VRM was sustained up to 52 weeks compared to baseline (5.7 kg; P < 0.001), but not in ADL score or SF-36. Endurance exercise improves health and may reduce disease activity in patients with established PM/DM. This potentially could be mediated through improved aerobic fitness. The results also indicate sustained muscle strength up to 1 year after a supervised program.

Health-related quality of life and functional ability in patients with early arthritis during remission steered treatment: results of the IMPROVED study

IntroductionThe aim of this study was to investigate patient reported outcomes (PROs) of functional ability and health related quality of life (HRQoL) in patients with early (rheumatoid) arthritis during one year of remission steered treatment.MethodsIn this study, 610 patients with early rheumatoid arthritis (RA) or undifferentiated arthritis (UA) were treated with methotrexate (MTX) and tapered high dose of prednisone. Patients in early remission (Disease Activity Score (DAS) <1.6 after 4 months) tapered prednisone to zero and when in persistent remission, also tapered MTX. Patients not in early remission were randomized to either MTX + hydroxychloroquine + sulphasalazine + prednisone (arm 1) or to MTX + adalimumab (arm 2). Every 4 months, patients filled out the Health Assessment Questionnaire (HAQ) and the McMaster Toronto Arthritis Patient Preference Questionnaire (MACTAR), the Short Form 36 (SF-36) and visual analogue scales (VAS). Change scores were compared between treatment groups. The association with achieving remission was analyzed using linear mixed models.ResultsDuring year 1, patients who achieved early remission had the most improvement in PROs with scores comparable to the general population. Patients in the randomization arms showed less improvement. Scores were comparable between the arms. There was a significant association between achieving remission and scores of HAQ, MACTAR and physical HRQoL.ConclusionsIn early arthritis, PROs of functional ability and HRQoL after one year of remission steered treatment reach normal values in patients who achieved early remission. In patients not in early remission, who were randomized to two strategy arms, PROs improved less, with similar scores in both treatment arms.Trial registrationsISRCTN11916566 and EudraCT2006-006186-16

Validity and Responsiveness of the Dutch McMaster Toronto Arthritis Patient Preference Questionnaire (MACTAR) in Patients with Osteoarthritis of the Hip or Knee

To determine the content validity, the construct validity, and the responsiveness of the Dutch McMaster Toronto Arthritis Patient Preference Questionnaire (MACTAR) in patients with osteoarthritis (OA) of the hip or knee. The MACTAR comprises 2 parts: a transitional part and a status part. Content validity was investigated by comparing patient-elicited activities to items on the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and the Medical Outcomes Study Short-Form 36 (SF-36). Construct validity was determined by correlating MACTAR outcomes with WOMAC/SF-36 outcomes. Responsiveness was investigated by correlating MACTAR, WOMAC, and SF-36 change scores with patient global assessment (PGA) scores and plotting a receiver-operating characteristics (ROC) curve. Eleven percent of the 894 impaired activities, identified by 192 patients, were not represented in either the WOMAC or the SF-36. The correlations (r(s)) investigated for the MACTAR transitional part varied between 0.27 and -0.40; the status part correlated moderately with the general health scale of the SF-36 (r(s) = 0.44). MACTAR change scores correlated better with PGA than with WOMAC/SF-36 change scores. The area under the ROC curve amounted to 0.90. Our results suggest that the MACTAR exhibits moderate construct validity and good responsiveness in a population of patients with OA of the hip or knee. The MACTAR is potentially better able to detect changes over time in activities that are important to individual patients compared to other tools measuring physical function (WOMAC, SF-36). Clinicians could use the MACTAR to evaluate clinically relevant changes over time in patient-specific physical functioning.

McMaster-Toronto Arthritis Patient Preference Disability Questionnaire Sensitivity to Change in Low Back Pain: Influence of Shifts in Priorities

ObjectiveTo assess the sensitivity to change of the McMaster Toronto Arthritis Patient Preference Disability Questionnaire (MACTAR) in chronic low back pain (CLBP) and shifts in patients' priorities of disabling activities over time.MethodsA prospective longitudinal survey of 100 patients (38 males) with CLBP in a tertiary care teaching hospital. Evaluation at baseline and 6 months by the MACTAR, Quebec Back Pain Disability Questionnaire (QUEBEC), Hospital Anxiety and Depression scale (HAD), Fear-Avoidance Beliefs Questionnaire (FABQ), Coping Strategies Questionnaire (CSQ), and pain and handicap visual analogue scales (VASs). Patients' perceived improvement or worsening of condition was assessed at 6 months. Effect size (ES) and Standardized response mean (SRM) and effect size (ES) were used to evaluate sensitivity to change of the MACTAR.ResultsThe MACTAR SRM and ES values (SRM = 0.25; ES = 0.37) were among the highest for the instruments evaluated. For patients considering their condition as improved, the SRM was 0.66 and the ES 1. The 3 disability domains, classified by the International Classification of Functioning, Disability and Health (ICF), most often cited as priorities at baseline remained the most cited at follow-up: mobility (40.9% of patients); community, social and civic life (22.7%); and domestic life (22.4%). At 6 months, 48 patients shifted their priorities, for a decrease in MACTAR SRM and ES values for patients considering their condition improved and an increase in these values for those considering their condition deteriorated.ConclusionsAlthough the MACTAR has similar sensitivity to change as other outcome measures widely used in CLBP, shifts in patient priorities over time are common and influence scores and sensitivity to change.

Cemented versus uncemented fixation of humeral components in total shoulder arthroplasty for osteoarthritis of the shoulder: a prospective, randomized, double-blind clinical trial—A JOINTs Canada Project

Although cemented humeral fixation is recognized as the standard of care in total shoulder arthroplasty (TSA), uncemented fixation has the potential to provide stable fixation, decrease operative time, and simplify potential revision procedures. This prospective, randomized, double-blind clinical trial compared cemented and uncemented humeral fixation in TSA for primary shoulder osteoarthritis. Patients with primary shoulder osteoarthritis requiring replacement were screened for eligibility. After providing informed consent, subjects received baseline clinical and radiologic assessments, computed tomography scans, and standardized TSA. After glenoid component insertion, patients were randomized to either a cemented or uncemented humeral component. The primary outcome was the WOOS (Western Ontario Arthritis of the Shoulder Index) score at 2 years. Other outcomes included the Short Form 12 score, American Shoulder and Elbow Surgeons score, McMaster-Toronto Arthritis Patient Preference Disability Questionnaire, operative time, complications, and revisions. Patients were assessed by a blinded evaluator at 2 and 6 weeks and 3, 6, 12, 18, and 24 months postoperatively. In total, 161 patients consented to be included and were randomized: 80 in the cemented group and 81 in the uncemented group. There were no significant differences in demographics or baseline evaluations between groups, except for gender. The 12-, 18-, and 24-month WOOS scores showed a significant difference in favor of the cemented group. The cemented group also had better strength and forward flexion. As expected, the operative time was significantly less for the uncemented group. These findings provide level I evidence that cemented fixation of the humeral component provides better quality of life, strength, and range of motion than uncemented fixation.

Sensitivity to Change in Systemic Sclerosis of the McMaster-Toronto Arthritis Patient Preference Disability Questionnaire (MACTAR): Shift in Patient Priorities Over Time

To assess the sensitivity to change of the McMaster-Toronto Arthritis Patient Preference Disability Questionnaire (MACTAR) in systemic sclerosis (SSc) and a shift in patient priorities over time. We assessed 49 patients with SSc (8 men) using the MACTAR in a prospective longitudinal study twice or more during annual meetings of the French patient association from 2004 to 2007. Patient-perceived improvement or worsening regarding health status was recorded. Sensitivity to change was assessed by the effect size (ES) and the standardized response mean (SRM) of the MACTAR. The MACTAR global score was significantly increased at followup in the whole group of patients, and the ES and SRM values were -0.37 and -0.34, respectively. These values were similar to those observed for widely used outcome measures for SSc such as the Health Assessment Questionnaire. As defined by the International Classification of Functioning, Disability and Health, the 3 disability domains most often cited at baseline were mobility (7 activities, cited 17 times; 33.3% of patients), domestic life (4 activities, cited 17 times; 33.3% of patients), and community, social and civic life (3 activities, cited 10 times; 19.6% of patients). At followup, 40 patients had changed their first priority and 34 changed 3 priorities. The evolution in MACTAR global score over time for patients with SSc reflects longterm general feelings of deterioration. However, shifts in patient priorities are common and may influence the sensitivity to change of the instrument.

Patient preferences before and after total knee arthroplasty

Objective Patients before total joint arthroplasty vary in the spectrum and importance of their concerns. The objectives of this study were to evaluate the psychometric properties of the Knee Patient-Specific Index (KPSI) and to determine the type and importance of patients' concerns before and after knee arthroplasty. Study Design and Setting A cohort of 119 patients scheduled for elective primary (or revision) total knee arthroplasty were interviewed at two tertiary care teaching hospitals. Patients also completed the Knee Society Scale (KSS), the Short Form 36, the Western Ontario and McMaster University Osteoarthritis Index (WOMAC), and the McMaster Toronto Arthritis Patient Preference Disability Questionnaire (MACTAR). Results Patients improved after total knee arthroplasty in all 42 symptoms and physical limitations, except crouching/kneeling and walking up and down stairs. Patients' summated concerns correlated with the WOMAC pain subscale (ranging from 0.72 to 0.79), WOMAC physical function subscale (ranging from 0.72 to 0.76), and KSS (ranging from 0.28 to 0.39). The summated responses changed after knee arthroplasty as demonstrated by the standardized response mean of 1.1. Conclusions The KPSI captures individual patient unique preferences for patients undergoing total knee arthroplasty. Patients improved in virtually all aspects of their symptoms and function after surgery, with the exception of crouching/kneeling and knee feeling hot.

Patient-Preference Disability Assessment for Disabling Chronic Low Back Pain

A cross sectional survey. OBJECTIVE.: To assess patient priorities in disability and restriction in participation with disabling chronic low back pain (CLBP) by use of the McMaster-Toronto Arthritis Patient Preference Disability Questionnaire (MACTAR) and to compare this questionnaire with other outcome measures widely used in this situation. Disability and participation restriction are widely assessed in CLBP but do not account for patient priorities. Knowing what is important to patients could be useful to help form treatment goals and plans. A total of 150 patients hospitalized in a tertiary care teaching hospital for the management of CLBP were enrolled in the study. Evaluation was by the MACTAR, the Quebec Back Pain Disability Questionnaire (QUEBEC), the Hospital Anxiety and Depression scale, the Fear-Avoidance Beliefs Questionnaire, the Coping Strategies Questionnaire, and pain and handicap visual analog scales. Correlations between the MACTAR score and scores for other scales were analyzed by the Spearman coefficient. On the MACTAR, patients with CLBP cited as most important 3 disability domains classified by the International Classification of Functioning, Disability, and Health: mobility (n = 23 activities, 165 times, 33% of the patients); community, social, and civic life (n = 7 activities, 138 times, 27.6% of the patients); and domestic life (n = 10 activities, 123 times, 24.6% of the patients). Patients ranked first in importance 37 different activities, especially sport (n = 29 times; 19.3% of the patients), shopping (n = 14; 9.3% of the patients), and walking (n = 13; 8.7% of the patients). The MACTAR score was correlated moderately with visual analog scale handicap (r = 0.51), weakly with the QUEBEC score (r = 0.40), and not at all with Hospital Anxiety and Depression scale, Fear-Avoidance Beliefs Questionnaire, and Coping Strategies Questionnaire scores. For assessing priorities in disability and participation restriction among patients with CLBP, the MACTAR has acceptable construct validity. The weak correlation between QUEBEC and MACTAR scores suggests that the latter scale adds useful information for assessing the health priorities of disabled CLBP patients.

Arthroscopic surgery provides no additional benefit over physiotherapy and medication for the treatment of knee osteoarthritis

What is the effect of the addition of arthroscopy to physiotherapy and medication in patients with osteoarthritis (OA) of the knee? Randomised, controlled trial with blinded outcome assessment and intention-to-treat analysis. A university sports medicine clinic in Ontario, Canada. Adults with idiopathic or secondary moderate-to-severe oa of the knee (Grade 2, 3, or 4 radiographic severity on the modified Kellgren-Lawrence classification). Key exclusion criteria were large meniscal tears, inflammatory arthritis, previous arthroscopic treatment for knee OA and more than 5 degrees of lateral deformity. Randomisation of 188 participants allotted 94 to an intervention group and 94 to a control group. The intervention group underwent arthroscopy within 6 weeks after randomisation and a standard physiotherapy and medication regimen was initiated within 7 days after surgery. the control group initiated the same physiotherapy and medication regimen at an equivalent time. Physiotherapy was provided for 1 hour once a week for 12 weeks. It included range-of-motion and strengthening exercises to be performed at home twice daily, information about activities of daily living, instruction in the use of heat and cold, and an educational video. Exercises were individualised according to the severity of oa and age. After the 12-week period, participants were advised to continue the exercise program. medications (potentially including paracetamol, non-steroidal anti-inflammatory drugs, hyaluronic acid, and glucosamine) were prescribed according to standard guidelines. The primary outcome was the WOMAC score at 2 years follow up. The WOMAC is scored from 0 (worst) to 2400, with subscales for pain, stiffness, and physical function. Secondary outcomes included the Physical Component Summary Score of the Short Form-36 (0 to 100); the McMaster Toronto Arthritis patient preference (MACTAR) questionnaire (0 to 500); and the Arthritis Self-Efficacy Scale (ASES) (10 to 100). 168 participants completed the study. After 2 years, the mean (SD) WOMAC scores were 874 (624) in the intervention group and 897 (583) in the control group, mean difference 23 (95% CI -208 to 161). The groups differed on the SF-36 by only 0.2 (95% CI -3.2 to 3.6), on the MACTAR questionnaire by only 6 (95% CI -37 to 49), and on each of the ASES subscales by less than 6 (all non-significant). The addition of arthroscopy to a regimen of physiotherapy and medication does not improve physical function, pain, or health-related quality of life in patients with moderate-to-severe OA of the knee.

Patient‐reported outcomes in a randomized trial comparing four different treatment strategies in recent‐onset rheumatoid arthritis

To investigate the effectiveness of 4 different treatment strategies for recent-onset rheumatoid arthritis (RA) on 2-year patient-reported outcomes, including functioning and quality of life. A total of 508 patients with recent-onset RA were randomly assigned to 1) sequential monotherapy, 2) step-up combination therapy, both starting with methotrexate, 3) initial combination therapy, including a tapered high-dose prednisone, or 4) initial combination therapy with methotrexate and infliximab. Treatment was adjusted every 3 months if the Disease Activity Score (DAS) remained >2.4. The McMaster Toronto Arthritis Patient Preference Disability Questionnaire, the Short Form 36 (SF-36), and scores for pain, global health, and disease activity measured on a 100-mm visual analog scale (VAS) were compared between groups at baseline and every 3 months thereafter for 2 years. After 2 years, all patient-reported outcomes had improved significantly from baseline, irrespective of the treatment strategy. SF-36 subscale scores approached population norms for 3 physical components, and achieved population norms (P > 0.05) for bodily pain and 4 mental components. Improvement in functioning, VAS scores, and physical items of the SF-36 occurred significantly earlier in patients treated with initial combination therapies (all comparisons after 3 months: overall P < 0.001; P < 0.05 for groups 1 and 2 versus groups 3 and 4). All 4 DAS-driven treatment strategies resulted in substantial improvements in functional ability, quality of life, and self-assessed VAS scores after 2 years. Initial combination therapy led to significantly faster improvement in all patient-reported measures.

Patient preference disability questionnaire in systemic sclerosis: A cross‐sectional survey

To assess patient priorities concerning disability in systemic sclerosis (SSc). A total of 150 SSc patients (22 men) fulfilling the American College of Rheumatology and/or LeRoy and Medsger criteria for SSc were evaluated by the McMaster Toronto Arthritis Patient Preference Disability Questionnaire (MACTAR), Karnofsky performance status (KPS), Cochin Hand Function Scale, Health Assessment Questionnaire (HAQ), Hospital Anxiety and Depression Scale, Mouth Handicap in SSc (MHISS) scale, and global perception regarding their health status. Correlations between scores were analyzed using Spearman's coefficient. Logistic regression analysis was used to determine factors associated with patients' global perception of their health. Of the patients investigated, 81 (54%) had limited cutaneous SSc, 65 (43.3%) diffuse SSc, and 4 (2.7%) limited SSc. The 3 disability domains most often cited were walking (82 patients [54.6%]), housekeeping (67 patients [44.6%]), and sport activities (59 patients [39.3%]). The MACTAR score correlated moderately with KPS (r = 0.58) but only weakly with the HAQ score (r = 0.38). In multivariate analysis, 2 factors were associated with patients' negative global perception of their health status: KPS (odds ratio [OR] 1.07, 95% confidence interval [95% CI] 1.00-1.15) and MHISS score (OR 0.93, 95% CI 0.88-0.99). For assessing SSc patient priorities concerning disability, the MACTAR has acceptable construct validity. Its weak correlation with the HAQ suggests that it adds useful information on disability.

Cost‐effectiveness of intensive exercise therapy directly following hospital discharge in patients with arthritis: Results of a randomized controlled clinical trial

To estimate the cost-utility and cost-effectiveness of a 3-week intensive exercise training (IET) program directly following hospital discharge in patients with rheumatic diseases. Patients with arthritis who were admitted to the hospital because of a disease activity flare or for elective hip or knee arthroplasty were randomly assigned to either the IET group or usual care (UC) group. Followup lasted 1 year. Quality-adjusted life years (QALYs) were derived from Short Form 6D scores and a visual analog scale (VAS) rating personal health. Function-related outcome was measured using the Health Assessment Questionnaire, the McMaster Toronto Arthritis (MACTAR) Patient Preference Disability Questionnaire, and the Escola Paulista de Medicina Range of Motion scale (EPMROM). Costs were reported from a societal perspective. Differences in costs and incremental cost-effectiveness ratios (ICERs) were estimated. Data from 85 patients (50 IET and 35 UC) could be used for health-economic analysis. VAS personal health-based QALYs were in favor of IET. Function-related outcome showed statistically significant improvements in favor of IET over the first 6 months, according to the MACTAR (P < 0.05) and the EPMROM (P < 0.01). At 1-year followup, IET was euro718 less per patient. The ICER showed a reduction in mean total costs per QALY. In 70% of cases the intervention was cost-saving. IET results in better quality of life at lower costs after 1 year. Thus, IET is the dominant strategy compared with UC. This highlights the need for implementation of IET after hospital discharge in patients with arthritis.