Post on 20-Jul-2020
9/29/2014
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Arthritis State of the Science Meeting Pentagon City, Virginia | April 7, 2014
Promoting Activity and Participation Among Persons with Arthritis
Rheumatological Rehabilitation:
How are We Doing?
Julie J. Keysor, PT, PhD
Director, ENACT
Arthritis State of the Science Meeting Pentagon City, Virginia | April 7, 2014
Arthritis:
Arthritis State of the Science Meeting April 7, 2014
PUBLIC HEALTH
THREAT
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Arthritis State of the Science Meeting Pentagon City, Virginia | April 7, 2014
Why this meeting?
Arthritis State of the Science Meeting April 7, 2014
Why should rehabilitation
professionals care??
Arthritis State of the Science Meeting Pentagon City, Virginia | April 7, 2014
Why this meeting?
ARTHRITIS:
Disability Threat
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Arthritis State of the Science Meeting Pentagon City, Virginia | April 7, 2014
Arthritis State of the Science Meeting Pentagon City, Virginia | April 7, 2014
1) A look to the past
2) Major advances
3) Current gaps and upcoming challenges
4) Future needs
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Arthritis State of the Science Meeting Pentagon City, Virginia | April 7, 2014
Promoting Activity and Participation Among Persons with Arthritis
Rheumatological Rehabilitation
Arthritis State of the Science Meeting Pentagon City, Virginia | April 7, 2014
Arthritis Rehabilitation: 1960s
“In 1965, as I started my career as a physical therapist,
my first patient was a woman with rheumatoid
arthritis, Functional Class IV. She had been treated with
high-dose corticosteroids for over 15 years and was
admitted to the rehabilitation unit for 2 weeks every
summer. Her treatment orders were for mat exercises
(passive and active-assisted range of motion.) I had
received 1 lecture on rheumatoid arthritis and
attended grand rounds about corticosteroids.”
Minor MA, The ACR at 75 2009
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Arthritis State of the Science Meeting Pentagon City, Virginia | April 7, 2014
Arthritis Rehabilitation…mid-late 1980s
Bluestone R. Br Med J. 1970; Katz WA.
Am J Med. 1985
Treatment supported by
limited research
Joint deformity often substantial
Arthritis State of the Science Meeting Pentagon City, Virginia | April 7, 2014
Got Arthritis? ….Rest…ahh….
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Arthritis State of the Science Meeting Pentagon City, Virginia | April 7, 2014
Now:MOVE!
ENGAGED IN
COMPLEX ROLES
Arthritis State of the Science Meeting Pentagon City, Virginia | April 7, 2014
Promoting Activity and Participation Among Persons with Arthritis
Major Advances over Past
Two Decades
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Arthritis State of the Science Meeting Pentagon City, Virginia | April 7, 2014
Advance #1: Medicine—Inflammatory
Conditions
• Early diagnosis & treatment
• Disease modifying medications
• Biological medications
• RESULT: Less joint and tissue destruction
• No cure
• Disability persists
Arthritis State of the Science Meeting Pentagon City, Virginia | April 7, 2014
Advance #2:
Exercise
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Arthritis State of the Science Meeting Pentagon City, Virginia | April 7, 2014
People with Osteoarthritis and Rheumatoid
Arthritis Can Exercise
• Intervention: Walking or Aquatic
Exercise
• Control: Range of motion
• Outcomes: No difference in
active joint counts & aerobic
capacity and walking speed
increased
Minor MA et al, Arthritis Care Res, 1989
Arthritis State of the Science Meeting Pentagon City, Virginia | April 7, 2014
1990s Decade of Exercise Clinical Trials
• 21 clinical trials
• 11 rheumatoid arthritis
• 10 osteoarthritis
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Arthritis State of the Science Meeting Pentagon City, Virginia | April 7, 2014
Systematic Reviews 2000s:
Osteoarthritis and Rheumatoid Arthritis
Outcomes Effect Level of Evidence
Aerobic
training
Pain
Function
Small-Moderate
Small-Moderate
Good
Good
Strength
training
Strength
Pain
Function
Moderate
Moderate
Small
Good
Good
Good
Ottowa Panel. Physical Therapy, 84: 2004 & 85: 2005; MOVE Consensus 2005;
Jamtvedt et al. Physical Therapy 88:2008; Fransen M., McConnell S. The
Cochrane Collaboration, 2009; Wang et al., Ann Inter Med 157: 2012
Arthritis State of the Science Meeting Pentagon City, Virginia | April 7, 2014
• Strongly recommended: (ACR 2012 Practice Guidelines; EULAR 2013
Practice Guidelines; OARSI 2014 Practice Guidelines)
• Aerobic and/or aquatic exercise
• Resistance exercises
• Moderate aerobic low impact activity 150 minutes/week
• Resistance training 2 times/week (CDC 2008)
NOW: Knee Osteoarthritis
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Arthritis State of the Science Meeting Pentagon City, Virginia | April 7, 2014
J Orthop Sports Phys Ther 2009: 39(4):A1-A25
Arthritis State of the Science Meeting Pentagon City, Virginia | April 7, 2014
CDC Endorsed Community Exercise Programs
• Walk with Ease
• Arthritis Foundation Exercise
Program
• Active Living Every Day
• Fit and Strong
• EnhanceFitness
• Arthritis Foundation Aquatic
Program
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Arthritis State of the Science Meeting Pentagon City, Virginia | April 7, 2014
Advance #3: Work Disability
Arthritis State of the Science Meeting Pentagon City, Virginia | April 7, 2014
Arthritis Linked to Work Disability 1980s
• Work loss recognized as a major health concern
among people with rheumatoid arthritis
• Disease duration, disease severity, physical function, work-
related factors recognized risk factors
Yelin et al. Ann Intern Med 1980; Meenan et al., Arthritis Rheum 1981; Pincus
et al. J Clin Epidemiol. 1989; Reisine et al., Arthritis Rheum. 1989
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Arthritis State of the Science Meeting Pentagon City, Virginia | April 7, 2014
Arthritis and Work Disability 1990s
• “Return” to work:
• Related to work/organization factors (Straaton et al., Arthritis Rheum,
1992)
• Measurement of work disability
• Epidemiology of work loss continued
Arthritis State of the Science Meeting Pentagon City, Virginia | April 7, 2014
Arthritis and Work Disability 2000s:
Clinical Trials
• Vocational rehabilitation approaches
• Positive impact on sustaining employment status (Allaire et al,
Arthritis Rheum, 2003)
• Ergonomic, occupational therapy, and exercise
approaches
• Positive impact on self-efficacy, fatigue, work performance (Baldwin et al. 2012; Macedo et al., 2009; Verekamp et al. 2011; Nyrop et al. 2011)
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Arthritis State of the Science Meeting Pentagon City, Virginia | April 7, 2014
Advance #4: Participation—Involvement
in Life Situations
Arthritis State of the Science Meeting Pentagon City, Virginia | April 7, 2014
International Classification of Functioning,
Disability and Health (ICF), WHO 2001
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Arthritis State of the Science Meeting Pentagon City, Virginia | April 7, 2014
ICF Activity and Participation…
BU ENACT
27
• Execution of a task or an activity by an individual
Activity/Activity
LimitationParticipation/Participation
Restriction
• Involvement in life situations
Arthritis State of the Science Meeting Pentagon City, Virginia | April 7, 2014
Prevalence of Participation Restriction among
Persons with Arthritis
• 11% (1 out of 9) of adults with self-reported arthritis
report social participation restriction (2009 National Health
Interview Data, Theis et al. 2013)
• 38% of older adults with symptomatic knee OA and
functional limitations had moderate or severe
participation restriction (Keysor et al. J. Gerontology 2009)
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Arthritis State of the Science Meeting Pentagon City, Virginia | April 7, 2014
Participation in OA: Does it Matter?
0
1
2
3
4
5
ImportanceGignac et al., J Rheumatol 2008
Extremely important
Not at all
Arthritis State of the Science Meeting Pentagon City, Virginia | April 7, 2014
Participation in OA: Does it Matter?
0
1
2
3
4
5
Importance Satisfaction with time spent
Satisfaction with role performance Gignac et al., J Rheumatol 2008
Extremely important/satisfied
Not at all
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Arthritis State of the Science Meeting Pentagon City, Virginia | April 7, 2014
Measurement: Participation
• PROMIS
• OA CAT
• Impact on Participation and Autonomy (IPA)
• Keele Assessment of Participation (KAP)
• Social Role Participation Questionnaire
• Participation Objective, Participation Subjective (POPS)
• Late Life Disability Instrument
Arthritis State of the Science Meeting Pentagon City, Virginia | April 7, 2014
Outcome Measures in Rheumatology
(OMERACT)
http://www.omeract.org/index.html
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Arthritis State of the Science Meeting Pentagon City, Virginia | April 7, 2014
Advances in Rheumatological
Rehabilitation Research and Practice
Arthritis State of the Science Meeting Pentagon City, Virginia | April 7, 2014
Rheumatological Outcomes Across the Decades
(Number of Studies Identified in Pubmed)
0
1000
2000
3000
4000
5000
6000
7000
1970s 1980s 1990s 2000s
Pain
Function
Disability
Social Participation
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Arthritis State of the Science Meeting Pentagon City, Virginia | April 7, 2014
…Yet, Gaps Remain
Great
Advances
Arthritis State of the Science Meeting Pentagon City, Virginia | April 7, 2014
Gap: Exercise Adherence
• 44% of people with arthritis are inactive (compared to
36% older adults) (Shih M et al., Am J Prev Med 2006)
• 13% (older adults) engage in recommended levels of
strength training activities (Kruger J et al., Prev Chronic Dis. 2007)
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Arthritis State of the Science Meeting Pentagon City, Virginia | April 7, 2014
Gap—Work Disability
Continues to be a Threat
for Millions
• Some but limited evidence regarding interventions to
sustain employment status and minimize work limitations
• Need research that translates effective approaches to
practice
Arthritis State of the Science Meeting Pentagon City, Virginia | April 7, 2014
Gap—Participation
• Participation restrictions are still present
• Little is known about how to enhance participation
• Little is known about how to promote participation in the
rehabilitation setting
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Arthritis State of the Science Meeting Pentagon City, Virginia | April 7, 2014
Gap—Pain Mechanisms
• Peripheral and centralized pain
• Pain experience (persistent, fluctuating, activity
related)
Arthritis State of the Science Meeting Pentagon City, Virginia | April 7, 2014
• Minority populations experience more disability due to
arthritis than non-minority populations
• Minority populations are less likely to receive knee and
hip joint replacement than non-minority populations
• Minority populations have more disability after joint
replacement
Gap—Disparities in Outcomes
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Arthritis State of the Science Meeting Pentagon City, Virginia | April 7, 2014
Arthritis State of the Science Meeting Pentagon City, Virginia | April 7, 2014
Shifting U.S. Demographics
National Center for Health Statistics, 2005 Chart book on Trends on Health in Americans
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Arthritis State of the Science Meeting Pentagon City, Virginia | April 7, 2014
Arthritis State of the Science Meeting Pentagon City, Virginia | April 7, 2014
Pain Reporting Increasing Over TimeFramingham Data from 1983-2005
15.718.3
32.9
8.711.4
27.7
0
5
10
15
20
25
30
35
1983-85 1992-95 2002-05
Females
Males
Nguyen et al., Ann Intern Med. 2011
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Arthritis State of the Science Meeting Pentagon City, Virginia | April 7, 2014
Primary Total Knee Arthroplasty,
Medicare 1991-2010 (Cram et al. JAMA 2012)
93,230 procedures in 1991
243,802 procedures
in 2010
161.5% increase
Arthritis State of the Science Meeting Pentagon City, Virginia | April 7, 2014
Technology
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Arthritis State of the Science Meeting Pentagon City, Virginia | April 7, 2014
• Better outcomes for
rehabilitation therapies
• Better ways to foster physical
activity adherence
• Better ways to promote
employment retention
Need: Interdisciplinary approaches
Arthritis State of the Science Meeting Pentagon City, Virginia | April 7, 2014
Arthritis State of the Science Meeting April 7, 2014
Objective: To create a dialog among experts in the field
with the goal of moving the arthritis activity and
participation research agenda forward.
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Arthritis State of the Science Meeting Pentagon City, Virginia | April 7, 2014
Promoting Activity and Participation:
Rehabilitation Setting
• Knee Pain/Osteoarthritis: Physical Therapy and Occupational
Therapy Approaches
• Susan Murphy, ScD, OTR and Kelley Fitzgerald, PT, PhD
• A Critical Look at Total Knee Replacement Outcomes
• Jessica Maxwell. PT, DPT, OCS, Doctoral Candidate
Arthritis State of the Science Meeting April 7, 2014
Moderator: Scott Hasson, EdD, PT, FACSM, FAPTA
Arthritis State of the Science Meeting Pentagon City, Virginia | April 7, 2014
Promoting Activity and Participation:
Community
• Behavioral Strategies to Improve Adherence
• Susan Hughes, PhD
• Innovations in Technology in Improving Physical Activity
Adherence
• Kristin Baker, PhD
• Environmental Approaches for Promoting Physical Activity
Adherence in People with Chronic Conditions and Disability
• James Rimmer, PhD
Arthritis State of the Science Meeting April 7, 2014
Moderator: Alan Jette, PhD
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Arthritis State of the Science Meeting Pentagon City, Virginia | April 7, 2014
Promoting Activity and Participation:
Employment
• Innovations Using Technology to Close the Gap Between
Clinic and Workplace
• Nancy Baker, OT, PhD and Karen Jacobs, EdD, OTR/L, CPE, FAOTA
• Employer Innovations for Sustaining Employees—What Does
the Science Say?
• Glenn Pransky, MD, M.Occ.H.
• Community-based Interventions to Sustain Employment
• Julie Keysor, PhD, PT
Arthritis State of the Science Meeting April 7, 2014
Moderator: Catherine Backman, PhD, OT
Arthritis State of the Science Meeting Pentagon City, Virginia | April 7, 2014
Promoting Activity and Participation:
Policy Initiatives
• Perspectives from the US: Advocacy, Access and
Research for a Cure
• Patience White, MD, MPH
• Perspectives from Canada: Models of Care
• Janet Yale, LLB, MA
Arthritis State of the Science Meeting April 7, 2014
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Arthritis State of the Science Meeting Pentagon City, Virginia | April 7, 2014
Panel: Stakeholder Reflections and Next Steps
• Catherine Backman, PhD, OT, FCAOT, University of British
Columbia
• David Felson, MD, MPH, Boston University
• Julie Keysor, PT, PhD, Boston University
• Susan Lin, ScD, OTR/L, American Occupational Therapy
Association
• Nancy White, PT, DPT, OCS, American Physical Therapy
Association
Arthritis State of the Science Meeting Pentagon City, Virginia | April 7, 2014
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School of Medicine
College of CommunicationSchool of Public Health
Sargent College of Health
& Rehabilitation Sciences
Arthritis State of the Science Meeting Pentagon City, Virginia | April 7, 2014
Acknowledgements:
The National NIDRR Arthritis Rehabilitation Research and
Training Center
NIDRR PR/Award #H133B100003
Saralynn Allaire
Molly Vaughan
Mary Slavin
ENACT
Health and Disability Research Institute
Clinical Epidemiology Research and
Training Unit