PUBLIC HEALTH THREAT Arthritis State of the Science Meeting - - PDF document

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PUBLIC HEALTH THREAT Arthritis State of the Science Meeting - - PDF document

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9/29/2014 Rheumatological Rehabilitation: How are We Doing? Julie J. Keysor, PT, PhD Director, ENACT Promoting Activity and Participation Among Persons with Arthritis Arthritis State of the Science Meeting Pentagon City, Virginia | April 7,

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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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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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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 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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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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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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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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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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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 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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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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ICF Activity and Participation…

BU ENACT

27

  • Execution of a task or an

activity by an individual

Activity/Activity Limitation Participation/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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Participation in OA: Does it Matter?

1 2 3 4 5 Importance Gignac 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?

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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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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Advances in Rheumatological Rehabilitation Research and Practice

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RheumatologicalOutcomes Across the Decades (Number of Studies Identified in Pubmed)

1000 2000 3000 4000 5000 6000 7000 1970s 1980s 1990s 2000s Pain Function Disability Social Participation

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…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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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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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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Shifting U.S. Demographics

National Center for Health Statistics, 2005 Chart book on Trends on Health in Americans

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Pain Reporting Increasing Over Time

Framingham Data from 1983-2005

15.7 18.3 32.9 8.7 11.4 27.7 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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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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  • 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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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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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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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

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School of Medicine College of Communication School 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