PUBLIC HEALTH THREAT - Boston University · • Knee Pain/Osteoarthritis: Physical Therapy and Occupational Therapy Approaches • Susan Murphy, ScD, OTR and Kelley Fitzgerald, PT,

9/29/2014

1

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:

Arthritis State of the Science Meeting April 7, 2014

PUBLIC HEALTH

THREAT

9/29/2014

2


Why this meeting?


Why should rehabilitation

professionals care??


Why this meeting?

ARTHRITIS:

Disability Threat

9/29/2014

3



1) A look to the past

2) Major advances

3) Current gaps and upcoming challenges

4) Future needs

9/29/2014

4



Rheumatological Rehabilitation


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

9/29/2014

5


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


Got Arthritis? ….Rest…ahh….

9/29/2014

6


Now:MOVE!

ENGAGED IN

COMPLEX ROLES



Major Advances over Past

Two Decades

9/29/2014

7


Advance #1: Medicine—Inflammatory

Conditions

• Early diagnosis & treatment

• Disease modifying medications

• Biological medications

• RESULT: Less joint and tissue destruction

• No cure

• Disability persists


Advance #2:

Exercise

9/29/2014

8


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


1990s Decade of Exercise Clinical Trials

• 21 clinical trials

• 11 rheumatoid arthritis

• 10 osteoarthritis

9/29/2014

9


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


• 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

9/29/2014

10


J Orthop Sports Phys Ther 2009: 39(4):A1-A25


CDC Endorsed Community Exercise Programs

• Walk with Ease

• Arthritis Foundation Exercise

Program

• Active Living Every Day

• Fit and Strong

• EnhanceFitness

• Arthritis Foundation Aquatic

Program

9/29/2014

11


Advance #3: Work Disability


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

9/29/2014

12


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 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)

9/29/2014

13


Advance #4: Participation—Involvement

in Life Situations


International Classification of Functioning,

Disability and Health (ICF), WHO 2001

9/29/2014

14


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


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)

9/29/2014

15


Participation in OA: Does it Matter?

0

1

2

3

4

5

ImportanceGignac et al., J Rheumatol 2008

Extremely important

Not at all


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

9/29/2014

16


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


Outcome Measures in Rheumatology

(OMERACT)

http://www.omeract.org/index.html

9/29/2014

17


Advances in Rheumatological

Rehabilitation Research and Practice


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

9/29/2014

18


…Yet, Gaps Remain

Great

Advances


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)

9/29/2014

19


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


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

9/29/2014

20


Gap—Pain Mechanisms

• Peripheral and centralized pain

• Pain experience (persistent, fluctuating, activity

related)


• 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

9/29/2014

21



Shifting U.S. Demographics

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

9/29/2014

22



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

9/29/2014

23


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


Technology

9/29/2014

24


• Better outcomes for

rehabilitation therapies

• Better ways to foster physical

activity adherence

• Better ways to promote

employment retention

Need: Interdisciplinary approaches



Objective: To create a dialog among experts in the field

with the goal of moving the arthritis activity and

participation research agenda forward.

9/29/2014

25


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


Moderator: Scott Hasson, EdD, PT, FACSM, FAPTA



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


Moderator: Alan Jette, PhD

9/29/2014

26



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


Moderator: Catherine Backman, PhD, OT



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


9/29/2014

27


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


9/29/2014

28

School of Medicine

College of CommunicationSchool of Public Health

Sargent College of Health

& Rehabilitation Sciences


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

Documents

PUBLIC HEALTH THREAT - Boston University · • Knee Pain/Osteoarthritis: Physical Therapy and Occupational Therapy Approaches • Susan Murphy, ScD, OTR and Kelley Fitzgerald, PT,