CMC Osteoarthritis: Outcome measures. Joy C MacDermid PT PhD

Transcription

1 CMC Osteoarthritis: Outcome measures Joy C MacDermid PT PhD

2 Purposes To give an example of how one outcome (post-op pain) varies between men and women to illustrate the complexity of outcome measure interpretation To discuss impairment and self-report measures that can be used in CMC arthritis To share some recent consensus activities happening in this area

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4 Gender expectations Women more likely to report Women have higher pain scores Women more sensitive Women have more psychological features

5 Psychological characteristics enhance the Prediction of Acute Postoperative Pain beyond Type of Surgery, Demographic and Clinical characteristics in Patients Surgically treated for Thumb Base Osteoarthritis a Cohort Study Robbert M. Wouters, MSc, PT, Jarry T. Porsius, PhD; Mark J.W. van der Oest, Harm P. Slijper, PhD, Sebastiaan Souer, Ruud W. Selles, PhD and Joy C. MacDermid, PhD, for the Hand-Wrist Study Group

6 Research Question To what extent are baseline demographic, clinical and psychological characteristics and type of surgery predictors for direct postoperative pain (24h after surgery) in patients that underwent surgical treatment for symptomatic CMC-1 OA?

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12 Gender:1.25 Gender: 1.14 Gender:1.19 Gender: 1.69

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14 Conclusions Using sex/gender based analysis in multi-variate modelling More precise estimates of covariates Informed our understanding of what mechanisms might underline sex/gender differences Not psychological? Differences in opiate response or effectiveness of pain management protocol for women

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16 Summary of impairments Pain Generalized loss of digital flexor strength Marked loss in pinch strength Deformity Small changes in sensory nerve function Impaired dexterity/coordination Swelling Instability

17 Impairment Measures Strength Grip ++++ Pinch ++++ ROM ---- mobility/stability Thumb all joints mov t Wrist all mov t Hand Span Dexterity Dexterity Test Stability

18 Methods- NK Dexterity Test

19 Women with HOA tend to use more activity of the muscles that control wrist extension and thumb movement towards the palm when manipulating a small bolt.

20 Motor deficits Digital Grip Strength Calder et al JHT 2010 EMG Calder KM, Galea V, Wessel J, Macdermid JC, Macintyre NJ. Muscle Activation during Hand Dexterity Tasks in Women with Hand Osteoarthritis and Control Subjects. J Hand Ther 2011 The loss of digital strength is generalized Ulnar /median ratio = 60/40 Pinch and grip are markedly reduced Motor recuitment patterns IEMG not different than normal during tasks after time adjustment Take longer to do tasks

21 Mapping Logonosia normal SNAPs reduced

22 Studied Goniometry Plexograph- custom made

23 Inter-metacarpal Distance Pros Reliable Cons Dependent on size of hand so not comparable between people

24 Goniometry Pros Used at many joints Angular measure Cons Limited studies One says unreliable

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26 Pollexograph Pros Reliable Angular Cons Uptake Need to make your own

27 Purdue Pegboard Nine Hole Pictorial Valpaar Jebsons Other... No evidence for which us best

28 CAT Generic Health Upper Extremity Wrist/Hand Global ratings Patient-specific Impairment Measures Types of Outcome Measures

29 Strengths vs Weaknesses CAT + Efficient (fewer items needed) Scoring performed by software Easier to assess multiple constructs Can present extreme items when needed _ Cannot compare items over time Responsiveness may not be better Time saved is marginal with setup Not always implementable Item pool development

30 Generic Measures + Comprehensive or big picture + May be prognostic + Allows comparison between populations + Economic evaluation - sensitivity to change in upper extremity conditions

31 Upper Limb- Regional Measure The QuickDASH (brief) manual - kdash_info_2010.pdf

32 Strengths vs Weaknesses DASH + + One measure for upper limb + Strong measurement properties + Most translated + Most comparative data + Performs well across conditions + Mandated by some insurers + QuickDASH is fairly equivalent - Responsiveness MAY be lower in some conditions Construct not clearly just function No separate symptom score Probably not unidimensional Not interval level scoring Proximal disability may mask changes in distal function

33 Name: Date: PATIENT RATED WRIST EVALUATION Patient-rated Wrist Evaluation Pain Scale 5 items Function 10 items The questions below will help us understand how much difficulty you have had with your wrist in the past week. You will be describing your average wrist symptoms over the past week on a scale of Please provide an answer for ALL questions. If you did not perform an activity, please ESTIMATE the pain or difficulty you would expect. If you have never performed the activity, you may leave it blank. 1. PAIN Rate the average amount of pain in your wrist over the past week by circling the number that best describes your pain on a scale from A zero (0) means that you did not have any pain and a ten (10) means that you had the worst pain you have ever experienced or that you could not do the activity because of pain. Sample scale No Pain Worst Ever RATE YOUR PAIN: At rest When doing a task with a repeated wrist movement When lifting a heavy object When it is at its worst How often do you have pain? Never Always Please turn the page...

34 Strengths vs Weaknesses PRWE + Brief Strong measurement properties Pain major reason for seeking health care Separates pain and disability Simple to score Low literacy and cognitive demand Many translation - Hand and wrist only Only interval level scoring with Rasch adjusted scoring Not as widely used as DASH

35 Michigan Hand Questionnaire Focuses on hand/wrist Impairment (5X2) Disability (12) Work (5) Pain (5) Aesthetics (4X2) Satisfaction with level of impairment (6X2) Total = 52 questions

36 Strengths / Weakness MHQ + Comprehensive + Strong measurement properties - High burden (patients/clinicians) Longest Hardest to score (Various weighted subscales) - No interval level scoring (Rasch) - Not unidimensional

37 COPM

38 PATIENT SPECIFIC PARTICIPATION SCALE (PS 2 ) PSFS Read by evaluator and completed at baseline visit. Note: Complete prior to the physical examination. Read at Baseline Assessment Patients pick the items I'm going to ask you to identify the 5 aspects of your life that are most important to you. These aspects may or may not be affected by your current injury. We are interested to know the roles you have in your life and the way you participate in your community. Pick the specific aspects of your life that mean the most to you (not necessarily that you do the most). Most salient/most affected Examples: My job as a (list); babysitting my grandchildren, working for the church, vacations, volunteer as a (list), parenting, caring for relative, student, participating in a sport (list), participating in a specific social group, spending time with my family, a hobby (list) The most important things I participate in are:

39 Strengths vs Weaknesses + + Brief + Most responsive + Patient-centered + Simple to score + Low literacy + Good for high or low demand No ceiling/floor - - Scores NOT comparable across individuals - No link to level of difficulty - COPM time-consuming

40 SANE- single question How would you rate your hand today as a percentage of normal (0% to 100% scale with 100% being normal)?

41 Strengths vs Weaknesses + + Brief + Simple to score + Low literacy - - Scores NOT comparable across individuals - Construct unclear

42 1996 Nicholas Bellamy. All Rights Reserved AUSCAN The following questions concern the amount of pain you have experienced due to arthritis in your hands. For each situation please enter the amount of pain experienced in the last 48 hours. (Please mark your answers with an X.) How much pain do you have in your hands? None Mild Moderate Severe Extreme 1 At rest (ie. When not using your hands). 2 When gripping objects with your hands. 3 subscales Pain 5 items Stiffness 1 item Function 9 items 0-4 scale likert 3 When lifting objects with your hands. 4 When turning objects with your hands. 5 When squeezing objects with your hands. The following question concerns the amount of joint stiffness (not pain) you have experienced in the last 48 hours in your hands. Stiffness is a sensation of restriction or slowness in the ease with which you move your hands. (Please mark your answers with an X.) 6 How severe is stiffness in your hands None Mild Moderate Severe Extreme after first wakening in the morning? The following questions concern your physical function. By this we mean your ability to move around and to look after yourself. For each of the following activities, please indicate the degree of difficulty you have experienced in the last 48 hours due to arthritis in your hands. (Please mark your answers with an X.) How much difficulty do you have with None Mild Moderate Severe Extreme the following? 7 Turning taps/faucets on. 8 Turning a round doorknob or handle. 9 Doing up buttons. 10 Fastening jewellery (eg. Watches, earrings, cufflinks, necklaces, broaches, and bracelets). 11 Opening a new jar. 12 Carrying a full pot with one hand. 13 Peeling vegetables/fruits. 14 Picking up large heavy objects. 15 Wringing out washcloths. Thank you for completing the questionnaire.

43 Strengths vs Weaknesses + + Brief + Simple to score + Low literacy + somewhat specific to OA (stiffness item) - - Costs

44 DASH, PRWHE and AUSCAN valid Relationship between impairments and disability low to moderate

45 Summary Self-report A number of viable scales- no winner

46 Consensus Efforts

47 ICHOM

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51 Thumb done

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58 Trends Patient-report MHQ used by team organizers and accepted by majority (mostly European) Burden may be addressed by using some subscales PSFS Goniometry- despite concerns IMD suggested but rejected Pinch strength

59 OMERACT framework

60 OMERACT Process

61 Pain, physical function, patient global assessment, joint activity and hand strength.

62 ITOW

63 IPR? Existing measure PRWHE or a new thumb measure Discussion on importance of stability- lack of measures ROM not seen as important Pinch strength

64 No consensus yet.