Archive
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AStretch
3rd Conference October 2006
AStretch
2nd Conference October 2005
The AStretch
2nd Conference took place on October 19th 2005 at the CSP. Sponsored
by two pharmaceutical companies - Wyeth and Schering-Plough, (both
involved in the production of anti-TNF drugs - now becoming used more
frequently in the management of AS), participants included 34 physiotherapists
from around the country who shared a keen interest and expertise in
the management of Ankylosing Spondylitis (A.S).
The opening
presentation, by Peter Sawyer, from Wyeth was an excellent start to
a very successful day. Peter gave a simple yet detailed overview as
to how anti-TNF medications work in the management of AS. His extremely
understandable talk explained how the balance of pro- and anti-inflammatory
cytokinins in the body is important and how anti-TNF medications such
as Enteracept can help resolve the imbalances often seen in inflammatory
diseases such as AS. Following on from Peter was Matthew Charge from
Schering Plough, who gave an interesting presentation on the use of
Remicade in AS with particular reference to patient selection for
treatment and evidence of effectiveness. This was followed by a lively
discussion from the floor, comparing practice in different parts of
the country.
Following
lunch, Dr. Helen Keen from Leeds University, gave an interesting presentation
on Work Instability and AS. This was a very thought stimulating talk
as it is often forgotten that AS affects individuals at a time when
they are most economically active, (most common in the third decade).
With 20% of AS patients losing their jobs due to AS, Dr. Gill Gilworth’s
talk on the AS Work Instability Score, (AS-WIS), and ways of reducing
Work Disability in AS was extremely interesting.
The final
presentation of the day was by Stuart Porter presenting a summary
of his PhD work to date on Determinants of Exercise Behaviour in AS.
As physiotherapists we spend much of our time wondering why some people
attend exercise groups, such as NASS Groups regularly, whilst others
do not - and the factors that influence these decision making processes.
Stuart’s presentation was very stimulating, giving an invaluable
insight into what patients actually think about exercise and AS and
it will be very exciting to see the final results of Stuart’s
work, hopefully next year.
The conference
has been very successful in bringing together practitioners from all
around the country to listen to a very high standard of presentations
on very relevant topics. Physiotherapists working with AS patients
are often isolated and the opportunity to share best practice and
network with likeminded individuals was a valuable experience.
AStretch
are in the process of organising another conference in November 2006.
For more details about this, AStretch or indeed about AS, please see
the website. www.astretch.co.uk
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Biographies
of the speakers and a summary of their talks
Biography
for Stuart Porter. BSc, Grad Dip Phys
Stuart
graduated from Manchester Royal Infirmary School of Physiotherapy
in 1987 (Graduate Diploma) he later obtained a BSc (Hons) Degree in
Health Studies at Salford University. Stuart spent 11 years working
in the NHS before taking up post as a lecturer at Salford University,
teaching anatomy, orthopaedics, rheumatology and soft tissue injuries.
Stuart is currently working on his PhD ‘Determinants of exercise
behaviour amongst people with ankylosing spondylitis’ which
he hopes to finish in 2006.
Stuart has also been the physiotherapist for the England’s women
football team and has travelled with them on several occasions. He
has also published 3 books including ‘The dictionary of Physiotherapy‘.
Determinants of exercise behaviour in ankylosing spondylitis
Background
Ankylosing Spondylitis (AS) is a chronic rheumatological disease in
which active exercise plays a pivotal self management role. People
with AS generally feel much better when they exercise, yet whilst
all people with AS are initially taught exercises, many people with
AS choose not to do the exercises at all or not in the format in which
they have been taught. AS research has not taken account of what people
with AS actually do in terms of their day to day self management,
the factors influencing these decisions and the role that exercise
plays.
Aim
The aim of the study is to identify the factors influencing the decision-making
processes of people with AS relating to their exercise behaviour,
and to identify, classify and represent these exercise behaviours
in a conceptual framework.
Methods
Following a preliminary quantitative survey to establish exercise
group attendance frequencies, purposive sampling was employed to ensure
a spectrum of beliefs. 20 semi structured interviews were undertaken
in people’s homes, each interview was recorded verbatim and
transcribed, then data analysis undertaken. A focus group was later
held with 8 of these participants to check trustworthiness of the
interpretation of the data.
Results
In the interviews a wealth of data emerged that highlights how effective
all patients with AS are at making informed choices about what type
of exercise is best for them.
Four distinct exercise behaviours have been identified along with
four distinct reactions to anthropometric deterioration. Patients
describe ongoing and dynamic appraisals of their AS status, a process
of cost benefit analysis relating to the use of exercise, encompassing
such factors as beliefs about exercise in AS, the results of their
physiotherapy assessment measurements, about the role of exercise
in the short and long-term management of their condition and about
what constitutes exercise. One sub group of people for example modify
their activities of daily living, or hobbies to resemble the exercises
that they were taught and expressed a preference for this form of
activity over prescribed exercises.
Conclusions
The study corroborates aspects of established health behaviour theory
but has also generated novel data in AS, which has not been previously
described. For example, all patients use anthropometric measurements
to monitor the progress of their condition, but for the first time,
different reactions in relation to deterioration in anthropometric
measurement in AS ranging from inaction to exercise targeted by the
anatomical region affected have been identified and categorised. This
research has recognised that discrete behavioural pathways are adopted
by people who have been diagnosed with AS. Patient’s responses
to the need to exercise are informed by their beliefs about exercise,
current disease status, experience of managing their own condition
and lifestyle demands. Understanding the interaction of these factors
has the potential to inform the development of a client-centred approach
to exercise programmes in AS tailored to the beliefs, priorities and
lifestyles of individuals, and produce a planning tool useful for
newly diagnosed people.
Next
phase
The single centre conceptual framework will now be taken to focus
groups to a different population of patients to asses its trustworthiness,
generalisibility and clinical utility.
Supervisory team
Professor J.Goodacre. Director of Clinical Research LPSMH University
of Central Lancashire
Dr L Goodacre. Senior Lecturer University of Central Lancashire
Dr J. Smith. Senior Lecturer in Psychology University of Central Lancashire
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Biography
for Gill Gilworth MPhil
Gill
is a Chartered Physiotherapist currently pursuing her joint interests
of research and Occupational Health. Gill’s professional experience
includes 10 years in the NHS where she specialised in musculoskeletal
out-patients and rehabilitation.
Gill has worked at the University of Leeds since 1994 where she completed
an MPhil in 2000. Main research interests include the use of qualitative
methodology in the development of health outcome measures, job retention
and vocational rehabilitation. Part of her current role as Senior
Research Fellow in the Academic Unit of Musculoskeletal Disease is
to manage the ‘Extending Working Life’ programme of research;
this has included project to develop Work Instability scales for Rheumatoid
Arthritis, Ankylosing Spondylitis, Traumatic Brain Injury and for
Nurses with musculoskeletal problems. Gill is also a director of Work
Fit Occupational Physiotherapy and Ergonomics Services Ltd.
Reducing work disability in Ankylosing Spondylitis: The AS work instability
scale (AS-WIS) Gill Gilworth
Academic Unit of Musculoskeletal Disease, University of Leeds and
Work Fit Occupational Physiotherapy and Ergonomics Services Ltd
Background:
Estimates for work disability in AS vary widely, however the impact
of AS on full labour force participation and occupational choice is
widely acknowledged. Work Instability (WI), where there is an increasing
mismatch between a person's functional ability and the demands of
their job has not previously been explored in this population although
a Work Instability Scale for Rheumatoid Arthritis (RA-WIS) is well
established and is being used to enable physicians to identify patients
at risk of job loss for rapid intervention.
Methods:
This study explored the concept of WI in AS through qualitative interviews
(n=13). New items generated from the interviews were combined with
relevant items from the existing RA-WIS to form a 55 item draft AS-WIS.
Rasch analysis was used to examine the scaling properties of the AS-WIS
using data generated through a postal survey. The new scale was validated
against a gold standard of expert vocational assessment (n=13).
Results:
Fifty-seven participants who were in work returned the postal survey.
Of the original 55 items 38 were shown to fit the Rasch model and
to be free of bias for gender and disease duration. Following analysis
for discrimination against the gold standard assessments 20 items
remained with good fit to the Rasch model. For high levels of risk
the sensitivity of the scale is 100% and specificity 82%. Ten items
on the AS-WIS are common with items on the 23-item RA-WIS.
Conclusion
The AS-WIS is a self-administered scale which meets the stringent
requirements of modern measurement, used as a screening tool it can
identify those experiencing a mismatch at work who are at risk of
work disability. Measurement of WI is emerging as an important indicator
for the use of biologics, thus the AS-WIS has the potential to become
an important outcome measure.
This study provides evidence that some aspects of WI are the same
across different diagnostic groups, although there are also disease-specific
aspects as well. As common items are identified in different Work
Instability Scales these can be used to stablish an item bank giving
comparability across disease.
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Biography
for Dr Helen Keen, MBBS, FRACP
Helen
trained as a Consultant Rheumatologist in Australia, largely Perth,
Western Australia. She undertook a position as a Rheumatology Research
in October 2004 in the Department of Musculoskeletal and Rehabilitation
Medicine, Leeds University. To date the projects she has been involved
in have largely been based around clinical and imaging outcomes of
patients with inflammatory diseases on biological agents.
Prevention
Of Work Instability In Ankylosing Spondylitis Ankylosing spondylitis
(AS) is a chronic inflammatory disease of joints and entheses associated
with a significant reduction in quality of life and is the prototypic
disease of the spondyloarthropathy group of disorders. It has traditionally
been considered a rare disease with few therapeutic options. AS is
more common than previously estimated with some studies suggesting
a prevalence as high as 1% (1). Clinical outcome with conventional
therapies has not been good, with 70% of patients progressing to fusion
of the spine by 10 to 15 years (2). There is no evidence that conventional
therapy with non-steroidal anti-inflammatory drugs (NSAIDs) or disease
modifying anti-rheumatic drugs (DMARDs) has any disease modifying
effect and mortality is also increased, by 1.5 to 4 times the general
population (3).
In contrast to rheumatoid arthritis (RA), the onset AS occurs in the
third decade or even earlier. Importantly it affects individuals at
a time when they are economically active (most commonly in the third
decade) and the disease has a major impact on their ability to work
(4). Work disability has been shown to be greater than in normal subjects.
Overall, 20% of patients have lost their job due to AS, and 25% are
in work but at risk of losing their job (4). Given that there may
a need to be targeting of treatment, this smaller group may be a priority
target for intervention, with the aim of job retention, with potential
health economic benefits.
Certainly
the intervention can be justified in terms of the health economic
aspects of AS given the level of work disability associated with this
disease. Recent evidence from a survey from our group shows that of
the patients still in work, 50% have major health problems due to
AS and suggest imminent job loss. Predictors of work disability are
poor physical function and high disease activity.
All the above suggest that suppression of inflammation should lead
to functional benefits translated which if translated into job retention
would justify the use of expensive therapies on health economic grounds.
The
advent of TNF-a blockade with etanercept marks the first therapeutic
advance in AS since the introduction of NSAIDs and these drugs are
rapidly effective in suppressing the entheseal lesions of inflammatory
back disease and improvement in quality of life and functional status
(5,6,7,8). This is likely to translate into enhanced ability to work.
Our unit has developed a Work Instability Scale validated specifically
for AS (AS-WIS), which can be used as an outcome measure. It is sensitive
to the impact of inflammatory back disease on ability to work. The
impact of anti-TNF therapies on Work Instability in AS is currently
unknown, as no specifically validated measure has previously been
available. The aim of this study is to determine whether anti-TNF
therapy with etanercept does improve the work instability, and consequently
in job retention, using validated measures.
Braun
J, Bollow M, Remlinger G et al. The prevalence of spondyloarthropathy
in HLA B 27 positive and negative blood donors. Arth Rheum 1998; 41:
58-67.
Brophy S, Mackay K, Al-Saidi A et al. The natural history of AS as
defined by radiological progression. J Rheumatol 2002; 29 (6):1236-43.
Lehtinen K. Mortality and cause of death in 398 patients admitted
to hospital with ankylosing spondylitis. Ann Rheum Dis 1993; 52: 174-76.
Barkham N, Emery P, Kong K et al. The Unmet need for biologic therapy
in Ankylosing Spondylitis.Accepted in abstract form for ACR 2003.
Braun J, Brandt J, Listing J et al. Treatment of active ankylosing
spondylitis with Infliximab: a randomised controlled multicentre trial.
Lancet 2002; 359: 1187-93.
Marzo-Ortega H, McGonagle D, O’Connor P et al. Efficacy of etanercept
in the treatment of entheseal pathology in resistant spondyloarthropathy.
A clinical and magnetic resonance imaging study. Arthritis Rheum 2001:
44; 2112-2117.
Braun J, Baraliakos X, Golder W et al. Magnetic Resonance Imaging
Examinations of the spine in patients with with Ankylosing Spondylitis,
before and after successful therapy with infliximab. Arthritis Rheum
2003; 48: 1126-36.
Rudwaleit M Baraliakos X, Listing J, Brandt J, Sieper J, Braun J.
magnetic resonance imaging f the spine and the sacroiliac joints in
Ankylosing Spondylitis and undifferentiated spondyloarthropathies
during treatment with etanercept. Ann Rheum Dis 2005;64:1305-1310.
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ASTRETCH
CONFERENCE OCTOBER 2004
The
inaugural conference of AStretch took place on October 5th 2004 at
the Chartered Society of Physiotherapy (CSP). It had been inspired
by the AStretch committee and subsequently organised by 3 of its members:
Karen Irons (Secretary), Claire Jeffries (Membership and Course secretary)
and Juliette O’Hea(Chairman) .
The event was sponsored by two pharmaceutical companies - Wyeth and
Schering-Plough. Participants included 40 physiotherapists and nurses
from all around the country who shared a keen interest and expertise
in the management of Ankylosing Spondylitis (A.S). Fergus Rogers from
the National Ankylosing Spondylitis Society (NASS) was also in attendance
and he was able to provide valuable information about NASS.
The conference
was opened by Juliette O’Hea, Chair of AStretch, who described
the aims and achievements of AStretch and introduced the new AStretch
website (www.astretch.co.uk).
This
was followed by an overview of the use of Remicade by a senior Medical
Affairs Project Manager from Schering-Plough.
Kirstie
Haywood completed the morning with a review of a range of patient-assessed
health instruments that could be used in the assessment of A.S. As
co-director of the Patient-assessed Health Instruments Group
(http://phi.uhce.ox.ac.uk),
National Centre for Health Outcomes
Development
at the University of Oxford, she was able to give an unbiased overview
of available tools available in the workplace Contact details: kirstie.haywood
During
a buffet lunch, there was a demonstration of a new device for measuring
neck rotation. It had been designed by an A.S patient and had been
on trial at the Royal National Hospital for Rheumatic Diseases in
Bath since April 2003. Please contact Peter Hamilton (01823 270074)
or at hamilton2005@gmail.com for further information.
The lunch
break also provided a perfect opportunity for networking. After lunch,
we were delighted to listen to Dr. Andrew Keat from Northwick Park
Hospital who gave a clear and entertaining overview of the BSR guidelines
for Biologic medication in A.S. As a specialist in the Spondyloarthropathies
and Chairman of the BSR working group on use of TNF Blockade Treatment
in A.S, his insight and knowledge was invaluable.
The final
two speakers of the day focused on psychological issues related to
A.S. Professor Julie Barlow (an A.S sufferer herself) from Coventry
University presented results from her research into the impact of
A.S on working life from a psychosocial perspective (contact details: j.barlow@coventry.ac.uk).
This
was followed by a presentation by Jane Martindale, a physiotherapist
at the Wrightington Hospital in Manchester. She and her colleagues
are undertaking a prospective study of A.S patients to establish any
possible links between disease status and psychological status (contact
details jane.martindale).
The conference
had been very successful in bringing together practitioners from all
around the country to listen to a very high standard of presentations
on very relevant topics. AStretch hope to organise another conference
in the Autumn.
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