SERVICE EVALUATION
Do Inpatient Multidisciplinary Rehabilitation Programmes Improve Health Status in People with LongTerm Musculoskeletal Conditions? A Service Evaluation William J. McCuish1* MSc, MCSP & Lindsay M. Bearne2 PhD, MSc, MCSP 1
Sussex Community NHS Trust, Bognor Regis, UK
2
King’s College London, London, UK
Abstract Background: Long-term musculoskeletal (MSK) conditions impair health and function. Guidelines recommend a multidisciplinary team (MDT) approach for the optimum management of people with long-term MSK conditions, but there is limited evidence for MDT care. This service evaluation investigates the short-term effectiveness of an inpatient MDT rehabilitation programme on self-reported function and disease status in people with long-term MSK conditions. Methods: A convenience sample of adults with rheumatoid arthritis (RA), osteoarthritis (OA), low back pain (LBP) and chronic widespread pain (CWP) participated in an inpatient MDT rehabilitation programme, consisting of needs assessment, collaborative goal setting and planning, exercise and self-management. The Routine Assessment of Patient Index Data (RAPID3) (primary outcome), the Multi-Dimensional Health Assessment Questionnaire (MDHAQ), Pain Visual Analogue Scale (VAS) and global well-being VAS were assessed at baseline and immediately following MDT rehabilitation. Results: A total of 183 people [mean age 62 (standard deviation, 14.5) years, 145 females] with RA, OA, LBP or CWP were evaluated before and after inpatient MDT rehabilitation (median duration, ten days). Overall, there was a 28% improvement in RAPID3 (mean difference [95% confidence intervals] in effect size, 5.0 [4.3, 5.8], d = –0.98, p < 0.05). Clinically relevant changes were found in people with RA (5.7 [4.4, 6.9], d = –1.08, p < 0.05, 32%), OA 6.1 [3.4, 8.7], d = –1.07, p < 0.05, 35%), LBP 4.0 [2.8, 5.2], d = –0.91, p < 0.05, 22%), CWP 4.6 [2.7, 6.6], d = –0.84, p < 0.05, 25%). These changes were reflected in all secondary outcomes. Conclusion: This inpatient MDT rehabilitation programme provides short-term evidence of improved function and disease status in people with long term MSK conditions. Copyright © 2014 John Wiley & Sons, Ltd. Keywords MDT; multidisciplinary; rehabilitation; musculoskeletal *Correspondence William McCuish, Rheumatology Unit, Bognor Regis War Memorial Hospital, Sussex Community NHS Trust, Shripney Road, Bognor Regis, PO22 9PP, UK. Tel: +44 (0)1243 623558. Email: [email protected]
Published online 19 May 2014 in Wiley Online Library (wileyonlinelibrary.com) DOI: 10.1002/msc.1072
Introduction Long-term musculoskeletal (MSK) conditions, defined as ‘conditions that cannot, at present, be cured, but can be controlled by medication and other therapies’ (Department of Health, 2013), impair health and function. They affect 4–5% of the adult population in 244
North America and Western Europe, are the leading medical cause for long-term absence from work and have considerable socioeconomic consequences (Woolf and Pfleger, 2003). Multidisciplinary care aims to improve disease activity, and physical and psychosocial function and is Musculoskelet. Care 12 (2014) 244–250 © 2014 John Wiley & Sons, Ltd.
McCuish and Bearne
a key, widely implemented management strategy for long-term MSK conditions such as osteoarthritis (OA) and rheumatoid arthritis (RA) (Carville et al., 2008; Koes et al., 2010; Luqmani et al., 2006; National Collaborating Centre for Chronic Conditions, 2009; Zhang et al., 2008). While the composition of multidisciplinary teams (MDTs) and mode of delivery (inpatient, outpatient, day care) vary, the MDT approach provides regular assessment and tailored disease management from specialist medical and allied health professional staff. One key element of MDT care is that it is formally organized and coordinated via team conferences, meetings or other forms of communication which identify, evaluate and refine collaborative goals and treatment plans with each patient (Jelles et al., 1995). While there is evidence to support the effectiveness of individual medical and therapy interventions in the management of long-term MSK conditions (Bearne et al., 2002; Chou and Huffman 2007a,2007b; Dziedzic and Hammond, 2010; Manning et al., 2014), there is limited evidence for the effectiveness of coordinated MDT care. This service evaluation investigated the effectiveness of a multidisciplinary inpatient rehabilitation programme in a UK primary care rheumatology unit on the function and disease status of people with long-term MSK conditions.
Methods Ethical and research governance approval was sought from the National Research and Ethics Service and Sussex Community NHS Trust (but was not required) for this before and after service evaluation. Participants An arbitrary sample of consecutive, eligible people admitted for MDT rehabilitation in a primary care rheumatology inpatient healthcare facility between April 2011 and September 2011 were invited to participate in this service evaluation. Admission to the inpatient MDT programme was based on a tailored, multidisciplinary needs assessment during an outpatient consultation, usually for uncontrolled pain, disease activity and/or deteriorating physical or psychosocial function, which would benefit from an intense inpatient MDT programme. Patients were eligible for inclusion in this service evaluation if they were: • over 18 years of age • able to participate in the MDT rehabilitation and had one of the following: Musculoskelet. Care 12 (2014) 244–250 © 2014 John Wiley & Sons, Ltd.
MDT Rehabilitation in Long-Term MSK Conditions
• established RA [American College of Rheumatology (ACR) 1987 revised criteria (Arnett et al., 1988)] • a primary, radiographically confirmed, diagnosis of OA in one or more joints • physician-confirmed persistent mechanical low back pain (LBP) (≥ 3 months’ duration) or • diagnosed chronic widespread pain (CWP) (including fibromyalgia [ACR criteria 1990 (Wolfe et al., 1990)]. Exclusion criteria Patients were excluded from the service evaluation if they: • had participated in our MDT rehabilitation programme within the previous six months • were unable to consent to or communicate sufficiently to complete the assessments. Protocol Eligible patients were approached by a consultant rheumatologist, a rheumatology nurse specialist, a specialist rheumatology physiotherapist or a consultant pain physician, and invited to participate in the service evaluation. All outcome measures were collected on admission and discharge from the MDT programme by a specialist rheumatology physiotherapist (WM). Outcome measures The primary outcome measure was the Routine Assessment of Patient Index Data (RAPID3), a measure of health and disease status that is appropriate for monitoring all rheumatic diseases (Pincus et al., 2009). This selfreported measure comprises the Multi-Dimensional Health Assessment Questionnaire (MDHAQ), Pain Visual Analogue Scale (VAS) and global well-being VAS (Pincus et al., 1999, 2005). The RAPID3 is scored on a 0–30 scale and, in people with RA, a score of >12 points represents high disease severity, 6.1–12 points moderate severity, 3.1–6 points low severity and ≤3 points represents disease remission (Pincus et al., 2011). Secondary outcome measures included: • The MDHAQ, a valid and reliable self-reported measure of function, which requires participants to rate their ability to complete ten tasks, within the previous seven days, on a 0 (without any difficulty) to 3 (unable to do) scale (Pincus et al., 1999, 2005). The total score ranges from 0 (no difficulty) to 30 245
MDT Rehabilitation in Long-Term MSK Conditions
(high difficulty), which is transformed to a 0–10 score for inclusion in the RAPID3. • Self-reported pain (VAS; 0 = no pain to 10 = pain as bad as could be) and global well-being (VAS; 0 = very well to 10 = very poorly) were recorded to assess patient-perceived pain and health status during the previous seven days (Jensen et al., 1999).
McCuish and Bearne
the rheumatology nurse specialist, who coordinated the MDT care. Participants were discharged from the programme after ten days, once the majority of the agreed short-term MDT goals had been achieved. If the majority of goals had not been achieved, participants continued with the inpatient rehabilitation programme for a further five days or referred to the appropriate community teams for further management.
The inpatient MDT rehabilitation programme The MDT consisted of a rheumatology consultant, rheumatology nurse specialist, specialist rheumatology physiotherapists and a specialist rheumatology occupational therapist, although referral to other health and social care professionals was available, if required (e.g. podiatrist, social worker and clinical psychologist). Typically, participants were admitted for a tenday rehabilitation programme from Monday to Friday and returned home for the weekend, although the programme could be extended, if required (maximum duration 15 days). The overarching aims of the MDT programme were to optimize disease and health status, including: conducting a needs assessment, optimizing physical and psychosocial function and disease activity, promoting pain management and self-management strategies. Each member of the MDT completed an individual assessment of the participant during the first two days of admission. Overarching rehabilitation goals, management and action plans were discussed and agreed during an MDT meeting. This meeting was attended by the participant, who was encouraged to contribute to their management goals and plan through open questioning, collaborative discussion and by actively seeking the participant’s contribution to goal setting. A daily tailored multidisciplinary rehabilitation programme was agreed by the MDT and coordinated by the rheumatology nurse specialist (Table 1). All participants attended the core elements of the programme, and additional group (hand therapy or circuit training) or individual treatment was completed, as required (Table 1). A record of attendance was recorded in the participant’s medical records. Participant progress, management and action plans were reviewed weekly in MDT meetings, in collaboration with each participant. Participants would usually attend two MDT meetings with all MDT members during the ten-day programme. However, the agreed goals and MDT plans were reviewed daily with the participant by 246
Data analysis Analysis was completed on an intention-to-treat basis using SPSS version 18 for Windows (SPSS Inc. Chicago, IL, USA) and values are presented as mean [95% confidence intervals (CIs)] unless otherwise stated. Differences in outcome before (data collected on admission) and after (data collected on discharge) MDT rehabilitation were examined using descriptive statistics (% change) and paired t-tests. Statistical significance was set at the 95% confidence level, and a 20% change was considered clinically relevant in people with RA (Felson et al., 1995). Standardized effect sizes of the pre- to post-MDT programme differences were calculated using Cohen’s d and interpreted as small d = 0.2, medium d = 0.5 and large d = 0.8 (Cohen, 1988).
Results Participant characteristics A total of 252 patients were admitted to the rheumatology unit between April and September 2011, of whom 183 [145 females, mean age 62 years (standard deviation 14.5)] were eligible, agreed to take part and completed this service evaluation (Table 2). Rehabilitation programme The median length of the inpatient MDT rehabilitation programme was ten days (range 5–15 days). All participants completed the core elements of the programme and were discharged when they achieved their main short-term goals. Five participants received 15 days of rehabilitation in order to achieve their main short-term goals. Primary outcome measure: The routine assessment of patient index data (RAPID3) Overall, following inpatient MDT rehabilitation, there was a 28% improvement in RAPID3 [mean difference, 5.0 (95% CI 4.3–5.8), d = 0.98, p < 0.05]. Changes in Musculoskelet. Care 12 (2014) 244–250 © 2014 John Wiley & Sons, Ltd.
McCuish and Bearne
MDT Rehabilitation in Long-Term MSK Conditions
Table 1. The components of a tailored inpatient Multidisciplinary Team (MDT) rehabilitation programme for people with long-term musculoskeletal conditions Frequency Daily
Weekly
As required
Intervention
MDT member(s)
Group exercise session (45 minutes) – consisting of aerobic, strengthening and range of movement exercises
Physiotherapy
Tailored self-directed exercise programme (30 minutes). Designed to be continued on as a home exercise programme Hydrotherapy (30 minutes) – a tailored programme of aerobic, strengthening and range of movement exercise Group relaxation sessions (60 minutes) Medical, nursing and pharmacological review MDT meeting
Nursing, physiotherapy and occupational therapy
Interactive group educational sessions on disease pathophysiology, pain management, medication management, lifestyle and exercise (60 minutes). Four sessions per week Group hand therapy (60 minutes) – hand therapy session Circuit training (45 minutes) – Group circuit training consisting of 12 stations of 2-minute exercise. Designed to increase strength and improve aerobic fitness. Individual treatment
Physiotherapy
Occupational therapy Medical and nursing team All team members All team members
Occupational therapy Physiotherapy.
All MDT members and other health and social care professionals (e.g. psychologist, podiatrist)
Highlighted sessions indicate core sessions completed by all participants
RAPID3 were found in those with RA (d = –1.08, 32%), OA (d = –1.07, 35%), LBP (d = –0.91, 22%) and CWP (d = –0.84, 25%) (all p < 0.05; Table 2). In people with RA, these changes are clinically relevant (Felson et al., 1995). At baseline, 86% of people with RA were categorized as having high disease severity, 11% moderate severity and 3% low severity. On discharge, 58% of participants with RA were categorized as having high disease severity, 23% moderate severity, 5% low severity and 3% were in remission (Pincus et al., 2011). Secondary outcomes All secondary outcomes, in all conditions, improved following MDT rehabilitation (Table 2).
Discussion In people with common, long-term MSK conditions, an inpatient MDT rehabilitation programme improves self-reported physical function, pain and global health status in the short term. These findings are important Musculoskelet. Care 12 (2014) 244–250 © 2014 John Wiley & Sons, Ltd.
as there is a paucity of evidence supporting the effectiveness of an MDT approach for the management of long-term MSK conditions, despite its recommendation in national clinical guidelines (National Collaborating Centre for Chronic Conditions, 2009). The present service evaluation has several strengths; it included a range of common long-term MSK conditions, in addition to which, the types of healthcare professional in our MDT, and the duration and content of our rehabilitation programme reflected those in other MDT programmes (Lambeek et al., 2010; Lambert et al., 1998; Tijhuis et al., 2002; Zhang et al., 2008). While our MDT rehabilitation programme contains interventions universal to all participants (e.g. assessment by MDT members, collaborative MDT goal setting, group exercise, pain and self-management education), it is tailored to the needs of each participant, allowing people with different conditions and disease severity to receive rehabilitation concurrently. During data collection, no eligible patients refused to participate in, or withdrew from, the service evaluation, so our outcome data set 247
MDT Rehabilitation in Long-Term MSK Conditions
McCuish and Bearne
Table 2. Disease and health status before and after an inpatient multidisciplinary team rehabilitation programme for people with longterm musculoskeletal conditions
Number (female) Age (years (SD)) RAPID3
MDHAQ
Pain
Global well-being
PrePostChange d PrePostChange d PrePostChange d PrePostChange d
Rheumatoid arthritis
Osteoarthritis
Persistent low back pain
Chronic widespread pain
72 (58) 63 (17.7) 17.9 (16.6–19.3) 12.2 (11.1–13.8) 5.7 (4.4–6.9) * –1.1 4.7 (4.4–5.2) 4.0 (3.8–4.6) 0.7 (0.4–1.0)* –0.4 7.1 (6.5–7.4) 4.7 (4.1–5.4) 2.4 (1.8–3.0)* –1.15 6.0 (5.5–6.6) 3.4 (3.0–4.0) 2.6 (2.0–3.3)* –1.1
23 (22) 75 (8.5) 17.4 (14.8–19.9) 11.3 (9.0–13.6) 6.1 (3.4–8.7)* –1.1 4.3 (3.6–5.0) 3.5 (2.8–4.2) 0.8 (0.2–1.4) ** -0.5 7.2 (6.1–8.3) 4.7 (3.6–5.7) 2.5 (1.1–3.9)** –1.00 5.8 (4.6–7.0) 3.0 (2.1–4.1) 2.8 (1.5–4.0) * –1.0
55 (37) 59 (16.4) 18.1 (16.9–19.3) 14.1 (12.8–15.4) 4.0 (2.8–5.2)* –0.9 4.4 (4.0–4.7) 3.8 (3.4–4.1) 0.6 (0.3–0.9)* –0.5 7.6 (7.0–8.1) 5.9 (5.3–8.5) 1.7 (1.1–2.3)* –0.8 6.2 (5.6–6.9) 4.4 (3.8–5.1) 1.8 (1.2–2.4)* –0.8
33 (28) 53 (15.5) 18.3 (16.2–20.3) 13.7 (11.7–15.6) 4.6 (2.7–6.6)* –0.5 4.7 (4.0–5.4) 3.7 (3.0–4.4) 1.0 (0.4–1.5)** –0.5 7.2 (6.4–8.1) 6.0 (5.1–7.0) 1.2 (0.2–2.1)* –0.5 6.4 (5.5–7.2) 3.9 (3.1–4.7) 2.5 (1.6–3.3)* –1.1
MDHAQ, Multi-Dimensional Health Assessment Questionnaire ; RAPID3, Routine Assessment of Patient Index Data. All mean (95% confidence interval) unless otherwise stated. *p
Do Inpatient Multidisciplinary Rehabilitation Programmes Improve Health Status in People with LongTerm Musculoskeletal Conditions? A Service Evaluation William J. McCuish1* MSc, MCSP & Lindsay M. Bearne2 PhD, MSc, MCSP 1
Sussex Community NHS Trust, Bognor Regis, UK
2
King’s College London, London, UK
Abstract Background: Long-term musculoskeletal (MSK) conditions impair health and function. Guidelines recommend a multidisciplinary team (MDT) approach for the optimum management of people with long-term MSK conditions, but there is limited evidence for MDT care. This service evaluation investigates the short-term effectiveness of an inpatient MDT rehabilitation programme on self-reported function and disease status in people with long-term MSK conditions. Methods: A convenience sample of adults with rheumatoid arthritis (RA), osteoarthritis (OA), low back pain (LBP) and chronic widespread pain (CWP) participated in an inpatient MDT rehabilitation programme, consisting of needs assessment, collaborative goal setting and planning, exercise and self-management. The Routine Assessment of Patient Index Data (RAPID3) (primary outcome), the Multi-Dimensional Health Assessment Questionnaire (MDHAQ), Pain Visual Analogue Scale (VAS) and global well-being VAS were assessed at baseline and immediately following MDT rehabilitation. Results: A total of 183 people [mean age 62 (standard deviation, 14.5) years, 145 females] with RA, OA, LBP or CWP were evaluated before and after inpatient MDT rehabilitation (median duration, ten days). Overall, there was a 28% improvement in RAPID3 (mean difference [95% confidence intervals] in effect size, 5.0 [4.3, 5.8], d = –0.98, p < 0.05). Clinically relevant changes were found in people with RA (5.7 [4.4, 6.9], d = –1.08, p < 0.05, 32%), OA 6.1 [3.4, 8.7], d = –1.07, p < 0.05, 35%), LBP 4.0 [2.8, 5.2], d = –0.91, p < 0.05, 22%), CWP 4.6 [2.7, 6.6], d = –0.84, p < 0.05, 25%). These changes were reflected in all secondary outcomes. Conclusion: This inpatient MDT rehabilitation programme provides short-term evidence of improved function and disease status in people with long term MSK conditions. Copyright © 2014 John Wiley & Sons, Ltd. Keywords MDT; multidisciplinary; rehabilitation; musculoskeletal *Correspondence William McCuish, Rheumatology Unit, Bognor Regis War Memorial Hospital, Sussex Community NHS Trust, Shripney Road, Bognor Regis, PO22 9PP, UK. Tel: +44 (0)1243 623558. Email: [email protected]
Published online 19 May 2014 in Wiley Online Library (wileyonlinelibrary.com) DOI: 10.1002/msc.1072
Introduction Long-term musculoskeletal (MSK) conditions, defined as ‘conditions that cannot, at present, be cured, but can be controlled by medication and other therapies’ (Department of Health, 2013), impair health and function. They affect 4–5% of the adult population in 244
North America and Western Europe, are the leading medical cause for long-term absence from work and have considerable socioeconomic consequences (Woolf and Pfleger, 2003). Multidisciplinary care aims to improve disease activity, and physical and psychosocial function and is Musculoskelet. Care 12 (2014) 244–250 © 2014 John Wiley & Sons, Ltd.
McCuish and Bearne
a key, widely implemented management strategy for long-term MSK conditions such as osteoarthritis (OA) and rheumatoid arthritis (RA) (Carville et al., 2008; Koes et al., 2010; Luqmani et al., 2006; National Collaborating Centre for Chronic Conditions, 2009; Zhang et al., 2008). While the composition of multidisciplinary teams (MDTs) and mode of delivery (inpatient, outpatient, day care) vary, the MDT approach provides regular assessment and tailored disease management from specialist medical and allied health professional staff. One key element of MDT care is that it is formally organized and coordinated via team conferences, meetings or other forms of communication which identify, evaluate and refine collaborative goals and treatment plans with each patient (Jelles et al., 1995). While there is evidence to support the effectiveness of individual medical and therapy interventions in the management of long-term MSK conditions (Bearne et al., 2002; Chou and Huffman 2007a,2007b; Dziedzic and Hammond, 2010; Manning et al., 2014), there is limited evidence for the effectiveness of coordinated MDT care. This service evaluation investigated the effectiveness of a multidisciplinary inpatient rehabilitation programme in a UK primary care rheumatology unit on the function and disease status of people with long-term MSK conditions.
Methods Ethical and research governance approval was sought from the National Research and Ethics Service and Sussex Community NHS Trust (but was not required) for this before and after service evaluation. Participants An arbitrary sample of consecutive, eligible people admitted for MDT rehabilitation in a primary care rheumatology inpatient healthcare facility between April 2011 and September 2011 were invited to participate in this service evaluation. Admission to the inpatient MDT programme was based on a tailored, multidisciplinary needs assessment during an outpatient consultation, usually for uncontrolled pain, disease activity and/or deteriorating physical or psychosocial function, which would benefit from an intense inpatient MDT programme. Patients were eligible for inclusion in this service evaluation if they were: • over 18 years of age • able to participate in the MDT rehabilitation and had one of the following: Musculoskelet. Care 12 (2014) 244–250 © 2014 John Wiley & Sons, Ltd.
MDT Rehabilitation in Long-Term MSK Conditions
• established RA [American College of Rheumatology (ACR) 1987 revised criteria (Arnett et al., 1988)] • a primary, radiographically confirmed, diagnosis of OA in one or more joints • physician-confirmed persistent mechanical low back pain (LBP) (≥ 3 months’ duration) or • diagnosed chronic widespread pain (CWP) (including fibromyalgia [ACR criteria 1990 (Wolfe et al., 1990)]. Exclusion criteria Patients were excluded from the service evaluation if they: • had participated in our MDT rehabilitation programme within the previous six months • were unable to consent to or communicate sufficiently to complete the assessments. Protocol Eligible patients were approached by a consultant rheumatologist, a rheumatology nurse specialist, a specialist rheumatology physiotherapist or a consultant pain physician, and invited to participate in the service evaluation. All outcome measures were collected on admission and discharge from the MDT programme by a specialist rheumatology physiotherapist (WM). Outcome measures The primary outcome measure was the Routine Assessment of Patient Index Data (RAPID3), a measure of health and disease status that is appropriate for monitoring all rheumatic diseases (Pincus et al., 2009). This selfreported measure comprises the Multi-Dimensional Health Assessment Questionnaire (MDHAQ), Pain Visual Analogue Scale (VAS) and global well-being VAS (Pincus et al., 1999, 2005). The RAPID3 is scored on a 0–30 scale and, in people with RA, a score of >12 points represents high disease severity, 6.1–12 points moderate severity, 3.1–6 points low severity and ≤3 points represents disease remission (Pincus et al., 2011). Secondary outcome measures included: • The MDHAQ, a valid and reliable self-reported measure of function, which requires participants to rate their ability to complete ten tasks, within the previous seven days, on a 0 (without any difficulty) to 3 (unable to do) scale (Pincus et al., 1999, 2005). The total score ranges from 0 (no difficulty) to 30 245
MDT Rehabilitation in Long-Term MSK Conditions
(high difficulty), which is transformed to a 0–10 score for inclusion in the RAPID3. • Self-reported pain (VAS; 0 = no pain to 10 = pain as bad as could be) and global well-being (VAS; 0 = very well to 10 = very poorly) were recorded to assess patient-perceived pain and health status during the previous seven days (Jensen et al., 1999).
McCuish and Bearne
the rheumatology nurse specialist, who coordinated the MDT care. Participants were discharged from the programme after ten days, once the majority of the agreed short-term MDT goals had been achieved. If the majority of goals had not been achieved, participants continued with the inpatient rehabilitation programme for a further five days or referred to the appropriate community teams for further management.
The inpatient MDT rehabilitation programme The MDT consisted of a rheumatology consultant, rheumatology nurse specialist, specialist rheumatology physiotherapists and a specialist rheumatology occupational therapist, although referral to other health and social care professionals was available, if required (e.g. podiatrist, social worker and clinical psychologist). Typically, participants were admitted for a tenday rehabilitation programme from Monday to Friday and returned home for the weekend, although the programme could be extended, if required (maximum duration 15 days). The overarching aims of the MDT programme were to optimize disease and health status, including: conducting a needs assessment, optimizing physical and psychosocial function and disease activity, promoting pain management and self-management strategies. Each member of the MDT completed an individual assessment of the participant during the first two days of admission. Overarching rehabilitation goals, management and action plans were discussed and agreed during an MDT meeting. This meeting was attended by the participant, who was encouraged to contribute to their management goals and plan through open questioning, collaborative discussion and by actively seeking the participant’s contribution to goal setting. A daily tailored multidisciplinary rehabilitation programme was agreed by the MDT and coordinated by the rheumatology nurse specialist (Table 1). All participants attended the core elements of the programme, and additional group (hand therapy or circuit training) or individual treatment was completed, as required (Table 1). A record of attendance was recorded in the participant’s medical records. Participant progress, management and action plans were reviewed weekly in MDT meetings, in collaboration with each participant. Participants would usually attend two MDT meetings with all MDT members during the ten-day programme. However, the agreed goals and MDT plans were reviewed daily with the participant by 246
Data analysis Analysis was completed on an intention-to-treat basis using SPSS version 18 for Windows (SPSS Inc. Chicago, IL, USA) and values are presented as mean [95% confidence intervals (CIs)] unless otherwise stated. Differences in outcome before (data collected on admission) and after (data collected on discharge) MDT rehabilitation were examined using descriptive statistics (% change) and paired t-tests. Statistical significance was set at the 95% confidence level, and a 20% change was considered clinically relevant in people with RA (Felson et al., 1995). Standardized effect sizes of the pre- to post-MDT programme differences were calculated using Cohen’s d and interpreted as small d = 0.2, medium d = 0.5 and large d = 0.8 (Cohen, 1988).
Results Participant characteristics A total of 252 patients were admitted to the rheumatology unit between April and September 2011, of whom 183 [145 females, mean age 62 years (standard deviation 14.5)] were eligible, agreed to take part and completed this service evaluation (Table 2). Rehabilitation programme The median length of the inpatient MDT rehabilitation programme was ten days (range 5–15 days). All participants completed the core elements of the programme and were discharged when they achieved their main short-term goals. Five participants received 15 days of rehabilitation in order to achieve their main short-term goals. Primary outcome measure: The routine assessment of patient index data (RAPID3) Overall, following inpatient MDT rehabilitation, there was a 28% improvement in RAPID3 [mean difference, 5.0 (95% CI 4.3–5.8), d = 0.98, p < 0.05]. Changes in Musculoskelet. Care 12 (2014) 244–250 © 2014 John Wiley & Sons, Ltd.
McCuish and Bearne
MDT Rehabilitation in Long-Term MSK Conditions
Table 1. The components of a tailored inpatient Multidisciplinary Team (MDT) rehabilitation programme for people with long-term musculoskeletal conditions Frequency Daily
Weekly
As required
Intervention
MDT member(s)
Group exercise session (45 minutes) – consisting of aerobic, strengthening and range of movement exercises
Physiotherapy
Tailored self-directed exercise programme (30 minutes). Designed to be continued on as a home exercise programme Hydrotherapy (30 minutes) – a tailored programme of aerobic, strengthening and range of movement exercise Group relaxation sessions (60 minutes) Medical, nursing and pharmacological review MDT meeting
Nursing, physiotherapy and occupational therapy
Interactive group educational sessions on disease pathophysiology, pain management, medication management, lifestyle and exercise (60 minutes). Four sessions per week Group hand therapy (60 minutes) – hand therapy session Circuit training (45 minutes) – Group circuit training consisting of 12 stations of 2-minute exercise. Designed to increase strength and improve aerobic fitness. Individual treatment
Physiotherapy
Occupational therapy Medical and nursing team All team members All team members
Occupational therapy Physiotherapy.
All MDT members and other health and social care professionals (e.g. psychologist, podiatrist)
Highlighted sessions indicate core sessions completed by all participants
RAPID3 were found in those with RA (d = –1.08, 32%), OA (d = –1.07, 35%), LBP (d = –0.91, 22%) and CWP (d = –0.84, 25%) (all p < 0.05; Table 2). In people with RA, these changes are clinically relevant (Felson et al., 1995). At baseline, 86% of people with RA were categorized as having high disease severity, 11% moderate severity and 3% low severity. On discharge, 58% of participants with RA were categorized as having high disease severity, 23% moderate severity, 5% low severity and 3% were in remission (Pincus et al., 2011). Secondary outcomes All secondary outcomes, in all conditions, improved following MDT rehabilitation (Table 2).
Discussion In people with common, long-term MSK conditions, an inpatient MDT rehabilitation programme improves self-reported physical function, pain and global health status in the short term. These findings are important Musculoskelet. Care 12 (2014) 244–250 © 2014 John Wiley & Sons, Ltd.
as there is a paucity of evidence supporting the effectiveness of an MDT approach for the management of long-term MSK conditions, despite its recommendation in national clinical guidelines (National Collaborating Centre for Chronic Conditions, 2009). The present service evaluation has several strengths; it included a range of common long-term MSK conditions, in addition to which, the types of healthcare professional in our MDT, and the duration and content of our rehabilitation programme reflected those in other MDT programmes (Lambeek et al., 2010; Lambert et al., 1998; Tijhuis et al., 2002; Zhang et al., 2008). While our MDT rehabilitation programme contains interventions universal to all participants (e.g. assessment by MDT members, collaborative MDT goal setting, group exercise, pain and self-management education), it is tailored to the needs of each participant, allowing people with different conditions and disease severity to receive rehabilitation concurrently. During data collection, no eligible patients refused to participate in, or withdrew from, the service evaluation, so our outcome data set 247
MDT Rehabilitation in Long-Term MSK Conditions
McCuish and Bearne
Table 2. Disease and health status before and after an inpatient multidisciplinary team rehabilitation programme for people with longterm musculoskeletal conditions
Number (female) Age (years (SD)) RAPID3
MDHAQ
Pain
Global well-being
PrePostChange d PrePostChange d PrePostChange d PrePostChange d
Rheumatoid arthritis
Osteoarthritis
Persistent low back pain
Chronic widespread pain
72 (58) 63 (17.7) 17.9 (16.6–19.3) 12.2 (11.1–13.8) 5.7 (4.4–6.9) * –1.1 4.7 (4.4–5.2) 4.0 (3.8–4.6) 0.7 (0.4–1.0)* –0.4 7.1 (6.5–7.4) 4.7 (4.1–5.4) 2.4 (1.8–3.0)* –1.15 6.0 (5.5–6.6) 3.4 (3.0–4.0) 2.6 (2.0–3.3)* –1.1
23 (22) 75 (8.5) 17.4 (14.8–19.9) 11.3 (9.0–13.6) 6.1 (3.4–8.7)* –1.1 4.3 (3.6–5.0) 3.5 (2.8–4.2) 0.8 (0.2–1.4) ** -0.5 7.2 (6.1–8.3) 4.7 (3.6–5.7) 2.5 (1.1–3.9)** –1.00 5.8 (4.6–7.0) 3.0 (2.1–4.1) 2.8 (1.5–4.0) * –1.0
55 (37) 59 (16.4) 18.1 (16.9–19.3) 14.1 (12.8–15.4) 4.0 (2.8–5.2)* –0.9 4.4 (4.0–4.7) 3.8 (3.4–4.1) 0.6 (0.3–0.9)* –0.5 7.6 (7.0–8.1) 5.9 (5.3–8.5) 1.7 (1.1–2.3)* –0.8 6.2 (5.6–6.9) 4.4 (3.8–5.1) 1.8 (1.2–2.4)* –0.8
33 (28) 53 (15.5) 18.3 (16.2–20.3) 13.7 (11.7–15.6) 4.6 (2.7–6.6)* –0.5 4.7 (4.0–5.4) 3.7 (3.0–4.4) 1.0 (0.4–1.5)** –0.5 7.2 (6.4–8.1) 6.0 (5.1–7.0) 1.2 (0.2–2.1)* –0.5 6.4 (5.5–7.2) 3.9 (3.1–4.7) 2.5 (1.6–3.3)* –1.1
MDHAQ, Multi-Dimensional Health Assessment Questionnaire ; RAPID3, Routine Assessment of Patient Index Data. All mean (95% confidence interval) unless otherwise stated. *p
