water exercise and manual therapies for arthritis melainie cameron thesis submitted to satisfy the

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JOINT EFFECTS:
WATER EXERCISE AND MANUAL THERAPIES FOR ARTHRITIS
MELAINIE CAMERON
THESIS SUBMITTED TO SATISFY THE REQUIREMENT FOR THE
DOCTOR OF PHILOSOPHY
SCHOOL OF HUMAN MOVEMENT, RECREATION AND PERFORMANCE
VICTORIA UNIVERSITY
20 JANUARY 2005
FTS THESIS
616.72206 CAM
30001008090203
Cameron, Melainie
Joint effects : water
exercise and manual
therapies for arthritis
ABSTRACT
This thesis was an investigation of the relative effects of manual therapies and
warm-water exercise on the health-related quality of life (HRQOL) of people with
common arthritides (rheumatoid arthritis [RA] or osteoarthritis [OA]). The thesis
comprised a pilot study and three linked clinical studies.
The three clinical studies were randomised, unblinded, controlled, clinical trials of
three or four groups with repeated measures. The mixed design allowed comparison
between and within groups. The intervention component of each clinical study lasted for
10 weeks (concurrent with one Victorian school term). Each clinical study included
adjunctive therapy and control (usual care) groups, to which participants were randomly
allocated. Participation in each of the studies was voluntary. Participants were free to
withdraw from any study at any time. Participants who were unable or unwilling to
participate in the intervention groups were re-allocated to the control group or withdrew
from the studies.
The Pilot Study (see Chapter 3) concerned validation of the data collection tools
prior to use in the clinical studies. A battery of standardised, validated questionnaires was
used for data collection in each of the clinical studies. Measures of generic quality of life
(SF-36; Ware & Sherboume, 1992), pain (Short Form McGill Pain Questionnaire, SF-
MPQ; Melzack, 1987), arthritis-specific health status (AIMS2; Meenan, Mason, Anderson,
Guccione, & Kazis, 1992) and social support (Medical Outcomes Study Social Support
Survey, MOS-SS; Sherboume & Stewart, 1991) were collected at baseline, week 5 and
week 9 of each of the 10-week trials, and at 2 weeks and 14 weeks after completion of the
interventions in Study 3 (i.e., weeks 12 and 24).
Analyses of covariance (ANCOVA) were used to assess group differences for the
SF-36, AIMS2, SF-MPQ, and MOS-SS measures. Pre-intervention (i.e., week 1, baseline)
scores for each HRQOL subscale and total social support at week 9, were used as
11
covariates to control for initial differences between groups and any social support
afforded by the interventions.
In Study 1 (people with OA) improvements in HRQOL were consistently observed
in the joint mobilisation group, and on many HRQOL domains, these improvements were
associated with large to very large effect sizes. Participants in the massage group improved
only moderately compared with the control group across the same measures.
Results differed according to disease profiles. Several participants with RA
assigned to manual therapy groups reported worsening pain and withdrew from Study 2.
Results from Study 2 were inconclusive, and hampered by small sample sizes. Reasons for,
and lessons arising from, the failure of Study 2 are discussed in detail (see Chapter 5).
Results from Studies 1 and 2 informed the design of Study 3, which did not include a
massage group or any people with RA.
In Study 3, 22 adults with an average of 15 years of osteoarthritis were randomly
assigned to usual care (control; n = 4), joint mobilization (n = 4), warm-water exercise {n =
8), or combined joint mobilization and warm-water exercise {n - 6) groups. At week 9
participants in the intervention groups reported better HRQOL across most subscales than
participants in the control (usual care) group. The combined therapies group outperformed
the control and single therapy groups on the mobility, household tasks, arthritis pain,
mood, and satisfaction subscales of the AIMS2, as well as the sensory pain, total pain, and
present pain index components of the SF-MPQ, and the physical role limitations, bodily
pain, general health, social function, and health transition subscales of the SF-36. Many of
the improvements in HRQOL reported at week 9 were maintained at week 12 and week 24
(2 and 14 weeks post intervention).
Repeated measures analyses of covariance (ANCOVA), using baseline measures
and week 9 social support scores as covariates, revealed that large to very large effects
(improvements) on the arthritis pain (r| = .25), mood {y\ = .35), and satisfaction {r\ = .21)
Ill
subscales of the AIMS2 could be attributed to participation in the combined therapies.
The same pattern was evident for the sensory pain (ri^ = .29), total pain (r|^ = .23), and
present pain index (T] = .37) components of the SF-MPQ, and the physical role limitations
(r| = .26), bodily pain (r\ = .18), social function (r| = .33), and health transition (r| =
.28) subscales of the SF-36.
Differences in social support, and medication use, across time and between groups
were negligible, and do not account for the reported improvements. The results are
interpreted, as recommended by Kazis, Anderson, and Meenan (1989), in terms of
clinically meaningful effect sizes, rather than statistical significance, due to the small
sample size and the increased probability of Type II errors. Omnibus effect sizes are
reported as r| . Eta squared (TJ ) represents the amount of variance in a variable accounted
for by group membership (Tabachnick & Fidell, 2001), and is therefore a relevant measure
of effect size because it explains the strength of association between treatments and the
variables measured. Univariate effect sizes (Cohen's d) are reported as estimates of the
magnitude of change between and within groups for each intervention and each HRQOL
domaia
Overall the results indicate that the combination of joint mobilisation and warm-
water exercise appears to be more effective than either therapy in isolation for improving
quality of life in people with OA. The usefulness of combined therapies needs to be
balanced against the financial costs of the same. The persistence of HRQOL improvements
at 2 weeks post therapy suggests that fortnightly therapy is worthy of investigation, an
approach that would make combined therapies more affordable.
IV
TABLE OF CONTENTS
ABSTRACT
TABLE OF CONTENTS
IV
DECLARATION OF AUTHORSHIP xi
ACKNOWLEDGEMENTS xii
DISCLOSURE xiii
LIST OF TABLES AND FIGURES xiv
LIST OF APPENDICES xvi
LIST OF PUBLICATIONS ARISING FROM THESIS xvii
CHAPTER 1: INTRODUCTION 1
Treatments for Arthritis 2
Health-Related Quality of Life 5
Why Do this Research? 6
Significance of the Research 6
Contribution to Knowledge 7
CHAPTER 2: REVIEW OF LITERATURE 8
Overview of Arthritis 8
Epidemiology 8
Incidence 8
Prevalence 9
Types of Arthritides 10
Diagnoses and Diagnostic Criteria 14
Treatment and Management of Arthritides 19
Usual Medical Care 19
Monitoring Arthritis 22
Joint Counts 23
Serology 24
Imaging 25
Osteoarthritis 25
Rheumatoid arthritis 26
Magnetic resonance imaging 27
Self-report Measures 28
Improvement Criteria 29
Allied Medical, Complementary, and Alternative Therapies 32
Active Therapies: Exercise 33
Passive Therapies: Manual Therapy 36
Physical and Manual Therapies: Possible Mechanisms of Action 39
Health-Related Quality of Life 40
Impairment, Disability, and Handicap 42
Psychological Considerations 44
Psychological Constructs Important in Arthritis Care 45
Working alliance 45
Locus of control 47
Self-efficacy 49
Stages of change 49
Life events. Disease onset. Diagnosis, and Psychological Health 52
Pain 54
Pain Behaviour 56
The Sick Role: Joint Protection as a Case Study 57
Depression 59
Anxiety 60
Loss and Grief 61
VI
Loss of Bodily Function 62
Loss of Social Role 62
Economic Loss 64
Loss of Social Support 65
Body Image 66
Psychological Interventions in Physical and Manual Therapies 67
Measurement and Statistical Issues 69
Measuring Health-Related Quality of Life 69
Statistical Concerns 70
Limitations of these Studies 72
CHAPTER 3: PILOT STUDY 73
Introduction 73
Method 75
Participants 75
Measures 75
AIMS2 75
SF-MPQ 77
SF-36 79
MOS-SS 80
Medication Use Survey 81
Procedures 81
82
Data Analysis
82
Results
87
Discussion
87
Participants' Feedback
89
Recall
vu
Health-Related Quality of Life 89
Impact of Arthritis: AIMS2 90
General Health-Related Quality of Life: SF-36 91
Pain 92
How This Study Informed Subsequent Studies 93
Conclusions 94
CHAPTER 4: STUDY 1 96
Introduction 96
Method 97
Participants 97
Measures 97
Compliance data 98
Procedures 98
Data Analysis 100
Results 102
Missing data 102
Floor and ceiling effects 103
Analysis of the Covariates 103
Medication use 104
Social support 104
Changes Within and Between Groups 105
Within-Groups Analyses 105
Between-Groups Analyses 108
Discussion 114
Health-Related Quality of Life 114
Covariate Measures 115
Vlll
Medication use 115
Social support 115
Impact of Arthritis: AIMS2 115
General Health-Related Quality of Life: SF-36 117
Pain 119
Social Functioning: Disparity Between Instruments 120
Clinical Implications 121
Costs and Benefits 122
Clinical Cautions and Limitations 124
Recommendations for Future Research and Conclusions 126
How this Study Informed Study 3 126
Future Research 126
Conclusions 126
CHAPTER 5: STUDY 2 128
Introduction 128
Method 129
Participants 130
Measures 130
131
Compliance data
131
Procedures
133
Issues Arising from the Research Design
137
Data Analysis and Results
137
Data Analysis
138
Issues Arising from the Data Analysis and Results
140
Recommendations for Future Research and Conclusions
142
CHAPTER 6: STUDY 3